脑梗死静脉溶栓治疗后出血性转化临床分析

摘要

目的 探讨急性脑梗死患者溶栓治疗后出血性转化(hemorrhagic transformation,HT)的危险因素以及继发HT患者的溶栓后并发症.方法 回顾性分析62例经静脉溶栓治疗的急性脑梗死患者的临床资料,结合文献选择溶栓后继发HT的危险因素,包括年龄、性别、高血压、糖尿病、心功能不全史、脑卒中史、有无早期CT缺血改变、是否大面积脑梗死、是否心源性脑栓塞、发病至溶栓时间、溶栓药物、溶栓前NIHSS评分、溶栓前血糖水平、溶栓后3d内最低纤维蛋白原水平、血小板计数、肌酐水平等进行分析,对单因素分析法发现有统计学差异的危险因素进一步行Logistic回归分析.结果 单因素分析发现,与无HT组相比,继发HT组年龄较大(P＜0.01),溶栓前血糖水平(P＜0.05)、溶栓后6h和12h的收缩压和舒张压较高(均P＜0.05),大面积脑梗死发病至溶栓时间＞3h、有早期CT缺血改变的患者比例高(均P＜0.05).Logistic多因素回归分析发现高龄(OR:1.129,P＜0.05)、溶栓时间＞3 h(OR:2.592,P＜0.05)、早期CT有缺血改变(OR:1.728,P＜0,05)是继发HT的危险因素.继发HT组出现颅外出血并发症(52.2％ vs 20.5％,x2=6.637,P＜0.05)、重度脑水肿(30.4％vs 5.1％,x2 =5.557.P＜0.05)和脑疝形成(26.1％ vs 2.6％,P＜0.05)的比例更高.结论急性脑梗死患者静脉溶栓后HT的发生率高,高龄、发病至溶栓时间＞3 h和早期CT缺血改变是HT的危险因素.%Objective To investigate the risk factors and complications of hemorrhagie transformation (HT) following thrombolytic treatment in acute cerebral infarction patients. Methods The clinical date of 62 cases treated with intravenous thrombolysis was summarized retrospectively, including medical histories, clinical presentations, laboratory examinations, treatment, outcome and complications. Risk factors related to HT following thrombolysis were analyzed, including age, gender, hypertension, diabetes, history of cardiac insufficiency, history of stroke, early ischemic changes on brain CT, large lesion, cardioembolism, time to treatment, thrombolytic drug, N1HSS scores, pre-therapeutic glycaemia, the lowest level of fibrinogen within 3 days after thrombolysis, platelets and ereatinine level. The factors that showed significant difference by univariaie analysis between the HT group and the non HT group were further assessed by Logistic regression analysis. Results The results of univariate analysis indicated that the following factors might be risks for HT, including advanced age [ (67. 8±8. 0) years old in HTLgroup vs (60. 3±11.1) years old in non HT group. 1=2. 841, P <0. 01], hyperglycaernia before thrombolysis [ (7.8±1.9) mmol/L to (6. 6±2. 0) mmol/L, t = 2.295, P< 0. 05], increased blood pressure at 6 h [systolic pressure: (158. 7±Z8. 7) mmHg to (143. 3±26. 1) mmHg. t= -2.168. P<0.05; diastolic pressure: (91.3 + 15.7) mmHg vs (83.1± 14.2) mmHg, t = 2.103. P<0.05) and 12 h [systolic pressure; (154.6 + 22.1) mmHg vs (142. 4±22. 4) mmHg, t=2.089, P<0.05; diastolic pressure: (91.4±11.7) mmHg vs (84. 9+12. 7) mmHg, r=-2.004, P = 0. 05] after thrombolysis, early ischemic changes on brain CT scan (56.5% vs 15.4%, X2= 5. 964, P<0. 05), time (>3 h) to treatment (91.3% vs59.0%, X2=7. 340, P<0. 05) and large area infarction (56.5% vs28.2%, X2 = 4. 890, P<0. 05).rnLogistic regression analysis revealed that advanced age. time (>3 h) to treatment and early ischemic changes on brain CT scan were associated with the presence of HT, and their odd ratios (OR) were 1.129 (95%CI: 1. 040 to 1.227. P<0.05). 2.592 (95%CI: 1.977 to 90. 302. P<0. 05) and 1. 728 (95%CI: 1.295 to 24. 481, P< 0.05) respectively. Moreover, the incidence of extracranial hemorrhage (52.2% to 20.5%, X2 = 6. 637, P< 0.05), serious brain edema (30.4% vs5.1%,X2=5. 567, P <0. 05) and brain hernia (26.1% vs 2. 6%, P< 0. 05) were higher in the HT group compared with those in the non HT group. Conclusions The incidence of HT following thxombolysis is high. Advanced age. increased time to treatment and early CT changes were all risk factors.