糖化血红蛋白与大动脉粥样硬化性缺血性卒中患者预后的关系研究

目的探讨急性缺血性卒中患者入院时糖化血红蛋白与不良心脑血管预后及神经功能预后的关系。方法入选2010年5月至2011年8月首都医科大学附属北京天坛医院脑血管病中心急性缺血性卒中住院患者373例,所有患者均为TOAST分型大动脉粥样硬化型。记录患者的基线资料,按照入院时患者糖化血红蛋白≥7%或7%进行分组并随访。终点事件包括卒中复发、心脑血管事件和心脑血管死亡、随访一年的神经功能恢复情况[改良Rankin量表(modified Rankin Scale,m RS)]。结果共300例患者资料纳入分析,高糖化血红蛋白组83例,低糖化血红蛋白组217例。随访(18.9±5.0)个月。高糖化血红蛋白组糖尿病发病率、1年的m RS评分、心脑血管事件均显著高于低糖化血红蛋白组(P0.01),Kaplan-Meier生存分析显示高糖化血红蛋白组患者无心脑血管事件的生存明显低于低糖化血红蛋白组(P0.001)。Cox回归发现糖化血红蛋白(HR 1.252,95%CI 1.061~1.477,P=0.008)和既往卒中史(HR 2.630,95%CI 1.365~4.970,P=0.004)是卒中患者心脑血管预后不良的预测因素。Logistic回归分析显示缺血性卒中患者随访一年时神经功能恢复不良的独立危险因素有高龄(OR 1.069,95%CI 1.037~1.101,P0.001)、既往有卒中史(OR 4.087,95%CI 2.051~8.144,P0.001)、高糖化血红蛋白(OR 1.208,95%CI 1.002~1.455,P=0.047)和入院美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分(OR 1.320,95%CI 1.217~1.431,P0.001)。结论入院时糖化血红蛋白升高是大动脉粥样硬化性急性缺血性卒中患者一年不良心脑血管预后和不良功能预后的预测因素。     

Comparison of Mechanical Embolectomy and Intraarterial Thrombolysis in Acute Ischemic Stroke within the MCA: MERCI and Multi MERCI compared to PROACT II

Introduction  Intraarterial thrombolysis and mechanical embolectomy have been studied for endovascular treatment of stroke. The MERCI and Multi MERCI trials of mechanical embolectomy with or without adjuvant intraarterial thrombolysis demonstrated effective recanalization, but with a higher mortality compared with control patients in the PROACT II trial of intraarterial thrombolysis. Differences in trial design may account for this mortality difference. Methods  We identified patients in the MERCI and Multi MERCI trials who would have been eligible for PROACT II. Rates of good outcome (mRS ≤2) and mortality at 90 days were compared, adjusting for differences in baseline NIHSS score and age. Results  Sixty-eight patients enrolled in MERCI and 81 enrolled in Multi MERCI were eligible for PROACT II. In both unadjusted and adjusted analyses, PROACT II-eligible embolectomy patients showed a trend toward better clinical outcomes compared to the PROACT II control arm (adjusted, MERCI 35.4% [p = ns], Multi MERCI 42.8% [p = 0.048], PROACT II control, 25.4%). In both unadjusted and adjusted analyses, mortality rates did not significantly differ between embolectomy patients and PROACT II control patients (adjusted analysis, MERCI 29.1%, Multi MERCI 18.0%, PROACT II control, 27.1%). Compared with the PROACT II treatment group, embolectomy groups showed similar rates of good outcome and mortality. Conclusions  Differences in mortality and proportion of good outcome between the MERCI/Multi MERCI trials and the PROACT II trial are explained by differences in study design and baseline characteristics of patients. Mechanical embolectomy and IA thrombolysis may each be reasonable strategies for acute stroke; a randomized trial is necessary to confirm these results.     

