急性缺血性卒中动脉溶栓后造影剂渗出的临床分析

目的 研究急性缺血性卒中动脉溶栓后造影剂渗出的相关因素和其对预后的影响.方法 采用前瞻性、开放性临床病例研究,对北京世纪坛医院神经内科2008年4月至2012年6月收治的78例发病6h内行动脉溶栓治疗的颈内动脉系统急性缺血性卒中患者的临床和影像学资料进行研究,比较基线和动脉溶栓治疗后头颅CT结果,观察造影剂渗出的发生情况.结果 血管造影显示颈内动脉闭塞30例,大脑中动脉闭塞48例.动脉溶栓后血管再通率为78.2％ （61/78）.动脉溶栓术后即刻头颅CT扫描显示,造影剂渗出共16例（占20.5％）,其中4例为颈内动脉起始部闭塞的患者,12例为大脑中动脉闭塞的患者,所有患者均为溶栓后获得部分或完全再通者.无造影剂渗出者3个月时预后良好率（modified Rankin Score,mRS 0 ～2）的比例（74.2％）明显高于发生造影剂渗出者（43.8％）,差异有统计学意义（P=0.020）.发生造影剂渗出者溶栓后症状性颅内出血的发生率（25％）明显高于无造影剂渗出者（3.2％）,差异有统计学意义（P =0.017）.单因素X2检验分析显示基线美国国立卫生研究院卒中量表（The National Institutes of Health Stroke Scale,NIHSS）评分＞16分（且＜22分）、动脉溶栓过程中收缩压高于160 mmHg、溶栓后血管获得再通、使用微导管和微导丝机械碎栓、经微导管造影和发病至溶栓后血管再通时间＞6h可能与发生造影剂渗出相关（P＜0.05）.多因素Logistic回归分析显示基线NIHSS评分＞16分（且＜22分）、动脉溶栓过程中收缩压高于160 mm Hg和发病至溶栓后血管再通时间＞6h可能是造影剂渗出的独立危险因素.结论 基线NIHSS评分＞16分（且＜22分）的急性缺血性卒中重症患者、动脉溶栓过程中收缩压高于160 mm Hg和发病至溶栓后血管再通时间＞6h者易于发生造影剂渗出.造影剂渗出与溶栓后症状性颅内出血的发生相关,而且预后不良.

Clinical analysis on contrast extravasation after intra-arterial thrombolysis for acute ischemic stroke

Objective To evaluate the risk factors and the prognosis for contrast extravasation after intraarterial（IA）thrombolysis for acute ischemic stroke.Methods A prospective and open-label trial was performed on 78 patients at the department of neurology in Beijing Shijitan Hospital from April 2008 to June 2012.Patients with acute ischemic stroke in the carotid artery system within 6 hours of symptom onset were treated with recombinant tissue plasminogen activator（rtPA） or urokinase （UK）by intra-artery thrombolysis approach.Arterial recanalization was assessed by the thrombolysis in cerebral infarction （TICI） classification.The functional outcome in 3-month was measured by mRS score.Contrast extravasation were observed by the baseline CT and postprocedure CTs.Results According to the results of digital subtraction angiography（DSA）,30 patients had the internal carotid artery （ICA） occlusion and 48 patients had the middle cerebral artery（MCA） occlusion.The rote of recanalization after IA thrombolysis was 78.2％ （61/78）,the rate of contrast extravasation was 20.5％ （16/78）.Contrast extravasation were noted on immediate CT scans after intra-arterial thrombolysis in 4 patients with the ICA occlusion and 12 patients with the MCA occlusion.Patients with contrast extravasation had a partial or complete vascular recanalization.Favorable prognosis outcome,defined as a modified Rankin Score of 0-2 at 90 days,were significantly higher in patients without contrast extravasation than in patients with contrast extravasation（74.2％ vs.43.8％） （P =0.020）.The rate of symptomatic intracerebral hemorrhage （SICH）were significantly higher in patients with contrast extravasation than in patients without contrast extravasation（25％ vs.3.2％）（P =0.017）.Baseline NIHSS score ＞16 points （＜ 22 points）,systolic pressure was more than 160 mm Hg during intra-arterial thrombolysis,vascular recanalization after intra-arterial thrombolysis,mechanical thrombus disruption by microcatheter and micrognidewire,microcatheter contrast injections during intra-arterial thrombolysis and the interval from onset of stroke to recanalization was more than 6 hours were significantly associated with contrast extravasation by x2 test（P ＜0.05）.In a multivariate logistic regression model,baseline NIHSS score ＞ 16 points （＜ 22 points） （P =0.008）,systolic pressure was more than 160 mm Hg during intra-arterial thrombolysis （P =0.043） and the interval from onset of stroke to recanalization was more than 6 hours（P =0.014） remained probably as independent predictors of contrast extravasation.Conclusions Acute serious ischemic stroke for NIHSS score ＞ 16 points （＜ 22 points） when systolic pressure was more than 160 mm Hg during intra-arterial thrombolysis and the interval from onset of stroke to recanalization was more than 6 hours is prone to contrast extravasation.Contrast extravasation is associated with symptomatic intracerebral hemorrhage after intra-arterial thrombolysis and the poor prognosis outcomes.