井延涛;陈苗苗;岳新灿;刘俊英;

• 1:周口市中心医院

摘要(Abstract)：

目的探讨大血管闭塞急性缺血性卒中患者静脉溶栓后转诊行血管内治疗的疗效,并对影响预后的相关因素进行分析。方法回顾性分析周口市中心医院2018-06—2019-06在外院静脉溶栓后转入至本院急诊行血管内治疗的前循环大血管闭塞患者40例,并根据术后90 d mRS评分将患者分成预后良好组(mRS≤2分)和预后不良组(mRS>2分)。单因素分析预后良好组与预后不良组的影响因素,并将其中P<0.05的变量采用二元Logistic回归分析法分析影响预后的独立因素。结果 (1)40例患者中15例(37.5%)患者90 d随访预后良好,25例(62.5%)患者预后不良,预后良好组患者中位发病至入院时间(ODT)小于预后不良组[330(240,600)min vs 460(300,1 440)min,Z=4.450,P<0.005]。(2)预后良好组血管再通率(mTICI≥2b～3)明显高于预后不良组[86.7%(13/15)vs 56%(14/25),χ²=4.019,P=0.046],差异具有统计学意义(P<0.005);术后症状性颅内出血和非症状性颅内出血比较,差异均无统计学意义(P>0.05)。(3)单因素分析结果显示,预后良好组患者年龄、基线NIHSS评分偏低;合并高血压史、高血脂、糖尿病史、吸烟史、饮酒史及既往脑卒中/TIA的比例更低,差异均具有统计学意义(P<0.05);多因素回归分析显示,ODT延长、高血压、糖尿病、脑卒中/TIA史均是影响患者导致不良预后的影响因素(P均<0.05)。结论正确识别大血管闭塞的急性脑卒中患者,减少院前延误,及早行血管内治疗可不同程度改善患者3个月的良好预后。

关键词(KeyWords)： 大血管闭塞;急性缺血性脑卒中;血管内治疗;转诊;影响因素

Abstract:

Keywords:

基金项目(Foundation): 河南省基础与前沿技术研究计划项目(编号:142300410418)

作者(Authors): 井延涛;陈苗苗;岳新灿;刘俊英;

