不同剂量重组组织型纤溶酶原激活剂静脉溶栓治疗对超早期急性脑梗死预后的影响

目的 通过对超早期脑梗死患者接受不同剂量重组组织型纤溶酶原激活剂（rt-PA）静脉溶栓治疗的分析，探讨使用rt-PA对超早期脑梗死预后的影响。方法 超早期脑梗死患者308例，根据家属的意愿及是否签署溶栓治疗知情同意书分别给予溶栓治疗和非溶栓治疗。溶栓组221例，接受rt-PA静脉溶栓，其中92例给予rt-PA 0.9 mg/kg，发病在3 h内68例，>3～≤4 h内9例，>4～≤6 h内15例。129例给予rt-PA0.6～0.8 mg/kg，发病在3 h内72例，>3～≤4 h内24例，>4～≤6 h内33例。对照组87例，未应用rt-PA治疗。记录各组在基线、治疗24 h、发病90 dNIHSS评分、Barthel指数。预后良好定义为发病90 d Barthel指数≥95；颅内出血分为症状性颅内出血和非症状性颅内出血。同时记录随访期间的血管性死亡事件和卒中再发事件。应用logistic多因素分析预后的独立相关因素。结果 预后良好的独立相关因素为患者接受治疗前NIHSS评分（OR＝2.067，95%CI 1.201～3.556，P =0.009），冠心病史（OR =1.942，95%CI 1.040～3.625，P =0.037）和溶栓治疗（rtPA 0.9 mg/kg时，OR =0.414，95%CI 0.207～0.826，P =0.012；rtPA 0.6～0.8 mg/kg时，OR =0.261，95%CI 0.137～0.497，P＜0.01）。症状性颅内出血发生率在rtPA 0.9 mg/kg溶栓组与rtPA 0.6～0.8 mg/kg溶栓组分别为3.3%（3/92）和4.7%（6/129），差别无统计学意义。结论 静脉应用r t - PA溶栓治疗超早期急性脑梗死可获得较好的预后，不同剂量 r t - PA（0.6～0.8 mg/kg vs 0.9 mg/kg）对预后的影响无统计学差异，伴有心房颤动、糖尿病史将可能影响预后。

The Effects on Prognosis of Thrombolytic Therapy for Ultra-acute Ischemic Stroke by Different IV rt-PA Doses

Objective To investigate the effects of rt-PA on the prognosis of ultra-acute ischemic stroke, we analyzed the outcome of thrombolytic therapy by IV rt-PA at different doses.Methods 308 cases of ultra-acute ischemic stroke patients were divided by intention into two groups:thrombolytic therapy group and control group. For 221 patients in the thrombolytic therapy group: IV rt-PA were given at different doses: 0.9mg/kg for 92 patients(time window within 3hr in 68 cases, 3 to 4hr in 9 cases and 4 to 6hr in 15 cases) and 0.6-0.8mg/kg for 129 patients(time window within 3hr in 72 cases, 3 to 4hr in 24 cases and 4 to 6hr in 33 cases). The control group consist of 87 patients who were not administered by rt-PA. NIHSS score and Barthel Index were evaluated at baseline,24h after treatment and 90d prospectively. Neurological outcome was categorized as favorable(BI≥95)or unfavorable(BI≥95) at 90d after treatment. Intracranial hemorrhage included symptomatic intracranial hemorrhage(SIH) and asymptomatic intracranial hemorrhage(AIH). Vascular fatal events and re-stroke events were also recorded at the same time during the follow-up periods. Multivariable logistic regression was used to explore the independent prognostic factors.Results The independent factors for good outcome are baseline NIHSS(OR =2.067, 95%CI 1.201-3.556, P =0.009), Cornory Heart disease(OR =1.942, 95%CI 1.040-3.625, P =0.037)and thrombolytic therphy(rtPA 0.9mg/kg, OR =0.414, 95%CI 0.207-0.826, P =0.012; rtPA 0.6-0.8mg/kg,OR =0.261, 95%CI 0.137-0.497, P <0.001). The rate of symptomatic intracranial hemorrhage(SIH)in the thrombolytic therphy group were 3(3.3%) for rtPA 0.9mg/kg and 6(4.7%) for rtPA 0.6-0.8mg/kg. The difference is no significant.Conclusion Using IV rt-PA in ultra-acute ischemic stroke may have a good effect at our study.There is no statistic difference on prognosis between B group(rt-PA 0.6-0.8mg/kg ) and A group(rt-PA 0.9mg/kg). Accompanying history of atrial fibrillation and diabetes may affect prognosis.Thisshould be further studied by more strictly designed RCT.