心房颤动合并急性缺血性脑卒中的溶栓及抗凝治疗研究进展

急性缺血性脑卒中是常见病、多发病。心房颤动(房颤)是临床上常见的心律失常,尤以非瓣膜性房颤为著。房颤合并急性缺血性脑卒中的患者临床常见,且病情重、出血转化率高、复发率高,给治疗带来一定的难度。重组组织型纤溶酶原激活剂是目前治疗急性缺血性脑卒中最有效的药物,可减少急性缺血性脑卒中患者的致残率;口服抗凝药可减少房颤相关急性缺血性脑卒中的复发;抗血小板治疗对房颤合并急性缺血性脑卒中患者也有一定的二级预防作用。鉴于房颤合并急性缺血性脑卒中所特有的临床特征,选择适宜的药物治疗至关重要。     

rt-PA溶栓时机对急性缺血性脑卒中伴心房颤动患者的溶栓效果及安全性的影响

目的 探讨rt-PA溶栓时机对急性缺血性脑卒中伴心房颤动患者的溶栓效果及安全性的影响。方法 选取本院2015年4月-2017年8月收治急性缺血性脑卒中伴心房颤动患者共124例,其中发病后3～4.5 h行rt-PA溶栓共64例设为对照组,发病后3 h内行rt-PA溶栓共60例设为观察组; 比较2组患者溶栓有效率、治疗前后NIHSS评分、随访mRS评分及严重出血事件发生率。结果 观察组患者溶栓有效率显著高于对照组(P<0.05); 2组患者治疗后1和7d NIHSS评分均显著低于治疗前(P<0.05); 观察组患者治疗后1 d NIHSS评分显著低于对照组(P<0.05); 2组患者治疗后7d NIHSS评分比较差异无显著性(P>0.05); 2组患者随访mRS评分分级情况比较差异无显著性(P>0.05); 2组患者出血性脑梗死和脑部症状性出血发生率比较差异无显著性(P>0.05); 观察组患者治疗后脑实质出血发生率显著低于对照组(P<0.05)。结论 急性缺血性脑卒中伴心房颤动患者在发病后3 h内行rt-PA溶栓在可提高溶栓效果和促进受损神经功能恢复方面较发病后3～4.5 h溶栓具有明显优势,但在远期疗效和严重出血事件发生风险方面两者接近。     

心房颤动相关急性缺血性脑卒中临床治疗的研究进展

急性缺血性脑卒中(AIS)是一种由于脑动脉狭窄或血栓阻塞导致脑血供不足而引起的脑组织缺血性损伤的疾病。心源性脑卒中占所有AIS的25%～30%,而心房颤动相关脑卒中占所有心源性脑卒中的79%以上,心房颤动是最重要的危险因素。心房颤动相关脑卒中症状更严重,致残率、致死率更高,更易复发,病死率是非心房颤动相关脑卒中的2倍。目前,心房颤动相关AIS的治疗方法有静脉溶栓、血管内机械取栓、桥接治疗及单纯抗凝,等。文中对上述治疗方法的研究进展进行综述。     

心房颤动对不同时间窗内急性缺血性脑卒中患者静脉溶栓疗效的影响

目的探讨急性缺血性脑卒中合并心房颤动患者不同时间窗内静脉溶栓的疗效差异。方法选取急性缺血性脑卒中行静脉溶栓治疗患者172例,根据发病-溶栓时间窗差异分为3组,时间窗分别为≤3.0 h(观察A组)、>3.0~4.5 h(观察B组)、>4.5 h(观察C组),对其中合并心房颤动者溶栓疗效进行评估分析。结果3组患者溶栓24 h后出血转化结果、溶栓3个月时神经功能结局良好率、病死率均无明显差异(P>0.05);溶栓时间窗>3 h者,心房颤动可显著增加患者发生PH型、HI型出血转化发生率,差异有统计学意义(P<0.05);单因素分析显示,合并心房颤动可造成溶栓时间窗≤4.5 h患者神经功能结局不良发生率增加,差异有统计学意义(P<0.05)。多因素分析显示,合并心房颤动与不同时间窗急性缺血性脑卒中患者静脉溶栓治疗后神经功能结局不良发生情况无明显相关性(P>0.05)。结论溶栓时间窗仍是影响急性缺血性脑卒中患者静脉溶栓疗效的重要因素,对于溶栓时间窗≤3.0 h者,合并心房颤动不会对溶栓疗效造成影响;对于发病-溶栓时间>3 h者,心房颤动可能造成患者溶栓后出血风险增加。     

急性缺血性脑卒中合并非瓣膜性心房颤动患者出院时抗凝药使用分析

目的 调查急性缺血性脑卒中(AIS)合并非瓣膜性心房颤动(NVAF)患者出院时未处方口服抗凝药的影响因素.方法 采用回顾性研究,提取2017年6月至2020年6月期间出院的合并NVAF的AIS患者的病例资料,根据出院医嘱记录,将患者分为处方抗凝药组和未处方抗凝药组,采用单因素分析和多因素Logistic回归分析,筛选影...     

