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| 血压管理对大血管闭塞急性缺血性脑卒中血管再通患者预后的影响 |
| 张萍△,陈蕾△,袁绘,朱宣,沈红健,于龙娟,张永巍,吴涛*,邓本强,刘建民 |
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(海军军医大学(第二军医大学)长海医院脑血管病中心, 上海 200433
△共同第一作者
*通信作者) |
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| 摘要: |
| 目的 探讨围手术期血压管理对前循环大血管闭塞急性缺血性脑卒中（AIS-LVO）血管再通患者预后的影响。方法 回顾性纳入2018年3月至2019年6月我院脑血管病中心连续收治的行血管内治疗后血管成功再通[脑梗死溶栓（TICI）分级≥2b级]的前循环AIS-LVO患者。对预后良好（改良Rankin量表评分≤2分）的影响因素进行单因素分析，将单因素分析中P < 0.1的变量纳入多因素logistic回归分析，确定术后24 h平均收缩压（mSBP）对预后的影响。根据术后24 h mSBP将患者分为低mSBP[100~< 120 mmHg （1 mmHg=0.133 kPa）]组、中mSBP （120~140 mmHg）组和高mSBP （>140~160 mmHg）组，比较3组患者术后3个月预后良好率、死亡率及术后24 h症状性颅内出血（sICH）发生率，然后将患者分为低中mSBP （100~140 mmHg）组与高mSBP （>140~160 mmHg）组进行预后分析。结果 共纳入患者238例，其中术后3个月预后良好161例（67.65%），预后不良77例（32.35%）。预后良好组患者年龄、术前和术后24 h美国国立卫生研究院卒中量表（NIHSS）评分、术前核心梗死体积（脑血流量< 30%的脑组织体积）及术后24 h mSBP均低于预后不良组，术前Alberta脑卒中计划早期计算机断层扫描评分（ASPECTS）高于预后不良组，差异均有统计学意义（P均< 0.05）。多因素logistic回归分析显示，术前ASPECTS （OR=1.338，95%CI 1.081~1.657，P=0.007）、术后24 h NIHSS评分（OR=0.838，95%CI 0.785~0.894，P < 0.001）和术后24 h mSBP （OR=0.966，95%CI 0.937~0.996，P=0.031）是预后的独立影响因素。随着mSBP增高，术后3个月死亡率和术后24 h sICH发生率均升高（P=0.001、0.032），而术后3个月预后良好率略有下降但差异无统计学意义（P=0.060）。低中mSBP组患者的术后3个月预后良好率高于高mSBP组（P=0.04），术后24 h sICH发生率低于高mSBP组（P=0.01），术后3个月死亡率与高mSBP组相比差异无统计学意义（P=0.19）。结论 术后24 h mSBP是前循环AIS-LVO血管再通患者预后的独立影响因素。建议将此类患者术后24 h mSBP控制在≤140 mmHg，如果出血转化的风险大则可控制在≤120 mmHg。 |
| 关键词: 急性缺血性脑卒中 血压管理 前循环 大血管闭塞 血管内治疗 脑出血 再灌注 |
| DOI：10.16781/j.0258-879x.2022.01.0093 |
| 投稿时间：2021-09-22 |
| 基金项目:上海市卫生和计划生育委员会智慧医疗专项研究项目（2018ZHYL0218） |
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| Impact of blood pressure management on prognosis of successful revascularization patients with acute large vessel occlusion ischemic stroke |
| ZHANG Ping△,CHEN Lei△,YUAN Hui,ZHU Xuan,SHEN Hong-jian,YU Long-juan,ZHANG Yong-wei,WU Tao*,DENG Ben-qiang,LIU Jian-min |
(Neurovascular Center, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai 200433, China
△Co-first authors.
* Corresponding author) |
| Abstract: |
| Objective To investigate the impact of perioperative blood pressure management on the prognosis of successful recanalization patients with anterior circulatory acute ischemic stroke with large vessel occlusion (AIS-LVO).Methods Consecutive patients with anterior circulation AIS-LVO who achieved successful recanalization (thrombolysis in cerebral infarction grade ≥ 2b) after endovascular treatment (EVT) in Neurovascular Center of our hospital from Mar. 2018 to Jun. 2019 were retrospectively enrolled. The influencing factors of good prognosis (modified Rankin scale score ≤ 2) were analyzed by univariate analysis, and the variables with P < 0.1 were included for multivariate logistic regression analysis to understand the prognostic value of mean systolic blood pressure (mSBP) in the first 24 h after EVT. According to the first 24 h mSBP after EVT, the patients were divided into 3 groups:low mSBP (100- < 120 mmHg[1 mmHg=0.133 kPa]) group, medium mSBP (120-140 mmHg) group and high mSBP (>140-160 mmHg) group. The good prognosis rate and mortality 3 months after EVT and the incidence of symptomatic intracranial hemorrhage (sICH) 24 h after EVT were compared among the 3 groups. Then the patients were divided into low to medium mSBP group (100-140 mmHg) and high mSBP group (>140-160 mmHg) for prognosis analysis.Results A total of 238 patients were included, including 161 (67.65%) with good prognosis and 77 (32.35%) with poor prognosis 3 months after EVT. The age, National Institutes of Health Stroke scale (NIHSS) scores before and 24 h after EVT, preoperative infarction core volume (brain tissue volume of cerebral blood flow < 30%) and first 24 h mSBP after EVT were significantly lower in the good prognosis group than those in the poor prognosis group, while preoperative Alberta Stroke Program early computed tomography score (ASPECTS) was significantly higher than that in the poor prognosis group (all P < 0.05). Multivariate logistic regression analysis showed that the preoperative ASPECTS (odds ratio[OR]=1.338, 95% confidence interval[CI] 1.081-1.657, P=0.007), NIHSS score 24 h after EVT (OR=0.838, 95% CI 0.785-0.894, P < 0.001) and first 24 h mSBP after EVT (OR=0.966, 95% CI 0.937-0.996, P=0.031) were independent prognostic factors. With the increase of mSBP, the mortality 3 months after EVT and the incidence of sICH 24 h after EVT were both significantly increased (P=0.001, 0.032), while the good prognosis rate 3 months after EVT was slightly decreased without significant difference (P=0.060). The good prognosis rate 3 months after EVT was significantly higher in the low to medium mSBP group than that in the high mSBP group (P=0.04), the incidence of sICH 24 h after EVT was significantly lower than that in the high mSBP group (P=0.01), while there was no significant difference in mortality 3 months after EVT between the 2 groups (P=0.19).Conclusion The mSBP in the first 24 h after EVT is an independent prognostic factor for anterior circulation AIS-LVO patients with successful recanalization. Active control of the mSBP ≤ 140 mmHg in the first 24 h after EVT is recommended, and if the risk of hemorrhagic transformation is high, it may be controlled at 120 mmHg or below. |
| Key words: acute ischemic stroke blood pressure management anterior circulation large vessel occlusion endovascular treatment cerebral hemorrhage reperfusion |
