磁共振成像指导急性缺血性脑卒中静脉溶栓治疗效果的真实世界研究  

A Real-world Study of MRI-guided Intravenous Thrombolytic Therapy in Acute Ischemic Stroke

作　　者：谈毅 祝丽红 尹增维 侯舒喃 俞厚明 TAN Yi;ZHU Lihong;YIN Zengwei;HOU Shunan;YU Houming(Department of Neurology,the First People's Hospital of Lin'an District,Hangzhou 311300,China)

机构地区：[1]浙江省杭州市临安区第一人民医院神经内二科,311300

出　　处：《中国全科医学》2025年第20期2508-2515,共8页Chinese General Practice

基　　金：杭州市卫生科技计划(B20230334)。

摘　　要：背景缺血性脑卒中有较高致残率和致死率,部分患者发病时间难以确认,对这部分患者的治疗较为重要。目的探索基层医院在缺少CT灌注情况下,对于发病时间不明的急性缺血性脑卒中患者利用磁共振成像(MRI)的弥散加权成像(DWI)-液体衰减反转恢复(FLAIR)不匹配指导静脉溶栓的有效性和安全性。方法回顾性选取2020年3月—2024年2月在杭州市临安区第一人民医院治疗的460例急性缺血性脑卒中患者为研究对象。排除大血管闭塞性病变,选择最后看起来正常时间>4.5 h以及发现症状到启动治疗<4.5 h的不明发病时间急性缺血性脑卒中患者,经MRI评估存在DWI/FLAIR不匹配,接受静脉溶栓治疗者纳入溶栓组;在明确时间窗为4.5 h内或不明发病时间急性缺血性脑卒中患者存在DWI/FLAIR不匹配可以静脉溶栓治疗而拒绝静脉溶栓治疗者纳入对照组。收集临床结局指标,包括早期神经功能、24 h美国国立卫生研究院卒中量表(NIHSS)评分、出血性转化、症状性颅内出血(sICH)及90 d改良Rankin量表(mRS)评分、90 d死亡情况,并记录阿替普酶过敏反应、转入重症监护病房(ICU)情况。比较两组治疗的有效性和安全性。采用单变量分析及多因素Logistic回归模型分析早期神经功能改善的影响因素。结果研究最终纳入溶栓组83例,其中男性51例(61.4%),平均年龄(70.1±12.4)岁;对照组55例,其中男性32例(58.2%),平均年龄(70.6±13.4)岁。溶栓组患者基线NIHSS评分高于对照组,症状识别-就诊时间长于对照组(P<0.05)。溶栓组患者早期神经功能改善率[50.6%(42/83)]高于对照组[23.6%(13/55)](P<0.05);两组患者24 h NIHSS评分、出血性转化发生率、SICH发生率比较,差异无统计学意义(P>0.05)。男性和女性在早期神经功能改善方面比较,差异无统计学意义[溶栓组:男性26例(61.9%)、女性16例(38.1%),χ^(2)=0.008,P>0.05,对照组:男性6例(46.2%)、女性7例(53.8%),χ^(2Background Ischemic stroke has a high rate of disability and mortality,and for some patients,the onset time is difficult to confirm,making treatment for these patients particularly important.Objective To explore the efficacy and safety of intravenous thrombolysis in patients with acute ischemic stroke of unknown onset time,guided by the mismatch between diffusion-weighted imaging(DWI)and fluid-attenuated inversion recovery(FLAIR)on MRI,in primary hospitals lacking CT perfusion.Methods A retrospective analysis was performed on 460 patients with acute ischemic stroke treated in the First People's Hospital of Lin'an District,Hangzhou,from March 2020 to February 2024.Patients with acute ischemic stroke and unknown onset time,excluding large vessel occlusion,were selected if their last known normal time was>4.5 hours and the time from symptom onset to treatment initiation was<4.5 hours.Those with DWI/FLAIR mismatch on MRI who received intravenous thrombolysis were included in the thrombolysis group.The control group consisted of acute ischemic stroke patients,within a clear time window of 4.5 hours or with an unknown onset time had DWI/FLAIR mismatch present and were eligible for intravenous thrombolysis,but refused the treatment.Clinical outcome measures were collected,including early neurological improvement,NIHSS score at 24 hours,hemorrhagic transformation,symptomatic intracranial hemorrhage(sICH),90-day Modified Rankin Scale(mRS)score,90-day mortality,and recorded occurrences of alteplase allergic reactions and ICU admissions.The efficacy and safety of treatment between the two groups were compared.Univariate analysis and multivariable binary Logistic regression models were used to analyze the influencing factors of early neurological improvement.Results A total of 83 patients were included in the thrombolysis group,51(61.4%)were male,with a mean age of(70.1±12.4)years.The control group had 55 patients,with 32(58.2%)male and a mean age of(70.6±13.4)years.The thrombolysis group had a higher baseline NIHSS score

关 键 词：卒中 醒后卒中 不明发病时间卒中 静脉溶栓 院前通知 磁共振成像 观察性研究 

分 类 号：R743[医药卫生—神经病学与精神病学]