急性缺血性卒中转归的血清生物标志物

血清生物标志物在预测急性缺血性卒中的严重程度、早期神经功能恶化和转归方面具有重要作用.了解这些血清生物标志物的种类、作用机制以及与急性缺血性脑损伤的相关性,有助于急性缺血性卒中患者的早期转归预测并指导治疗.     

Stress hyperglycemia and acute ischemic stroke in-hospital outcome

Background and AimsStress hyperglycemia is frequent in patients with acute ischemic stroke. However, it is unclear whether stress hyperglycemia only reflects stroke severity or if it is directly associated with adverse outcome. We aimed to evaluate the prognostic significance of stress hyperglycemia in acute ischemic stroke.MethodsWe prospectively studied 790 consecutive patients who were admitted with acute ischemic stroke (41.0% males, age 79.4 ± 6.8 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Stress hyperglycemia was defined as fasting serum glucose levels at the second day after admission ≥ 126 mg/dl in patients without type 2 diabetes mellitus (T2DM). The outcome was assessed with adverse outcome rates at discharge (modified Rankin scale between 2 and 6) and with in-hospital mortality.ResultsIn the total study population, 8.6% had stress hyperglycemia. Patients with stress hyperglycemia had more severe stroke. Independent predictors of adverse outcome at discharge were age, prior ischemic stroke and NIHSS at admission whereas treatment with statins prior to stroke was associated with favorable outcome. When the NIHSS was removed from the multivariate model, independent predictors of adverse outcome were age, heart rate at admission, prior ischemic stroke, log-triglyceride (TG) levels and stress hyperglycemia, whereas treatment with statins prior to stroke was associated with favorable outcome. Independent predictors of in-hospital mortality were atrial fibrillation (AF), diastolic blood pressure (DBP), serum log-TG levels and NIHSS at admission. When the NIHSS was removed from the multivariate model, independent predictors of in-hospital mortality were age, AF, DBP, log-TG levels and stress hyperglycemia.ConclusionStress hyperglycemia does not appear to be directly associated with the outcome of acute ischemic stroke. However, given that patients with stress hyperglycemia had higher prevalence of cardiovascular risk factors than patients with normoglycemia and that glucose tolerance was not evaluated, more studies are needed to validate our findings.     

急性脑梗死患者急性期持续高血糖对预后的影响

目的动态观察急性脑梗死患者发病3 d内的血糖变化,了解血糖情况与脑卒中预后的相关性。方法选择发病≤12 h,经头颅MRI证实的首发或再发的急性脑梗死患者1 67例,其中糖尿病患者56例(糖尿病组),非糖尿病患者111例(非糖尿病组)。糖尿病组和非糖尿病组患者分别根据血糖正常、基线高血糖、平均高血糖、持续高血糖4个不同血糖水平进行比较,评估各项危险因素,动态观察入院时及发病3 d内的血糖情况,发病30 d以改良的Rankin残障量表(mRS)评估预后。结果与非糖尿病组比较,糖尿病组患者mRS评分明显降低。与血糖正常患者比较,糖尿病组和非糖尿病组平均高血糖和持续高血糖患者预后良好率明显降低,差异有统计学意义(P0.05,P0.01)。logistic回归分析显示,急性脑梗死的预后与基线美国国立卫生研究院卒中量表、是否发生合并症及血糖情况相关。结论脑卒中后持续高血糖预示着脑卒中预后不良,脑卒中后的血糖水平是动态变化的,与单个血糖值比较,持续血糖变化情况能够更充分的预测脑卒中的预后。     

Diabetes and the treatment of ischemic stroke

This white paper examines the current challenges for treating ischemic stroke in diabetic patients. The need for a greater understanding of the mechanisms that underlie the relationship between diabetes and the cerebral vascular responses to ischemia is discussed. The critical need to improve the efficacy and safety of thrombolysis is addressed, as is the need for a better characterization the off-target actions of tPA, the only currently approved thrombolytic for the treatment of ischemic stroke.     