Clinical Outcome of Ischemic Stroke in Old Patients Versus Oldest-Old

Background: It is unclear whether very old patients benefit from stroke unit. The aim of our work was to compare the clinical outcome of patients with ischemic stroke aged either 70 or 80 (G 1) versus oldest-old greater than or equal to 81 years (G 2). Methods: Of 1187 patients admitted with stroke during 5 years in our stroke unit, we included 252 patients with independent functional status (modified Rankin scale, [mRS] ≤ 2) before the stroke. All patients underwent clinical examination, blood test, electrocardiography, brain imaging, and cerebrovascular ultrasound. Clinical outcome was assessed with the mRS and National Institutes of Health Stroke Scale (NIHSS) at discharge. We considered favorable outcome mRS 0-2 at discharge. Results: Of 252 patients included, 55% were male, 150 (59.5%) patients belonged to G1 and 102 (40.5%) G2. We detected a significant increase of atrial fibrillation, bronchoaspiration, mortality, higher NIHSS at admission, and worse functional status at discharge in G2. No significant differences in other demographic, vascular risk factors, hospital stay, NIHSS at discharge or subtype of stroke were found. NIHSS at discharge was the only independent predictor of good functional status (odds ratio 0.4; 95% confidence interval, 0.3-0.6; P < .001). Conclusions: Oldest-old patients showed similar NIHSS at discharge than younger patients despite having higher neurological severity at admission. Our results support the hypothesis that oldest-old patients have good recovery potential, and should not be excluded from the stroke unit. The worse functional status detected at discharge in these patients could be attributed to others factors and not to neurological severity.     

Leukoaraiosis on Magnetic Resonance Imaging Is Related to Long-Term Poor Functional Outcome after Thrombolysis in Acute Ischemic Stroke

Objective

Leukoaraiosis (LA) has been suggested to be related to the poor outcome or the occurrence of symptomatic intracerebral hemorrhage (sICH) after acute ischemic stroke. We retrospectively investigated the influences of LA on long-term outcome and the occurrence of sICH after thrombolysis in acute ischemic stroke (AIS).

Methods

In this study, we recruited 164 patients with AIS and magnetic resonance image (MRI)-detected thrombolysis. The presence and extent of LA were assessed using the Fazekas grading system. The National Institutes of Health Stroke Scale score was used to assess the baseline measure of neurologic severity, and the modified Rankin Scale score assessment was used up to 1 year after thrombolysis.

Results

Of 164 subjects, 56 (34.2%) showed LA on MRI. Compared to the 108 patients without LA, the patients with LA were of much older age (p<0.01), had a higher prevalence of hypertension (p<0.01), and had a much poorer outcome at 90 days (p=0.05) and 1 yr (p=0.01) after thrombolysis. There were no significant differences in sICH between patients with and without LA on MRI. In univariate analysis for the occurrence of poor outcome at 90 days after thrombolysis, the size of ischemic lesion on diffusion weighted images (DWI), [odds ratio (OR), 1.03; 95% confidence interval (95% CI), 1.01-1.04; p<0.01], recanalization (OR, 0.03; 95% CI, 0.01-0.10; p<0.01), sICH (OR, 12.2; 95% CI, 1.54-95.8), neurologic severity (OR, 1.17; 95% CI, 1.09-1.25; p<0.01), blood glucose level (OR, 1.01; 95% CI, 1.00-1.02; p=0.03), and the presence of LA on MRI (OR, 2.01; 95% CI, 1.04-3.01; p=0.04) were statistically significant. In multivariate analysis, neurologic severity (OR, 1.14; 95% CI, 1.04-1.24; p<0.01), recanalization (OR, 0.03; 95% CI, 0.01-0.11; p<0.01), lesion size on DWI (OR, 1.02; 95% CI, 1.01-1.03; p=0.02), serum glucose level (OR, 1.01; 95% CI; 1.01-1.02; p=0.03), and the presence of LA on MRI (OR, 3.2; 95% CI, 1.22-8.48; p<0.01) showed statistically significant differences. These trends persisted up to 1 yr after thrombolysis.