脑电图分级标准在急性大面积缺血性脑卒中患者预后评估中的临床研究

目的 探讨脑电图(electroencephalogram, EEG)分级标准在急性大面积缺血性脑卒中患者脑功能损伤评价及预后评估中的作用。方法 收集2016年7月-2020年7月首都医科大学附属复兴医院神经内科收治的发病5 d内的68例急性大面积缺血性脑卒中患者脑电图进行EEG分级判定,记录并使用格拉斯哥昏迷评分(glasgow coma scale, GCS)、美国国立卫生研究院卒中量表(NIH stroke scale, NIHSS)评分,随访至90 d进行格拉斯哥预后评分(glasgow outcome scale, GOS),并采用Logistic回归分析评估各项评分系统的预测价值。结果 本组患者的EEG分级标准与预后有显著相关性(P<0.01),EEG分级评分越高,患者的神经功能预后越差。Logistic回归分析显示EEG分级标准的转归良好及不良预测准确率、综合预测准确率最高。结论 脑电图分级标准在急性大面积缺血性脑卒中患者预后研究中能更客观地反映脑功能损伤的程度,可以作为发病早期预后评估的预测指标。     

入院当日白细胞状况对急性缺血性脑卒中出院当日MRS评分的影响

目的探讨入院当日白细胞计数和中性粒细胞比率对急性缺血性脑卒中(AIS)患者出院当日MRS评分的影响,为科学评估住院期间病情转归提供依据。方法采用回顾性队列研究的方法,录入2011.6.1-2014.6.1阜新市中心医院3151例AIS患者,收集人口统计学、生活方式及入院当日白细胞计数,中性粒细胞比率等血常规信息。出院当日按照生活质量评分量表(MRS)评分将研究对象分为2组:MRS≥3分为神经功能缺损组,MRS3分为对照组。按照白细胞计数(≤10.0×10~9·L~(-1),10.1～11.0×10~9·L~(-1),11.1～12.0×10~9·L~(-1),≥12.1×10~9·L~(-1))水平将研究对象分为4组,按照中性粒细胞比率(≤70.00%,70.01-80.00%,≥80.01%)将研究对象分为3组,采用Logistic回归分析白细胞计数及中性粒细胞比率对AIS出院当日MRS评分的影响。结果 MRS≥3分组的白细胞计数、中性粒细胞比率均高于MRS3分组,差异有统计学意义(P0.05);经多因素校正后,白细胞计数与第1组相比,第2、3和4组均增加了AIS发生MRS评分增高神经功能缺损的风险,OR值及95%CI分别为1.700(1.103～2.620),2.756(1.714～4.433),3.355(2.453～4.589);中性粒细胞比率与第1组相比,第2和3组均增加了AIS患者MRS评分增高神经功能缺损的风险;并且随着白细胞计数和中性粒细胞比率的增加,残疾和死亡复合结局的风险也随着增加(P趋势性检验0.0001)。结论 AIS患者入院当日白细胞计数增加及中性粒细胞比率升高加大了出院当日MRS评分增高的风险,并存在计量反应关系。     

急性缺血性脑卒中患者血清钙调蛋白水平检测及意义

目的 研究急性缺血性脑卒中患者血清钙调蛋白(CaM)水平及临床意义.方法 采用病例对照研究,选取92例急性缺血性脑卒中患者,入院后按照美国国立卫生研究院卒中量表评分(NIHSS评分)分为NIHSS≤5分组和NIHSS ＞5分组.选择45例健康体检者作为对照组.运用酶联免疫吸附法(ELISA法)检测所有入组者血清CaM水平,并分析CaM水平与NIHSS评分的相关性.结果 (1)急性缺血性脑卒中患者血清CaM水平明显高于健康对照组,有统计学意义(t =0.296,P＜0.01);(2) NIHSS＞5分组患者血清CaM水平显著高于NIHSS≤5分组有统计学意义(=2.417,P＜0.05);(3)急性缺血性脑卒中患者血清CaM水平与NIHSS评分呈正相关(r=0.318,P=0.002).结论 急性缺血性脑卒中患者血清CaM水平明显增高,可作为判定病情严重程度的重要指标.     