出血性转化对急性缺血性卒中患者转归的影响

Objective To investigate the effect of hemorrhagic transformation (HT) on the outcome of acute ischemic stroke.Methods One hundred and one patients with acute ischemic stroke were divided into cerebral infarction without HT,hemorrhagic infarction (HI),and parenchymal hematoma (PH) according to the CT and/or MRI findings.The modified Rankin Scale (mRS) was used to evaluate the outcome at 3 months after onset,and the good outcome was defined as mRS ≤ 2.The multivariate logistic regression analysis was used to identify the predictors of outcome in patients with acute ischemic stroke.Results There were 53 patients without HT,44 HI,and 4 PH,respectively in 101 patients with acute ischemic stroke.HI (OR =0.07,95% CI0.01-0.30;P ＜0.001),＜65 years (OR =52.94,95% CI9.12-307.27;P＜0.001),and NIHSS score ＜ 15 (OR= 0.63,95% CI 0.50-0.78;P＜0.001) were the independent predictors of good outcome for patients with acute ischemic stroke.Conclusions HI is one of the independent predictors of good outcome at 3 months after acute ischemic stroke.     

出血性转化对急性缺血性卒中患者转归的影响

目的 探讨出血性转化(hemorrhagic transformation,HT)对急性缺血性卒中预后的影响.方法 根据CT和(或)MRI所见将101例急性缺血性卒中患者分为无HT的脑梗死(无HT)、出血性脑梗死(hemorrbagic infarction,HI)和脑实质血肿(parenchymal hematoma,PH).应用改良Rankin量表评分(modified Rankin Scale,mRS)评价发病3个月时的临床转归,mRS≤2分定义为转归良好.采用多变量logistic回归分析确定影响急性缺血性卒中患者转归的预测因素.结果 101例急性缺血性卒中患者中,53例无HT,44例为HI,4例为PH.HI(OR=0.07,95%CI0.01～0.30;P=0.001)、年龄＜65岁(OR=52.94,95%CI9.12～307.27;P＜0.001)、NIHSS评分＜15分(OR=0.63,95%CI0.50～0.78;P＜0.001)是急性缺血性卒中患者预后良好的独立预测因素.结论 HI是急性缺血性卒中患者发病3个月时转归良好的独立预测因素之一.     

低血清陷窝蛋白-1预测急性缺血性卒中患者的转归不良

目的：探讨基线血清陷窝蛋白-1(caveolin-1, Cav-1)水平与急性缺血性卒中患者发病后90 d时临床转归的相关性。方法连续纳入住院治疗的急性缺血性卒中患者。采用酶联免疫吸附法检测血清 Cav-1水平,在发病后90 d采用改良 Rankin 量表(modified Rankin Scale, mRS)进行转归评价,0~2分定义为转归良好。对转归良好组与转归不良组人口统计学和临床特征进行比较,应用多变量 logistic 回归分析确定低血清 Cav-1水平与发病后90 d时转归不良的相关性。结果共169例急性缺血性卒中患者纳入分析,男性116例(68．5%),年龄50~83岁,平均(63．4±9．1)岁,平均血清Cav-1水平为(5．483±2．617)ng/ml。转归良好组83例(49．1%),转归不良组86例(50．9%)。单变量分析显示,转归不良组皮质下梗死(60．5%对43．4%;χ2=4．944,P =0．026)、弥散加权成像-阿尔伯塔卒中项目早期 CT 评分( diffusion-weighted imaging- Alberta Stroke Program Early CT Score, DWI-ASPECTS)≤7分(58．1%对40．9%;χ2=4．984, P =0．026)的患者比例以及年龄[(65．5±8．9)岁对(61．2±10．7)岁;t =2．793,P =0．006]、基线收缩压水平[(140．6±17．2)mmHg 对(134．9±13．4)mmHg;t =2．368,P =0．019;1 mmHg =0．133 kPa]和美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale, NIHSS)评分[(4．8±3．4)分对(3．9±2．2)分;t =2．211,P =0．036]均显著高于转归良好组,而血清 Cav-1水平显著低于转归良好组[(4．9±2．3)ng/ml 对(6．1±2．1)ng/ml;t =2．977,P =0．003]。在校正相关混杂因素后,多变量 logistic 回归分析显示,血清 Cav-1水平低是急性缺血性卒中患者90 d转归不良的独立预测因素(优势比1．157,95%可信区间1．016~1．319;P =0．028)。结论血清 Cav-1水平低是急性缺血性卒中患者转归不良的独立预测因素。     