Conclusion

In this study, we demonstrated that the presence of LA on MRI might be related to poor outcome after use of intravenous tissue plasminogen activator in AIS.     

急性缺血性卒中动脉溶栓和取栓治疗的研究进展

发病时间窗内采用静脉溶栓是治疗急性缺血性卒中的首选方法。然而对于大血管闭塞性 脑梗死,静脉溶栓血管再通率偏低,血管内治疗可提高血管再通率。本文主要对动脉溶栓及机械取 栓的研究进展进行综述,旨在指导未来的临床工作。     

卒中后吞咽延迟患者与健康志愿者吞咽任务相关功能磁共振的对比研究

目的 探讨吞咽延迟卒中患者吞咽任务相关的吞咽中枢激活区域的变化,以期寻找吞咽延迟与吞咽中枢异常之间的关系。方法 5例经电视透视检查证实存在吞咽延迟的缺血性卒中患者以及7例健康志愿者接受功能磁共振成像检查。试验者间隔一定时间（从20、25、30 s中随机抽取一个时间）向受试者口中注入1 ml室温纯净水,令受试者进行吞咽。共注入11 ml水。在3.0 T核磁共振仪（西门子）上,利用血氧水平依赖法（BOLD）采集吞咽过程的数据。结果 电视透视检查发现吞咽延迟卒中患者吞咽潜伏期中位数为0.09（0.03～0.15）s。2 例患者有轻度的会厌谷滞留,1 例患者存在咽部感觉减退,其余无明显异常表现。患者的功能磁共振结果显示研究组没有岛叶激活,但有扣带回激活。对照组有岛叶激活但没有扣带回激活。研究组运动区激活区域少于健康志愿者。结论 患者在自主吞咽过程中没有岛叶激活提示自主吞咽脑区功能异常,可能与吞咽延迟有关。运动皮层激活区少于健康志愿者可能与吞咽肌力弱有关。     

卒中单元对急性缺血性卒中患者医疗质量和在院预后的影响

目的 调查中国卒中单元对缺血性卒中患者收治的现况，并探索卒中单元对改善卒中医疗质量绩效
指标及患者在院预后的影响。
方法 本研究数据来自中国多中心缺血性卒中住院患者登记研究。按照是否进入卒中单元，将
研究对象分为卒中单元组与非卒中单元组。比较两组间患者的卒中医疗质量关键绩效指标（key
performance index，KPI）和在院预后（卒中复发、联合血管事件、全因死亡）的差异，并采用多因素回归，
分析与卒中单元相关的KPI及卒中单元与缺血性卒中患者在院预后的相关性。
结果 本研究共纳入了全国1374家医院的269 428例急性缺血性卒中住院患者。其中，63 548例
（23.6%）患者纳入卒中单元组。卒中单元与较高比例的rt-PA静脉溶栓（OR 1.48，95%CI 1.43～1.53）、
早期抗栓治疗（OR 1.13，95%CI 1.10～1.17）、深静脉血栓预防（OR 1.19，95%CI 1.16～1.22）、吞
咽功能筛查（OR 1.36，95%CI 1.32～1.39）、康复评估（OR 1.31，95%CI 1.28～1.34）、出院抗栓治疗
（OR 1.12，95%CI 1.08～1.15）、合并心房颤动患者抗凝治疗（OR 1.13，95%CI 1.08～1.19）、戒烟宣教
（OR 1.22，95%CI 1.20～1.25）独立相关，与较低的在院卒中复发率（HR 0.79，95%CI 0.75～0.82）和
联合血管事件发生率（HR 0.80，95%CI 0.77～0.84）独立相关（均P <0.001）。
结论 进入卒中单元的缺血性卒中患者，卒中医疗质量KPI完成较好，在院卒中复发率及联合血管事
件率较低。     

International benchmarking for acute thrombolytic therapy implementation in Australia and Japan

