强化降压对急性缺血性卒中静脉溶栓患者早期再灌注及预后的影响  

Effects of intensive blood pressure lowering on the early reperfusion and prognosis after intravenous thrombolysis in patients with acute ischemic stroke

作　　者：张羽乔[1] 周俊山[1] 张颖冬[1] 陈霓红[1] 周峰[1] 杨杰[1] 王蒙[1] 侯健康 

机构地区：[1]南京医科大学附属南京医院神经内科,210006

出　　处：《中华神经科杂志》2017年第5期348-353,共6页Chinese Journal of Neurology

基　　金：江苏省卫生厅面上项目（H201541）

摘　　要：目的 比较强化降压与指南推荐的标准降压对急性缺血性脑卒中静脉重组组织型纤溶酶原激活剂（rtPA）溶栓后早期再灌注及预后的影响.方法 前瞻性收集2012年7月至2016年4月在南京医科大学附属南京医院神经内科接受静脉rtPA溶栓治疗的急性缺血性脑卒中患者118例,收缩压在150-185 mmHg（1 mmHg=0.133 kPa）,均经多模MRI证实存在缺血半暗带.根据计算机生成随机数法将其分为强化降压组和指南标准降压组.强化降压组目标收缩压140-150 mmHg,指南标准降压组目标收缩压〈180 mmHg,两组患者收缩压均需在60 min内达标,并至少维持72 h,溶栓后24 h复查多模MRI.主要终点指标：早期神经功能缺损评分、90 d改良Rankin量表评分及90 d病死率;次要终点指标：缺血脑组织早期再灌注率及梗死灶、低灌注区体积变化,出血转化及症状性颅内出血发生率.结果 共有105例患者得到可分析多模MRI图像,其中强化降压组49例,指南降压组56例.24 h后强化降压组梗死灶体积较溶栓前增加（13.21±9.51） cm3,指南降压组增加（12.95±9.68） cm3,两组梗死灶体积增加值、24 h后低灌注区体积、再灌注率比较差异无统计学意义;强化降压组出血转化率（9.4%,5/53）较指南降压组（23.1%, 15/65）减少,比较差异有统计学意义（χ2=3.860, P=0.049）,但两组症状性颅内出血率差异无统计学意义.两组早期神经功能缺损变化、90 d预后（mRS 0-2分）、90 d病死率差异均无统计学意义.结论 早期强化降压对急性缺血性脑卒中静脉溶栓患者缺血半暗带转化及预后无不利影响,并可一定程度上减少出血转化的发生.Objective To compare the effects of intensive blood pressure （BP） lowering and guideline-recommended standard BP lowering on the early reperfusion and prognosis after intravenous thrombolysis in patients with acute ischemic stroke. Methods This is a randomised controlled trial consisting of 118 consecutive patients who came from Department of Neurology, Nanjing First Hospital from July 2012 to April 2016, accepting intravenous recombinant tissue plasminogen activator thrombolysis with the systolic blood pressure （SBP） being 150-185 mmHg（1 mmHg=0.133 kPa）. The patients with ischemic stroke were diagnosed by multi-mode MRI and confirmed to have ischemic penumbra. The SBP of patients randomly assigned to intensive BP lowering group and guideline BP lowering group was maintained in 140-150 mmHg or below 180 mmHg respectively for 72 h and all patients needed to reexamine multi-mode MRI at 24 h. The primary endpoints were the neurologic function at early stage, modified Rankin Scale （mRS） score and the mortality at 90 d;the secondary endpoints were the volume of infarction and hypoperfusion area, the rate of reperfusion, hemorrhagic transformation （HT） and syptomatic intracerebral hemorrhage （sICH）. Results Forty-nine cases in intensive BP lowering group and 56 cases in guideline BP lowering group acquired the available images. The volume of infarction was increased both in these two groups, and there was no statistically significant difference in the increased values （（13.21±9.51） cm3 vs （12.95±9.68） cm3）. There were no statistically significant differences in the volume of hypoperfusion, reperfusion rate, neurologic function at early stage, the mRS scores and mortality at 90 d, the incidence of sICH except the rate of HT （9.4%, 5/53 vs 23.1%, 15/65, χ2=3.860, P=0.049） between the two groups.Conclusion Early intensive BP-lowering treatment has no adverse effects on the transformation of ischemic penumbra and prognosis after intravenous thrombolysis in patients with acute isch

关 键 词：卒中 血栓溶解疗法 血压 磁共振成像 预后 

分 类 号：R743.3[医药卫生—神经病学与精神病学]