炎性标记物对急性脑梗死早期预后的影响

目的探讨炎性标记物对急性脑梗死早期预后的影响。方法连续收集急性脑梗死患者272例,根据高敏C反应蛋白(hs-CRP)水平分为高hs-CRP组(hs-CRP>3mg/L,116例)和低hs-CRP组(hs-CRP≤3mg/L,156例)。入院后行TOAST分型,美国国立卫生研究院卒中量表(NIHSS)评分、Barthel指数(BI)评分和改良Rankin量表(mRS)评分;检测入院后24h内血白细胞、空腹血糖、同型半胱氨酸和hs-CRP;并采用多因素logistic回归分析对急性脑梗死早期预后不良的独立危险因素进行探讨。结果高hs-CRP组年龄、心房颤动、TOAST分型心源性栓塞、同型半胱氨酸、空腹血糖、白细胞和1、7、14dNIHSS评分及1、7、14、90dmRS评分明显高于低hs-CRP组,1、7、14dBI评分明显低于低hs-CRP组,2组比较差异有统计学意义(P<0.01)。hs-CRP、白细胞、高脂血症、入院1d时BI评分是急性脑梗死早期预后不良的独立危险因素。结论炎性标记物hs-CRP及白细胞计数增高可能是急性脑梗死早期预后不良的独立危险因素。     

Prediction of long-term functional outcome in patients with acute ischemic non-embolic stroke

In a prospective observational study, we assessed the relative value of conventional stroke risk factors and emerging markers in the prediction of functional outcome of patients surviving the acute phase of an ischemic non-embolic stroke. All available eligible patients consecutively admitted due to a first-ever acute ischemic non-embolic stroke during a 2-year period were evaluated. In a total of 105 patients (54 males, 51 diabetic) a series of clinical, biochemical and imaging characteristics were recorded, including demographic data, blood pressure, serum glucose, insulin, lipids, inflammatory markers, intima-media thickness of the carotid arteries (IMT), brain damage location and size of the infarct volume. Barthel Activities of Daily Living Index (BI) scale was used to assess the severity of neurological deficit on admission and the functional outcome 6 months after discharge. Brain infarct volume, stroke location in the anterior circulation, age, diabetes mellitus, IMT and plasma interleukin-1beta levels proved to be significant determinants of long-term functional outcome, assessed by BI disability score. ROC curve analyses indicated that the infarct volume is superior to other predictors in the diagnosis of patients with unfavorable functional outcome (BI<95) at 6 months post-discharge (area under the curve, AUC=0.80, 95% confidence interval 0.64-0.95; p=0.003). Significant differences in the mean infarct volume were noted among age tertiles, with the diabetic patients in the 3rd tertile of age experiencing the worst outcome (LSD test, p=0.019). Taken together, the assessment of infarct volume seems to have a significant predictive value regarding long-term functional outcome, especially in the elderly diabetic patients.     

急性缺血性卒中患者的出血性转化与转归的相关性

目的:探讨出血性转化（hemorrhagic transformation, HT）及其不同亚型对急性缺血性卒中（acute ischemic stroke, AIS）患者临床转归的影响。方法:回顾性纳入2018年1月至2021年1月河南省人民医院收治的发病24 h内的AIS患者。HT定义为AIS发病后7 d内CT复查...     