Although a wide range of strategies have been established to improve intravenous tissue plasminogen activator (IV-tPA) treatment rates, international benchmarking has not been regularly used as a systems improvement tool. We compared acute stroke codes (ASC) between two hospitals in Australia and Japan to study the activation process and potentially improve the implementation of thrombolysis. Consecutive patients who were admitted to each hospital via ASC were prospectively collected. We compared IV-tPA rates, factors contributing to exclusion from IV-tPA, and pre- and in-hospital process of care. IV-tPA treatment rates were significantly higher in the Australian hospital than in the Japanese (41% versus 25% of acute ischaemic stroke patients, p = 0.0016). In both hospitals, reasons for exclusion from IV-tPA treatment were intracerebral haemorrhage, mild symptoms, and stroke mimic. Patients with baseline National Institutes of Health Stroke Scale score ⩽5 were more likely to be excluded from IV-tPA in the Japanese hospital. Of patients treated with IV-tPA, the door-to-needle time (median, 63 versus 54 minutes, p = 0.0355) and imaging-to-needle time (34 versus 27 minutes, p = 0.0220) were longer in the Australian hospital. Through international benchmarking using cohorts captured under ASC, significant differences were noted in rates of IV-tPA treatment and workflow speed. This variation highlights opportunity to improve and areas to focus targeted practice improvement strategies.     

Stroke presenting under 3 hours in patients younger than 18 years of age

We report a 14-year-old girl with a delayed diagnosis of stroke, highlighting one of the most significant obstacles to offering acute thrombolytic therapies in teenagers and children. Feasibility of treatment is further limited by a lack of dosage and safety data in the paediatric population. Improved community awareness and more rapid recognition of stroke may reduce lag time to diagnosis.     

The Mortality and the Risk of Aspiration Pneumonia Related with Dysphagia in Stroke Patients

Background: Dysphagia may result in poor outcomes in stroke patients due to aspiration pneumonia and malnutrition. Goal: The aim of the study was to investigate aspiration pneumonia and the mortality rate in stroke patients with dysphagia in Taiwan. Methods: We selected 1220 stroke patients, divided them into dysphagia and nondysphagia groups, and matched them according to age; covariates and comediations from 2000 to 2005 were identified from the NHIRD 2000 database. The date of the diagnosed stroke for each patient was defined as the index date. All patients were tracked for 5 years following their index visit to evaluate mortality and the risk of aspiration pneumonia. We estimated the adjusted hazard ratio using Cox proportional hazard regression. Results: Within 1 year, the dysphagia group was 4.69 times more likely to develop aspiration pneumonia than the nondysphagia group (adjusted hazard ratio [aHR], 4.69; 95% confidence interval [CI] 2.83-7.77; P < .001). The highest significant risk of aspiration pneumonia was in the cerebral hemorrhage patients within 3 years of the index visit (aHR, 5.04; 95% CI 1.45-17.49; P = .011). The 5-year mortality rate in the dysphagia group was significantly higher than that in the nondysphagia group (aHR, 1.84; 95% CI 1.57-2.16; P < .001). Conclusion: Dysphagia is a critical factor in aspiration pneumonia and mortality in stroke patients. Early detection and intervention of dysphagia in stroke patients may reduce the possibility of aspiration pneumonia.     

机械通气对重型颅脑损伤预后的影响

目的：探讨机械通气对重型颅脑损伤预后的影响。方法：对34例患经吸氧不能改善缺氧且ALI指数＜300，行机械通气治疗3－7d；机械通气前后行GCS评分，LIS评分，ALI指数及氧分压比较，结果：治疗后上述各指标较治疗前均有显改善。本组恢复良好及轻残23例，重残3例，植物生存6例，结论：对吸氧不能改善缺氧的患尽早采用机械通气，有利于意识恢复。     