急性缺血性脑卒中患者P300的变化分析

目的探讨事件相关电位中(ERP) P300指标对急性缺血性脑卒中(AICA)患者认知功能的预测价值.方法检查32例AICA患者急性期ERP,并依据6～8个月后复合认知指数标准,分为痴呆和非痴呆组对比P300,并与健康人比较.结果痴呆和非痴呆组P300改变呈同一方向即波幅下降,潜伏期延长.进一步分析所见痴呆组P300潜伏期较非痴呆组延长,波幅下降(P＜0.05～0.01).结论 P300改变可优于量表,结合临床后可作为AICA患者急性期认知功能评定的预测手段.     

缺血性脑卒中的流行病学研究

据国外研究报道,正常情况下成年女性缺血性脑卒中(ischemic stroke,IS)年发病率为170/10万,男性为212/10万,年平均发病率为0.58%~0.61%;复发率为21.8%~12.9%,其中,伴有房颤的1年脑卒中复发率为10%~20%,发病前和发病后接受过抗血小板治疗的分别为9.0%和6.2%~14.0%。据国内文献统计:缺血性脑卒中发病率为91.3~263.1/10万,年平均发病率为145.5/10万;复发率为8.47%。     

房颤对急性缺血性脑卒中患者尿激酶溶栓疗效的影响

目的 探讨房颤是否对急性缺血性脑卒中患者尿激酶溶栓疗效产生影响及对于合并房颤的急性缺血性脑卒中患者是否给予尿激酶溶栓治疗.方法 本研究为回顾性病例对照研究.从2006年4月到2012年1月连续收集发病6小时内给予尿激酶溶栓的急性缺血性脑卒中患者作为研究对象.根据有无合并房颤将符合入选标准的病例分为两组:房颤组(26例)和无房颤组(60例).采用美国国立卫生研究院卒中量表(NIHSS)、改良的Rankin量表评价治疗效果.结果 房颤组与无房颤组溶栓治疗后7d溶栓有效率比较,差异无统计学意义(57.7％ vs 56.7％,P＞0.05).在尿激酶静脉溶栓治疗后90 d,房颤组57.7％的病人功能恢复好,无房颤组65.0％的病人功能恢复好,两组比较差异无统计学意义(P＞0.05).房颤组颅内出血的发生率、症状性颅内出血的发生率及死亡率均较高,但与无房颤组比较差异均无统计学意义.结论 合并房颤的急性缺血性脑卒中患者与无合并房颤的急性缺血性脑卒中患者均可以从溶栓中获益,房颤对急性缺血性脑卒中患者尿激酶溶栓疗效无显著影响,合并房颤的急性缺血性脑卒中患者应予尿激酶溶栓治疗.     

Chronic kidney disease is independently associated with acute recurrent cerebral infarct in patients with atrial fibrillation

Background and purposeThe present study aimed to determine the frequency and time of recurrent cerebral infarct (RCI) in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF), and to clarify associated factors.MethodsWe retrospectively assessed and compared the clinical features of 79 consecutive patients (male, n = 56; median age, 75 y; median baseline NIHSS, 4) who were hospitalized due to AIS accompanied by AF, and who did or did not develop RCI between January 2012 and March 2015.ResultsDirect oral anticoagulants were administered to 59% of the patients after a median of two days from the onset of the index stroke. Stroke recurred in 10 (13%) of the 79 patients about 5 days after admission. The proportion of men was lower (30% vs. 77%, P = 0.005) and the patients were older (82 vs. 75 y, P = 0.049) in the group with RCI. Chronic kidney disease was significantly more prevalent in the group with RCI (50% vs. 16%, P = 0.025) and independently associated with RCI (OR, 6.59; 95%CI, 1.19–36.63; P = 0.031).ConclusionsWe found that RCI frequently develops about 5 days after admission in patients with AIS and AF and that chronic kidney disease is independently associated with RCI.     

Development and validation of a risk score to predict 30-day mortality in patients with atrial fibrillation-related stroke: GPS-GF score

Objective Stroke due to atrial fibrillation (AF) is common and frequently devastating. However, there is no specific tool to accurately estimate the risk of mortality. This study aims to develop and validate a comprehensive risk score for predicting 30-day mortality in the patients with AF-related stroke.