每日间血压变异性与急性缺血性卒中后转归的相关性

目的 探讨急性缺血性卒中后1周内每日间血压变异性与6个月时转归的相关性.方法 连续登记2013年1月至2015年12月住院治疗的急性缺血性卒中患者,监测入院后7d内每日清晨血压并计算血压变异性参数.随访6个月,根据改良Rankin量表(modified Rankin Scale,mRS)进行转归评价,转归良好定义为mRS评分0～2分.比较转归良好组与转归不良组的临床特征、血压和每日间血压变异性参数.应用多变量logistic回归分析确定每日间血压变异性参数与6个月时转归的相关性.结果 共纳入169例患者,其中89例(52.7％)转归不良.转归不良组每日间平均收缩压[(147.1±15.9)mmHg对(139.6±19.0)mmHg;t2.666,P=0.008;1 mmHg=0.133 kPa]、收缩压标准差[中位数和四分位数间距:16.5(13.7 ～19.4)mmHg对13.4(10.7 ～ 18.3)mmHg;Z=2.909,P=0.004]和收缩压最大值与最小值之差[47.0(38.0 ～56.0)mmHg对37.0(29.0 ～49.0)mmHg;Z=3.634,P＜0.001]均显著高于转归良好组.多变量logistic回归分析显示,每日间收缩压极差值增大是急性缺血性卒中发病后6个月时转归不良的独立危险因素(优势比1.028,95％可信区间1.007～1.050;P =0.008).结论 急性缺血性卒中急性期每日间血压变异性高与转归不良独立相关.     

微量白蛋白尿与急性缺血性卒中患者短期转归的相关性

目的 探讨尿微量白蛋白(microalbuminuria, MAU)与急性缺血性卒中患者短期转归的关系.方法 前瞻性纳入住院治疗的连续急性缺血性卒中患者.入院后次日晨起留取首次尿标本测定尿白蛋白/肌酐比率(urine albumin/ creatinine ratio, UACR),UACR 30~300 mg/g定义为MAU阳性.入院时采用美国国立卫生研究院卒中量表(National Institute of Health Stroke Scale, NIHSS)评价卒中严重程度,出院时采用改良Rankin量表(modified Rankin Scale, mRS)评价功能转归,0~2分定义为转归良好.结果 共纳入244例急性缺血性卒中患者,其中53例(21.72%)MAU阳性,67例(27.50%)转归不良.单变量分析显示,MAU阳性组患者年龄、基线NIHSS评分、收缩压、空腹血糖、球蛋白、D-二聚体、白细胞计数、中性粒细胞以及缺血性心脏病构成比显著高于MAU阴性组(P均<0.05).转归不良组基线NIHSS评分、空腹血糖、纤维蛋白原、间接胆红素、直接胆红素、C反应蛋白、D-二聚体、白细胞计数、中性粒细胞以及MAU阳性患者构成比显著高于转归良好组(P均<0.05).多变量logistic回归分析显示,MAU[优势比(odds ratio, OR)1.520,95%可信区间(confidence interval, CI)1.151~1.794;P=0.031]、基线NIHSS评分(OR 1.570,95% CI 1.357~1.808;P<0.001)是急性缺血性卒中患者短期转归不良的独立危险因素.结论 急性缺血性卒中患者的MAU发生率较高,MAU阳性可作为急性缺血性卒中患者短期转归不良的独立预测指标之一.     

Management of acute ischemic stroke

The management of acute ischemic stroke aims to verify the clinical diagnosis, to start general supportive care and to enable decision-making about specific forms of therapy.The risk-benefit ratio is time-dependent for many therapeutic options; therefore time delays are a disadvantage within the rescue chain. The trained and multidisciplinary team of the stroke unit forms the backbone of acute management. In addition, technical infrastructure influences therapeutic options and cerebral imaging is the cornerstone.The following four therapies are evidence-based: treatment on a stroke unit, thrombolysis, early administration of acetylsalicylic acid (ASS) and hemicraniectomy in patients younger than 60 years with a so-called malignant infarction.This article describes the necessary diagnostic steps and the general and specific therapeutic options that comprise acute management within the first 48?h.     

