血糖对急性缺血性卒中静脉溶栓治疗后结局的影响

摘要

Objective To investigate the association between glucose parameters and outcome measures in acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT).Methods Two hundred and two eligible cases were enrolled in the cohort study.Blood glucose (BG),fasting BG and glycosylated hemoglobin A1c (HbA1c) determined on admission were taken as continuous variables,therapeutic outcome measures [e.g.,nodified Rankin Scale (mRS) ≤2 at discharge,early neurological improvement (ENI) or deterioration (END),and recanalization status] and safety outcome measures [symptomatic intracranial hemorrhage (SICH) and all intracranial hemorrhage (ICH)] were taken as endpoint indicators.Results Of the recruited cases,the median age was 61 years,25.2％ female,median National Institute of Health Stoke Scale (NIHSS) 9 scores and onset to needle (OTN) time 230 min.The median fasting BGs were much lower in subgroups with favorable outcome (mRS ≤ 2) or recanalization than those in the related reference subgroups,while the comparisons according to ICH and SICH didnt reach significance.Significantly higher admission BG was only found in the comparison according to SICH and the HbAlc levels were similar in all comparisons.Adjusted for age,sex,OTN and baseline NIHSS,admission BG [odds ratio (OR),1.24;95％ confidence interval (CI):1.03-1.50] was the only independent predictor of SICH,while fasting BG was negatively associated with all therapeutic outcome measures,with an OR of 0.72 (0.58-0.90) for mRS ≤ 2 at discharge,an OR of 0.69 (0.55-0.87) for ENI,and an OR of 0.80 (0.66-0.98) for recanalization.Elevated fasting BG was only significantly associated with Non-SICH related END (OR:1.42,95％ CI:1.04-1.95) after adjustment for explanatory variables.Conclusion Acute glucose parameters could be independent predictors of outcomes in AIS after IVT and elevated fasting BG negatively affected the functional outcome probably through the mechanism of an impaired response of IVT.%目的 探讨血糖指标对急性缺血性卒中静脉溶栓治疗后结局的影响.方法 纳入202例接受静脉溶栓治疗的缺血性卒中病例分析.终点事件包括疗效指标(如出院时良好预后定义为改良Rankin评分≤2,早期神经功能改善,早期神经功能恶化和血管再通)和安全性指标(症状性脑出血和全部脑出血).结果 所纳入病例的中位年龄为61岁,其中25.2％为女性,美国国立卫生研究院卒中量表(National Institute of Health Stoke Scale,NIHSS)的中位评分为9分,中位发病至静脉溶栓给药(onset toneedle,OTN)时间为230 min.血糖指标中,良好预后组和有血管再通组的中位空腹血糖显著升高,但在全部脑出血及症状性脑出血的组间比较,差异无统计学意义(P＞0.05);空腹血糖在有症状性脑出血亚组显著升高,在其他组间比较,差异无统计学意义(P＞0.05).糖化血红蛋白在所有组间比较中差异均无统计学意义(P＞0.05).在校正年龄、性别、发病至静脉溶栓给药时间和NIHSS后,入院基线随机血糖是症状性脑出血的唯一独立影响因素,其比值比(odds ratio,OR)为1.24,对应的95％可信区间(confidence interval,CI)为1.03～1.50;而空腹血糖则与出院时预后良好,早期神经功能改善和血管再通均负性相关,对应的OR及95％ CI分别为0.72(0.58 ～0.90),0.69(0.55 ～0.87),和0.80(0.66 ～0.98).校正混淆因素后,高空腹血糖浓度与非症状性脑出血相关的早期神经功能恶化显著相关,对应的OR及95％ CI为1.42(1.04 ～1.95).结论 缺血性卒中急性期的血糖指标可能是静脉溶栓治疗后结局终点事件的独立影响因素,而空腹血糖升高很可能通过降低静脉溶栓的疗效反应而非增加症状性脑出血不良反应对功能预后产生不利影响.