Methods A retrospective multi-center clinical study was performed based on the data from the project of secondary prevention of stroke in patients with nonvalvular AF in Shaanxi province, China. A total of 1077 consecutive patients were randomly classified into derivation (66.7%, n = 718) and internal validation cohort (33.3%, n = 359). Independent predictors of 30-day mortality were obtained using univariate and multivariable analyses. The area under the receiver operating characteristic curve (AUROC) and the Hosmer–Lemeshow test were used to assess model discrimination and calibration, respectively.

Results Two hundred patients (18.6%) of 1077 participants died within 30 days. An 8-point score was generated from the five independent predictors for 30-day mortality including Glasgow Coma Scale, pneumonia, midline shift on brain images, blood glucose, and female sex, which was named GPS-GF. The resulting score showed good discrimination (AUROC) and well calibrated (Hosmer–Lemeshow test) in the derivation (0.909; p = 0.102) and internal validation cohort (0.922; p = 0.153). Compared with iScore, the GPS-GF score exhibited remarkably better discriminative power and predictive accuracy regarding the 30-day mortality in patients with AF-related stroke.

Conclusion The GPS-GF score is a simple and valid tool for predicting 30-day mortality in patients with AF-related stroke.     

血清Galectin-3水平联合CHA2DS2-VASc评分对非瓣膜性房颤患者发生缺血性脑卒中的预测价值

目的 探讨血清半乳糖凝集素-3(Gal-3)水平联合CHA2DS2-VASc评分对非瓣膜性房颤患者发生缺血性脑卒中的预测价值。方法 选取2017年8月-2018年8月在本院接受治疗的非瓣膜性房颤患者226例,所有患者均进行为期1年的随访,根据随访将发生缺血性脑卒中的患者纳入到脑卒中组(32例),将未发生缺血性脑卒中的患者纳入到无脑卒中组(194例),收集患者的一般资料及常规指标水平,采用酶联免疫吸附试验检测血清Gal-3的水平,记录所有患者的CHA2DS2-VASc评分。结果 脑卒中组的收缩压、左心房内径(LAD)、Gal-3水平、CHA2DS2-VASc评分均高于无脑卒中组(P<0.05); LAD、Gal-3水平、CHA2DS2-VASc评分过高均是非瓣膜性房颤患者发生缺血性脑卒中的独立危险因素(P<0.05); 非瓣膜性房颤患者的血清Gal-3水平与空腹血糖、LAD、CHA2DS2-VASc评分均呈正相关(P<0.05); ROC分析显示,Gal-3水平与CHA2DS2-VASc评分对非瓣膜性房颤患者发生缺血性脑卒中的预测价值均较高,曲线下面积分别为0.708和0.797,而二者联合分析可使得预测价值进一步提升。结论 血清Galectin-3水平联合CHA2DS2-VASc评分对非瓣膜性房颤患者发生缺血性脑卒中的预测价值较高     

STAF score is a new simple approach for diagnosing cardioembolic stroke

Background and purpose: Detecting cardioembolic stroke soon after acute cerebral ischemia has a major impact on secondary stroke prevention. Recently, the Score for the Targeting of Atrial Fibrillation (STAF) was introduced to identify stroke patients at risk of atrial fibrillation. However, whether the STAF score could be a useful approach to differentiate cardioembolic stroke from other stroke subtypes is unclear. Methods: Consecutive patients with acute ischemic stroke that were admitted to our stroke center were enrolled. Each patient was assessed (age, baseline National Institutes of Health Stroke Scale, left atrial dilatation and absence of vascular etiology) to calculate the STAF score. A follow-up visit was conducted for each patient during hospitalization to determine the diagnosed stroke etiology according to the Trial of Org 10172 in Acute Stroke Treatment criteria. Results: The median and interquartile range of the STAF score was significantly higher in the cardioembolic than in the non-cardioembolic group [6 (2) vs. 2 (3), p < 0.001]. The discriminating ability of the STAF score model was good as demonstrated by the receiver operating characteristic curve. The area under the curve (AUC) of STAF score (AUC = 0.98; 95% CI, 0.96–0.99) was significantly greater than B-type natriuretic peptide (AUC = 0.87; 95% CI, 0.83–0.91) (p < 0.05). The optimal STAF cut-off value was ≥ 5, which diagnosed cardioembolic stroke with a sensitivity of 90% and specificity of 95%. Conclusions: The STAF score is a simple and accurate tool that can discriminate the cardioembolic stroke from other types during hospitalization for acute ischemic stroke.     

