重组组织型纤溶酶原激活剂治疗心源性脑栓塞的疗效与安全性分析

目的 探讨重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator，rt-PA）治疗心源性脑栓塞的有效性与安全性。 方法 采用回顾性分析方法，非连续性选取北京积水潭医院2007年1月～2011年12月间发病4.5～12 h内的（前循环梗死发病4.5 h内，后循环12 h内）心源性脑栓塞患者45例，其中接受rt-PA溶栓治疗的22例患者为溶栓组，接受常规二级预防的23例作为对照组。收集患者牛津郡社区卒中项目（Oxfordshire Community Stroke Project，OCSP）分型、危险因素、既往史、用药史和神经功能缺损情况。比较两组患者基线（治疗前）、24 h、90 d神经系统功能缺损情况、预后良好的比例及两组间梗死后出血转化（hemorrhagic transformation，HT）的发生率以及90 d患者死亡率。 结果 两组患者基线美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）评分及OCSP分型差异均无显著性。发病24 h后，溶栓组NIHSS改善分值［4.5（－1.5，8）］较对照组［0（0，3）］差异具有显著性（P=0.04）。溶栓组早期改善百分比（54.55%）高于对照组（34.78%），但差异无显著性。发病90 d，溶栓组NIHSS改善分值［9（7，11）］较对照组［3.5（2，4.75）］差异具有显著性（P＜0.01）。溶栓组预后良好百分比（22.7%～36.4%）较对照组（17.4%～26.1%）升高，但差异无显著性。溶栓组和对照组HT患者均为4例，其中症状性出血转化（symptomatic intracranial hemorrhage，sICH）每组各3例，溶栓组4例HT患者均无糖尿病病史，对照组4例患者均有糖尿病病史，6例sICH患者收缩压均大于140 mmHg。发病90 d，两组患者死亡例数均为3例，6例死亡患者入院时NIHSS分值普遍偏高，且梗死类型以完全前循环梗死（total anterior circulation infarct，TACI）为主。 结论 rt-PA用于治疗心源性脑栓塞能够改善发病24 h、90 d的神经功能缺损程度，使用rt-PA相对安全。

Effectiveness and Safety of Thrombolytic Therapy for Cardiogenic Cerebral Embolism by Intravenous Recombinant Tissue Plasminogen Activator

Objective To investigate the effectiveness and safety of thrombolytic therapy for cardiogenic cerebral embolism by intravenous recombinant tissue plasminogen activator(rt-PA).
Methods Retrospective analysis was used in this study. Forty five patients who was hospitalized between January 2007 and December 2011 in Beijing Jishuitan Hospital and suffered from cardiogenic cerebral embolism were selected. Twenty two patients were treated with rt-PA within 4.5~12 hours from the onset(4.5 hours for anterior circulation infarct and 12 hours for posterior circulation infarct) as thrombolytic group and 23 patients who accepted regular secondary prevention of acute ischemic stroke were selected as controls. The Oxfordshire Community Stroke Project(OCSP) classification, risk factors, past history and drug history and neurological deficits were collected. The neurological deficits, and the incidence of favorable outcome on the base line, 24th hour and 90th day were compared. The incidence of hemorrhagic transformation(HT) and mortality within 90 days were analyzed.
Results There was no significant difference in the National Institutes of Health Stroke Scale(NIHSS) score and OCSP classification in the onset between both groups. On the time of 24 hours after the onset, the NIHSS score improved significantly in the thrombolytic group(4.5-1.5, 8]) compared with the control group(00, 3])(P=0.04). The incidence of early improvement in the thrombolytic group(54.55%) increased compared with the control group(34.78%). But there was no significant difference in it between both groups. On the 90 days after onset, the NIHSS score improved significantly in the thrombolytic group(97,11]) compared with the control group(3.52, 4.75])(P<0.01). The incidence of favorable outcome in the thrombolytic group(22.7%~36.4%) increased compared with the control group(17.4%~26.1%). But there was no significant difference in it between both groups. There were 4 HT cases and 3 symptomatic intracranial hemorrhage(sICH) cases in each group. In the control group, all the 4 HT cases had diabetes history and the 4 cases in the thrombolytic group did not. The systolic blood pressure in the 6 sICH cases were over 140 mmHg. There were 3 death cases in each group within 90 days from the onset. All of the 6 cases had high score of NIHSS. The OCSP classification of most of the deaths was total anterior circulation infarct(TACI).
Conclusion Giving rt-PA to the patients who suffered from cardiogenic cerebral embolism could improve the neurological deficits on the time of 24 hours and 90 days after the onset. Intravenous thrombolysis with rt-PA is relatively safe.