血液生物学标记物与急性缺血性卒中患者的神经功能转归

急性缺血性卒中具有高发病率、高致死率和高致残率等特点,严重影响着中老年人群的健康,寻找影响急性缺血性卒中患者神经功能转归的相关因素,并对其干预是该领域的研究热点之一.近年来的研究显示,基质金属蛋白酶-9、神经元特异性烯醇化酶、S-100B蛋白、脑利钠肽、和肽素、血脂、血糖等血液学指标均可能与急性缺血性卒中患者的神经功能转归有关.     

Treatment of acute ischemic stroke

Acute ischemic stroke is the third leading cause of death in the United States and the leading cause of adult disability. The direct and indirect costs of stroke care exceed $51 billion annually. In 1996, the US Food and Drug Administration approved the first treatment for acute ischemic stroke, intravenous tissue plasminogen activator. Later that year, the National Institute of Neurologic Disorders and Stroke (a branch of the National Institutes of Health) convened a consensus conference on the Rapid Identification and Treatment of Acute Ischemic Stroke, setting goals for stroke care in the United States. Since then, it has become imperative that emergency physicians understand the pathophysiology of stroke, the basis and rationale for treatment, and the therapeutic approaches. This article reviews the state of the art of acute stroke treatment, its foundation, as well as its future.     

Management of acute ischemic stroke

Prior to 1995 no proven therapy existed for acute ischemic stroke. In 1996 the U.S. Food and Drug Administration approved the use of intravenous rt-PA in acute stroke based largely on the results of a two-part trial sponsored by the National Institutes of Health and National Institute of Neurological Disorders and Stroke (NIH/NINDS). Five years following approval, however, thrombolytic treatment remains underutilized, occurring in only 1 to 2% of all stroke patients. The medical community is now being called upon to organize systems capable of delivering acute stroke care in a time-urgent manner not previously contemplated. Critical care specialists may be called upon to treat stroke occurring in hospitalized patients or to continue care initiated in the emergency department. This article briefly reviews the pathogenesis of cellular injury in stroke and its initial evaluation and care and then focuses on the data involving thrombolytic reperfusion. Special attention is given to postthrombolytic critical care issues as these represent an important determinant in patient outcome. Secondary stroke prevention strategies and complication management are discussed along with general intensive care issues for the stroke patient.     

低高密度脂蛋白胆固醇血症对缺血性脑卒中患者一年预后的影响

目的分析低HDL-C与急性缺血性脑卒中患者1年预后的关系。方法以前瞻性、多中心的中国国家卒中登记研究数据库中符合标准的住院患者8876例为研究对象,男性5555例,女性3321例。将HDL-C<0.9mmol/L的1440例患者作为低HDL-C,HDL-C≥0.9mmol/L的7436例患者作为正常HDL-C。采用多变量logistic回归模型分析低水平HDL-C对缺血性脑卒中患者1年预后的影响。结果 8867例患者中低HDL-C发生率16.2%。低HDL-C与正常HDL-C患者基线血压、LDL-C和TG水平比较,差异有统计学意义(P<0.05,P<0.01)。男性低HDL-C患者1年预后不良发生率明显高于正常HDL-C患者(27.9%vs 24.1%,P<0.05)。低HDL-C是男性脑卒中1年预后不良的独立危险因素(OR=1.289,95%CI:1.068¹.555,P=0.008)。基线LDL-C<2.59mmol/L患者中,低HDL-C水平仍是男性脑卒中患者1年预后不良的独立危险因素(OR=1.528,95%CI:1.1621.555,P=0.008)。基线LDL-C<2.59mmol/L患者中,低HDL-C水平仍是男性脑卒中患者1年预后不良的独立危险因素(OR=1.528,95%CI:1.162².010,P=0.002)。结论低HDL-C是男性缺血性脑卒中患者发病1年预后不良的独立危险因素,并且独立于基线LDL-C水平。LDL-C水平越低,升高HDL-C的临床获益越大。