合并房颤的急性缺血性卒中患者CHADS2评分与预后的关系

目的 探讨CHADS2评分与合并非瓣膜性房颤的急性缺血性卒中患者近期预后的关系.方法 前瞻性纳入发病7d内合并非瓣膜性房颤的卒中患者,行发病前CHADS2评分,分3组(0～1、2、3～6分),随访住院期间并发症和3个月时预后情况[改良Rankin量表评分(mRS)≤2为预后良好,mRS≥5为预后极差],单因素分析筛选影响3个月预后的危险因素后,再采用Logistic逐步回归分析CHADS2评分与3个月预后的关系.结果 共纳入203例患者,其中CHADS2 0～1、2、3～6组各72、53、78例,CHADS2评分高者入院时NIHSS评分较高,均数分别为9.8、12.6、13.0(F =3.404,P =0.035);肺部感染发生率较高,分别为12.5％、34.0％、39.7％( X2=14.643,P=0.001);预后良好率较低;预后极差率较高;多因素Logistic回归分析显示CHADS2评分是预后良好和预后极差的独立预测因子,以CHADS23～6组为参考,CHADS20～1预测良好预后的OR值为5.018(95％ CI为2.055 ～ 12.560);以CHADS2 0～1组为参考,CHADS23～6预测极差预后的OR值为6.197(95％ CI为1.670～22.996).结论 发病前CHADS2评分与合并非瓣膜性房颤的缺血性卒中患者预后相关,评分低者(0～1)预后良好可能性大,评分高者(3～6)预后极差可能性大.     

Anticoagulation-related reduction of first-ever stroke severity in Chinese patients with atrial fibrillation

Atrial fibrillation (AF) is an independent risk factor for ischemic stroke and warfarin related anticoagulation has been recommended as an effective treatment for stroke prevention. We aimed to determine whether pre-stroke oral anticoagulation therapy would reduce initial stroke severity in AF patients with first-ever ischemic stroke. We identified consecutive patients who developed first-ever ischemic stroke and were eligible for anticoagulation therapy from the China National Stroke Registry. Multivariate logistic analysis was used to assess the association between warfarin usage and initial stroke severity, measured by the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). Of 9519 patients, 1140 (11.98%) had AF, including 440 (38.6%) without known AF before presentation, 561 (49.2%) with known AF but not taking warfarin, and 139 (12.2%) with known AF who were taking warfarin. Compared to patients with known AF but not on warfarin, the odds ratio (OR) of having a major stroke (NIHSS ⩾4) was lower in patients with known AF who were on warfarin (OR = 0.68; 95% confidence interval [CI] 0.57–0.84). The OR of developing a severe coma (GCS 3–8) was also reduced in the warfarin group (OR = 0.71; 95% CI 0.56–0.91). In conclusion, pre-stroke warfarin therapy lowered the severity of the first-ever ischemic stroke in patients with known AF. Considering its efficacy in stroke prevention and the significant under-usage of warfarin in China, the primary prevention of stroke in AF patients should be reinforced.     

Early neurological outcomes according to CHADS2 score in stroke patients with non-valvular atrial fibrillation

Background and purpose:  A higher CHADS₂ score or CHA₂DS₂‐VASc score is associated with an increased risk of ischaemic stroke in patients with non‐valvular atrial fibrillation (NVAF). However, there are no data regarding early neurological outcomes after stroke according to the risk levels. Methods: In this study, a total of 649 stroke patients with NVAF were enrolled and categorized into three groups: low‐risk (CHADS₂ score of 0–1), moderate‐risk (CHADS₂ score 2–3), or high‐risk group (CHADS₂ score ≥4). CHA₂DS₂‐VASc score was divided into four groups including 0–1, 2–3, 4–5, and ≥6. We investigated whether there were differences in initial stroke severity, early neurological outcome, and infarct size according to CHADS₂ score or CHA₂DS₂‐VASc score in stroke patients with NVAF. Results: The initial National Institutes of Health Stroke Scale (NIHSS) score was highest in high‐risk group [9.5, interquartile range (IQR) 4–18], followed by moderate‐risk (8, IQR 2–17) and low‐risk group (6, IQR 2–15) (P = 0.012). Likewise, initial stroke severity increased in a positive fashion with increasing the CHA₂DS₂‐VASc score. During hospitalization, those in the high‐risk group or higher CHA₂DS₂‐VASc score had less improvement in their NIHSS score. Furthermore, early neurological deterioration (END) developed more frequently as CHADS₂ score or CHA₂DS₂‐VASc score increased. Multivariate analysis showed being in the high‐risk group was independently associated with END (OR 2.129, 95% CI 1.013–4.477). Conclusions: Our data indicate that patients with NVAF and higher CHADS₂ score or CHA₂DS₂‐VASc score are more likely to develop severe stroke and a worse clinical course is expected in these patients after stroke presentation.