脑梗死急性期血压对近期及远期预后的影响

目的 观察脑梗死急性期血压的动态变化，分析脑梗死急性期血压对不同患者预后的影响。方法 采用回顾性病例研究，连续登记自2008年1～10月入院的，发病24小时内的脑梗死患者121例，按牛津郡社区脑卒中规划（Oxford shire community stroke project，OCSP）进行临床分型，完全前循环梗死（totalanterior circulation infarct，TACI）9例、部分前循环梗死（partial anterior circulation infarct，PACI）59例、后循环梗死（posterior circulation Infarct，POCI）9例及腔隙性脑梗死（lacunar infarct，LACI）44例。按脑血管狭窄程度，无狭窄组27例，轻中度狭窄组50例，重度狭窄或闭塞组44例。记录患者入院后14天内血压及半年内血压平均水平，分别于入院、住院14 d及恢复期（6个月时）对患者进行神经系统功能缺损评分，包括美国国立卫生研究院卒中量表评分（The National Institutes of Health StrokeScale，NIHSS）、Bathel指数（Bathel index，BI）以及改良Rankin评分（modified Rankin Score，mRS），统计分析血压与预后的关系。完成6个月随访109例，失访12例。结果 ①脑梗死急性期，76.9%（93/121）患者出现血压升高，且血压有自动下降的趋势，以前3天下降最明显。②PACI患者59例，55例完成6个月随访，失访4例。前3天收缩压120～150 mm Hg组（n=29）6个月时预后（BI 89.14±15.00，mRS 1.59±1.02）优于收缩压＜120 mm Hg组（n=4）（BI 85.00±14.72，mRS 2.00±0.82，P值分别为0.024和0.032）和收缩压＞150 mm Hg组（n=22）（BI 78.41±20.95，mRS2.27±1.20，P值分别为0.023和0.034）。③伴脑血管重度狭窄或闭塞组44例，37例完成6个月随访，失访7例。前3天平均收缩压≤145 mm Hg组（n=15）预后优于收缩压＞145 mm Hg组（n=22），6个月的BI评分为91.33±7.90分 vs 67.70±31.42分，P =0.002；mRs为1.40±0.99分 vs 2.68±1.29分，P =0.003。结论 脑梗死患者急性期血压水平与预后明显相关，PACI患者远期预后与急性期血压呈U型曲线关系；在脑血管重度狭窄或闭塞的患者中，前3天收缩压平均值低于145 mm Hg的患者，其预后明显优于收缩压＞145 mm Hg者，提示伴脑血管重度狭窄或闭塞的脑梗死患者仍需适当控制血压。

Effect of Blood Pressure during the Acute Period of Ischemic Stroke on Short-term and Long-term Outcome

Objective To investigate the relationship between blood pressure and the short-term outcome as well as long-term outcome of cerebral infarction. Methods One hundred and twenty one inpatients with acute ischemic stroke from January 2008 to October 2008 were enrolled in this retrospective analysis. Blood pressure （BP） was consecutively recorded everyday in the duration of hospital stay, and the mean level BP after discharge was also recorded; Scores of Barthel Index （BI）, modified Rankin Score （mRS） and the National Institutes of Health Stroke Scale （NIHSS） were recorded at admission, discharge as well as 6 months after discharge. The patients were distributed into different groups according to Oxford shire community stroke project （OCSP） classification and their vascular stenosis. The relationship between BP and short-term outcome and long-term outcome were analyzed in each group. Results One hundred and twenty one patients were enrolled and 109 followed-up. In the acute period, blood pressure increased in 76.9% patients, and decreased afterwards. The tendency was most significant at the third day. Among the 59 patients of partial anterior circulation infarct （PACI）, there were 55 patients followed-up. The patients whose average systolic blood pressure （SBP） of the first three days were between 120±150 mm Hg （n=29） had significantly better longterm outcome （BI was 89.14±15.00, mRS was 1.59±1.02 at 6 months） than those whose average SBP were higher than 150 mm Hg （n=22） （BI 78.41±20.95, mRS 2.27±1.20, P=0.023 and P=0.034 respectively）, or lower than 120 mm Hg （n=4） （BI 85.00±14.72, mRS 2.00±0.82, P=0.024 and P=0.032 respectively）. Among the 44 patients with severe arterial stenosis or occlusion, there were 37 patients followed-up. The BI （91.33±7.90） and mRs （1.40a：0.99） at 6 months of the patients whose average SBP of the first 3 days ≤145 mm Hg （n=15）, were better than that of the patients whose average SBP〉145 mm Hg （n=22） （BI 67.70±31.42, mRS 2.68±1.29）, P=0.002 and P=0.003 respectively. Conclusion The outcome of patients with acute cerebral infarction is significantly related to the level of BP; A U-shaped relationship was found between BP and prognosis among the patients of PACI; Among the patients with severe arterial stenosis or occlusion, patients whose SBP average of the first 3 days≤145 mm Hg had good outcome than those whose SBP〉145 mm Hg, suggesting that BP should be controlled properly even in the patients with severe vascular stenosis.