三种代谢综合征诊断标准在急性卒中患者中应用的比较

目的 比较急性卒中患者中三种代谢综合征（metabolic syndrome,MetS）诊断标准的一致性。方法 连续收集2008年7月～2011年6月期间住院的年龄在40～96岁之间的急性卒中患者505例,分别应用国际糖尿病联盟（International Diabetes Federation,IDF）、美国国家胆固醇教育计划成人治疗方案第三次报告（National Cholesterol Education Program-Adult Treatment Panel Ⅲ,NCEP－ATPⅢ）和中华医学会糖尿病分会（Chinese Diabetes Society,CDS）三个关于代谢综合征的诊断标准分析代谢综合征的患病率,并应用Kappa一致性检验分析三个诊断标准的一致性。结果 505例被调查的卒中患者中代谢综合征的患病率分别为：IDF标准45.1%,NCEP-ATPⅢ标准33.7%,CDS标准44.8%,三个诊断标准的符合率为70.88%,其中IDF标准和CDS标准的符合率,为83.1%,Kappa值为0.660,P<0.01。结论 IDF、NCEP-ATPⅢ、CDS三个标准的诊断一致性较好,IDF标准和CDS标准的诊断一致性最好。     

既往卒中病史对缺血性脑血管病患者卒中结局的影响研究

目的 探讨中国人群中首发和复发缺血性脑血管病患者的临床特征和卒中结局差异。 方法 本研究基于全国多中心前瞻性中国国家卒中登记研究Ⅲ（the third China national stroke regi stry,CNSR-Ⅲ）,连续纳入2015年8月-2018年3月急性缺血性卒中或TIA患者,收集人口学信息、血 管危险因素、既往用药史及病因分型系统（causative classification system,CCS）等临床资料,记录随 访3个月和1年时卒中结局。卒中结局包括卒中复发（缺血性卒中或出血性卒中）、联合血管事件（卒中、 心肌梗死及血管性死亡事件）、脑血管病源性死亡及不良功能结局（mRS＞2分）。依据患者既往是否 有卒中病史分为有卒中病史组和无卒中病史组,比较两组的临床特征及卒中结局差异,并分析卒中病 史与卒中结局间的关系。 结果 最终纳入15 166例患者,平均年龄62.2±11.3岁,其中女性4802例（31.7%）;有卒中病史患者 3355例,无卒中病史患者11 811例。有卒中病史组患者年龄,冠心病、高血压、脂代谢紊乱、糖尿病、心 房颤动比例,既往用药史比例、入院NIHSS评分、住院期间降糖和降压治疗比例均高于无卒中病史组, 目前吸烟和重度饮酒比例、入院时LDL-C水平及住院期间抗血小板治疗比例低于无卒中病史组,差 异均有统计学意义。两组CCS分型的分布差异有统计学意义,其中有卒中病史组大动脉粥样硬化型和 心源性栓塞型卒中比例高于无卒中病史组。多因素分析结果显示,卒中病史是随访3个月不良功能结 局（校正OR 1.25,95%CI 1.09～1.44,P =0.002）,随访1年卒中复发（校正HR 1.44,95%CI 1.25～1.67, P＜0.001）、联合血管事件（校正HR 1.43,95%CI 1.24～1.64,P＜0.001）、脑血管病源性死亡（校正 HR 1.42,95%CI 1.12～1.80,P =0.004）、不良功能结局（校正OR 1.63,95%CI 1.42～1.88,P＜0.001）的 危险因素。 结论 有无卒中病史的缺血性卒中患者的临床特征及随访结局差异较大,尽管患者进行卒中二级 预防治疗,卒中病史仍然是患者1年卒中复发、联合血管事件、脑血管病源性死亡及不良功能结局的 危险因素。     