参考文献(References)：

• [1] WU S,WU B,LIU M,et al.Stroke in China:advances and challenges in epidemiology,prevention,and management[J].Lancet Neurol,2019,18(4):394-405.
• [2] CATANESE L,TARSIA J,FISHER M.Acute Ischemic Stroke Therapy Overview[J].Circ Res,2017,120(3):541-558.DOI:10.1161/CIRCRESAHA.116.309278.
• [3] GOYAL M,MENON B K,VAN ZWAM W H,et al.HERMES collaborators.Endovascular thrombectomy after large-vessel ischaemic stroke:a meta-analysis of individual patient data from five randomised trials[J].Lancet,2016,387(10029):1723-1731.DOI:10.1016/S0140-6736(16)00163-X.
• [4] LAPERGUE B,BLANC R,GORY B,et al.ASTER Trial Investigators.Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion:The ASTER Randomized Clinical Trial[J].JAMA,2017,318(5):443-452.DOI:10.1001/jama.2017.9644.
• [5] EMBERSON J,LEES K R,LYDEN P,et al.Effect of treatment delay,age,and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke:a meta-analysis of individual patient data from randomised trials[J].Lancet,2014,384(9958):1929-1935.
• [6] HASAN T F,TODNEM N,GOPAL N,et al.Endovascular Thrombectomy for Acute Ischemic Stroke[J].Curr Cardiol Rep,2019,21(10):112.DOI:10.1007/s11886- 019-1217-6.PMID:31471811.
• [7] BALAMI J S,WHITE PM,MCMEEKIN P J,et al.Complications of endovascular treatment for acute ischemic stroke:Prevention and management[J].Int J Stroke,2018,13(4):348-361.DOI:10.1177/1747493017 743051.
• [8] JAHAN R,SAVER J L,SCHWAMM L H,et al.Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice[J].JAMA,2019,322(3):252-263.DOI:10.1001/jama.2019.8286.
• [9] CHEN C J,DING D,STARKE R M,et al.Endovascular vs medical management of acute ischemic stroke[J].Neurology,2015,85(22):1980-1990.DOI:10.1212/WNL.0000000000002176.
• [10] BAEK J H,KIM B M,HEO J H,et al.Outcomes of Endovascular Treatment for Acute Intracranial Atherosclerosis-Related Large Vessel Occlusion[J].Stroke,2018,49(11):2699-2705.DOI:10.1161/STROKEAHA.118.022327.
• [11] DESAI S M,STARR M,MOLYNEAUX B J,et al.Acute Ischemic Stroke with Vessel Occlusion-Prevalence and Thrombectomy Eligibility at a Comprehensive Stroke Center[J].J Stroke Cerebrovasc Dis,2019,28(11):104315.DOI:10.1016/j.jstrokecerebrovasdis.2019.104315.
• [12] DEREX L,CHO T H.Mechanical thrombectomy in acute ischemic stroke[J].Rev Neurol(Paris),2017,173(3):106-113.DOI:10.1016/j.neurol.2016.06.008.
• [13] KADONO Y,NAKAMURA H,SAITO S,et al.Endovascular treatment for large vessel occlusion stroke in patients with ventricular assist devices[J].J Neurointerv Surg,2019,11(12):1205-1209.DOI:10.1136/neurintsurg-2018- 014645.
• [14] YOSHIMURA S,SAKAI N,UCHIDA K,et al.Endovascular Therapy in Ischemic Stroke With Acute Large-Vessel Occlusion:Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2[J].J Am Heart Assoc,2018,7(9):e008796.DOI:10.1161/JAHA.118.008796.
• [15] RANGEL-CASTILLA L,RAJAH G B,SHAKIR H J,et al.Management of acute ischemic stroke due to tandem occlusion:should endovascular recanalization of the extracranial or intracranial occlusive lesion be done first?[J].Neurosurg Focus.2017,42(4):E16.DOI:10.3171/2017.1.FOCUS16500.
• [16] UCHIDA K,YOSHIMURA S,SAKAI N,et al.Sex Differences in Management and Outcomes of Acute Ischemic Stroke With Large Vessel Occlusion[J].Stroke,2019,50(7):1915-1918.DOI:10.1161/STROKEAHA.119.025344.
• [17] NOGUEIRA R G,JADHAV A P,HAUSSEN D C,et al.Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct[J].N Engl J Med,2018,378(1):11-21.
• [18] ALBERS G W,MARKS M P,KEMP S,et al.Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion lmaging[J].N Engl J Med,2018,378(8):708-718.