血浆甘油三酯水平与缺血性卒中出院结局关系研究

目的   探讨急性缺血性卒中患者入院时血浆甘油三酯（triglyceride,TG）水平与出院结局不良的关系。 方法  采用回顾性队列研究的方法,连续纳入内蒙古兴安盟人民医院2009年6月1日～2012年5月31日急性缺血性卒中患者,共计3351例。结局不良组定义为患者出院时改良Rankin量表（modified Rankin Scale,mRS）评分≥3分,对结局不良组和结局良好组患者间基线资料进行比较。用四分位数法将患者入院时血浆TG水平分为4组,用非条件Logistic回归分析入院时TG水平与急性缺血性卒中出院结局不良的关系,计算比值比（odds ratio,OR）及95%可信区间（confidence interval,CI）。 结果  研究对象中发生结局不良的共341例,发生率为10.2%。单因素非条件Logistic回归分析结果显示,TG相对最高分位数组（TG＞2.12?mmol/L）,第1、2、3分位数组（TG分别为≤1.06?mmol/L、1.06～1.46?mmol/L、1.46～2.12?mmol/L）的结局不良发生率差异有显著性（P＜0.001）。在调整了年龄、住院天数、发病到入院时间、缺血性卒中首发、吸烟、饮酒、心脏病史、心房颤动史、高血压、高血糖和心率后,相对于最高分位数组,第3分位数组的结局不良发生率差异无显著性（P=0.0758）,而第1、2分位数组结局不良发生率升高（均P＜0.0001）,其OR（95%CI）分别为11.883（1.307～2.714）和2.063（1.436～2.963）。 结论  急性缺血性卒中患者入院时低水平TG可能独立地增加出院结局不良的风险。     

北京和加拿大安大略省卒中/短暂性脑缺血发作基线和住院治疗的比较

目的 旨在比较中国北京和加拿大安大略省卒中/短暂性脑缺血发作（transient ischemic attack,TIA）
住院患者的基线特征、卒中治疗和住院结局的差异。
方法 中国国家卒中登记于2007年9月～2008年8月在北京地区的11个研究中心连续收集了1775例急
性卒中及TIA患者。加拿大安大略省的数据来源于2007年4月～2008年3月安大略省的11个卒中中心的
3551例卒中及TIA患者。本研究对北京地区患者的基线特征、卒中治疗和住院结局的数据进行了分析,
并与加拿大卒中登记研究中安大略省的数据进行比较。
结果 ①基线信息：北京地区的患者较安大略省的患者年轻（64.5±12.9 vs 70.2±15.3,P＜0.001）,
并且男性较多（64.8% vs 51.6%,P＜0.001）;既往史有吸烟、饮酒、卒中、高血压的比例北京地区均
高于安大略省（P均＜0.001）,而既往史有TIA、高脂血症、心房颤动的人数安大略省高于北京地区（P
均＜0.001）。②院前信息：与安大略省的患者相比,北京地区的患者使用救护车到达急诊的比率较低
（33.5% vs 78.4%,P＜0.001）,并且2.5 h内到达急诊的比例较低（21.0% vs 42.4%,P＜0.001）。③
治疗情况：北京地区的患者中,进行影像学检查的比例低于安大略省（93.9% vs 99.2%,P＜0.001）,
并且进入卒中单元治疗的比例较低（23% vs 64.7%,P＜0.001）。在缺血性卒中的患者中,北京地区
的患者进行溶栓治疗的比例较低（8.1% vs 17.4%,P＜0.001）,然而伴有心房颤动的患者中,给与抗
凝治疗的比例两者无明显的差异（75.9% vs 75.5%,P =0.945）。北京地区和安大略省地区缺血性卒
中患者出院给予抗栓治疗的比例相近（77.0% vs 77.9%,P =0.544）。④结局事件：与安大略省地区
相比,北京地区患者住院期间新发卒中的比例较低（3.4% vs 5.1%,P＜0.001）,然而住院期间肺炎
的发生率较高（12.5% vs 7.6%,P＜0.001）。北京地区患者的住院死亡率、7 d死亡率和30 d死亡率均
显著低于安大略省地区（7.7% vs 14.7%,5.7% vs 9.3%,7.9% vs 15.9%,P均＜0.001）。
结论 北京和安大略地区的卒中/TIA住院患者在基线信息、住院治疗和结局方面有较大的差异。认
识到这些差异将有助于提高中国卒中住院治疗的质量,有助于更好地制订卒中的控制和预防策略。