• [19] BERKHEMER OA,FRANSEN PS,BEUMER D,et al.A randomized trial of intraarterial treatment for acute ischemic stroke[J].N Engl J Med,2015,372(1):11-20.
• [20] FRANSEN P S,BERKHEMER O A,LINGSMA H F,et al.Time to Reperfusion and Treatment Effect for Acute Ischemic StrokeA Randomized Clinical Trial[J].JAMA Neurol,2016,73(2):190-196.
• [21] ASSIS Z,MENON BK,GOYAL M,et al.Acute ischemic stroke with tandem lesions:technical endovascular management and clinical outcomes from the ESCAPE trial[J].J Neurointerv Surg,2018,10(5):429-433.DOI:10.1136/neurintsurg-2017- 013316.
• [22] STEIN L K,TUHRIM S,FIFI J,et al.Interhospital Transfers for Endovascular Therapy for Acute Ischemic Stroke[J].Stroke,2019,50(7):1789-1796.DOI:10.1161/STROKEAHA.119.024869.
• [23] 郝云飞,陈合成,李小丽,等.rtPA静脉溶栓桥接血管内治疗急性缺血性脑卒中临床观察[J].中国实用神经疾病杂志,2018,21(5):475-478.
• [24] 罗根培,李润雄,吴志强,等.血管内取栓治疗急性后循环缺血性脑卒中临床分析[J].中国实用神经疾病杂志,2020,23(11):930-934.
• [25] POWERS W J,DERDEYN C P,BILLER J,et al.American Heart Association Stroke Council.2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment:A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association[J].Stroke,2015,46(10):3020-3035.DOI:10.1161/STR.0000000000000074.
• [26] PIEROT L,GAWLITZA M,SOIZE S.Techniques for endovascular treatment of acute ischemic stroke[J].Rev Neurol (Paris),2017,173(9):594-599.DOI:10.1016/j.neurol.2017.09.005.Epub 2017 Oct 2.
• [27] LESLIE-MAZWI T,RABINOV J,HIRSCH J A.Endovascular treatment of acute ischemic stroke[J].Handb Clin Neurol,2016,136:1293-1302.DOI:10.1016/B978- 0-444-53486-6.00066-1.
• [28] FAROUK M,SATO K,MATSUMOTO Y,et al.Endovascular Treatment of Internal Carotid Artery Dissection Presenting with Acute Ischemic Stroke[J].J Stroke Cerebrovasc Dis,2020,29(3):104592.DOI:10.1016/j.jstrokecerebrovasdis.2019.104592.
• [29] PIRSON F A V,VAN OOSTENBRUGGE R J,VAN ZWAM W H,et al.Repeated Endovascular Thrombectomy in Patients With Acute Ischemic Stroke:Results From a Nationwide Multicenter Database[J].Stroke,2020,51(2):526-532.DOI:10.1161/STROKEAHA.119.027525.
• [30] MARQUARDT R J,CHO S M,THATIKUNTA P,et al.Acute Ischemic Stroke Therapy in Infective Endocarditis:Case Series and Systematic Review[J].J Stroke Cerebrovasc Dis,2019,28(8):2207-2212.DOI:10.1016/j.jstrokecerebrovasdis.2019.04.039.
• [31] SPARACO M,CIOLLI L,ZINI A.Posterior circulation ischemic stroke-a review part II:imaging and acute treatment[J].Neurol Sci,2019,40(10):2007-2015.DOI:10.1007/s10072- 019- 03936-x.
• [32] SAIRANEN T,RITVONEN J.Should we thrombolyse prior to endovascular treatment in acute stroke?[J].Clin Neurol Neurosurg.2019 Feb;177:117-122.DOI:10.1016/j.clineuro.2018.10.012.Epub 2018 Oct 25.PMID:30446414.
• [33] PATEL R A,WHITE C J.Acute ischemic stroke treatment:State of the art[J].Vasc Med.2011,16(1):19-28.DOI:10.1177/1358863X10382945.Epub 2010 Oct 21.PMID:20965957.
• [34] YOO A J,CHAUDHRY Z A,LESLIE-MAZWI T M,et al.Endovascular treatment of acute ischemic stroke:current indications[J].Tech Vasc Interv Radiol,2012,15(1):33-40.DOI:10.1053/j.tvir.2011.12.013.
• [35] RAPHAELI G,MAZIGHI M,PEREIRA V M,et al.State-of-the-art endovascular treatment of acute ischemic stroke[J].Adv Tech Stand Neurosurg,2015,42:33-68.DOI:10.1007/978-3-319- 09066-5_3.
• [36] NATARAJAN S K,ELLER J L,SNYDER K V,et al.Endovascular treatment of acute ischemic stroke[J].Neuroimaging Clin N Am,2013,23(4):673-94.DOI:10.1016/j.nic.2013.03.014.
• [37] ASADI H,DOWLING R,YAN B,et al.Advances in endovascular treatment of acute ischaemic stroke[J].Intern Med J,2015,45(8):798-805.DOI:10.1111/imj.12652.PMID:25443686.