本文選題：再通 + 出血轉(zhuǎn)化�。� 參考：《浙江大學(xué)》2014年博士論文

【摘要】：研究背景 腦血管病是威脅人類生命最常見的神經(jīng)系統(tǒng)疾病,根據(jù)最新的流行病學(xué)調(diào)查結(jié)果,卒中已攀升為我國成人中第一位致殘和死亡原因,且發(fā)病有逐年增多的趨勢。隨著動脈內(nèi)機械取栓技術(shù)的發(fā)展,分析急性缺血性卒中顱內(nèi)動脈新鮮血栓的組織病理學(xué)變成可能。在一項大腦中動脈取栓的組織病理學(xué)研究發(fā)現(xiàn),所有的血栓都包含纖維蛋白、血小板、有核細(xì)胞(中性粒細(xì)胞／單核細(xì)胞)以及紅細(xì)胞等成分,但不同血栓內(nèi)各種成分比例不同。在股動脈血栓形成模型中,富含血小板的白色血栓對靜脈rt-PA溶栓顯示出一定的阻抗,而富含紅細(xì)胞的紅色血栓則表現(xiàn)出更快速的藥物反應(yīng)。血栓的特性決定了血管再通治療的療效。 大腦中動脈(middle cerebral artery, MCA)是臨床上最為常見的顱內(nèi)大血管閉塞部位。梯度回波序列(gradient-recalled echo, GRE)提供了一個特異性和敏感性高的顯示血栓的方法。GRE序列對脫氧血紅蛋白非常敏感,大腦中動脈的磁敏感血栓征,可能提示血栓成分中含有較多的紅細(xì)胞。此外,最近的一項影像學(xué)及病理學(xué)關(guān)聯(lián)性研究表明,GRE上的磁敏感血栓征與CT上的大腦中動脈高密度征都提示血栓成分中包含了更多的紅細(xì)胞。所以磁敏感血栓征可能存在預(yù)測血管再通及臨床預(yù)后的潛在價值。 在動脈纖溶治療或者靜脈重組組織型纖溶酶原激活劑(rt-PA)治療中,責(zé)任血管內(nèi)血栓的體積或長度是血管是否再通和預(yù)后的重要影響因素。一項最新的機械取栓研究表明,不規(guī)則形狀的血栓提示影響了大腦中動脈主干的Merci取栓后再通成功率。靜脈rt-PA溶栓治療與動脈取栓不同rt-PA需將纖溶酶原激活成纖溶酶,通過滲透進(jìn)入目標(biāo)血栓,溶解纖維蛋白絲起到溶解血栓的作用。目前大腦中動脈磁敏感血栓征與急性缺血性卒中靜脈rt-PA治療后血管再通缺乏相關(guān)研究。 研究目的 觀察影響大腦中動脈磁敏感血栓征出現(xiàn)的因素,明確大腦中動脈磁敏感血栓征對于急性缺血性卒中患者靜脈重組組織型纖溶酶原激活劑(rt-PA)溶栓后大腦中動脈的再通、出血轉(zhuǎn)化以及3個月后神經(jīng)功能結(jié)局的影響。 研究方法 連續(xù)收集就診于我科并接受靜脈rt-PA溶栓治療的急性缺血性卒中患者,入組行溶栓前后磁共振檢查的大腦中動脈閉塞患者,分析其臨床資料,在磁敏感序列上評價血栓征體積、長度及形態(tài),利用動脈閉塞病灶(Arterial Occlusive Lesion,AOL)量表評估治療后血管再通情況,出血轉(zhuǎn)化根據(jù)歐洲協(xié)作性急性卒中研究Ⅱ(ECASS II)標(biāo)準(zhǔn)評定,改良Rankin評分≥3分定義為不良神經(jīng)功能結(jié)局。 研究結(jié)果 72例患者符合入組條件,平均年齡為(66.14±13.19)歲,女性22例(30.6%),發(fā)病至溶栓時間為(229.10±67.77)分,溶栓前NIHSS為(12.90±5.92)分。共27例(37.5%)影像學(xué)表現(xiàn)為溶栓后出血轉(zhuǎn)化,18例(25.0%)為出血性梗死(HI)型,9例(12.5%)為腦實質(zhì)出血(PH)型,其中3例(4.2%)為癥狀性腦出血(sICH).其中50例(69.4%)患者存在磁敏感血栓征,33例(45.8%)復(fù)查磁共振血管檢查提示再通。經(jīng)二元Logistic回歸分析提示,合并糖尿病(OR=0.157,95%CI0.031～0.784,P=0.024)與低國際標(biāo)準(zhǔn)化比值(INR)(OR=0.215per0.1,95%CI0.080～0.577,P=0.002)是磁敏感血栓征存在的獨立影響因素,使用基線血糖水平替代糖尿病病史進(jìn)入模型,仍有統(tǒng)計學(xué)差異(OR=0.741,95%CI0.562-0.977,P=0.033)。相對于初次診斷的房顫來說,慢性房顫有更容易出現(xiàn)磁敏感血栓征的趨勢(OR=4.424,95%CI0.913-21.439,P=0.065).單純磁敏感血栓征的存在與否無法預(yù)測溶栓后無再通(OR=2.333,95%CI0.760-7.161,P=0.139),出血轉(zhuǎn)化(OR=0.635,95%CI0.189.2.136,P=0463)以及3月不良神經(jīng)功能結(jié)局(OR=2.003,95%CI0.507-7.915,P=0.322)。 在50例存在磁敏感血栓征的患者中,平均長度為14.744±7.971mm(范圍為3.98-38.31mm),平均體積為0.377±0.255ml(范圍為0.02-1.22m1)。M1閉塞的患者中存在更多的不規(guī)則磁敏感血栓征。不規(guī)則磁敏感血栓征的長度要大于規(guī)則的血栓征(18.134±8.787mm VS11.072±4.936mm, P=0.001),并且體積也更大(0.490±0.270ml VS0.256±0.172ml,P=0.001).而且存在規(guī)則磁敏感血栓的患者,其溶栓后24小時大腦中動脈再通的比例更高(62.5%VS23.1%,P=0.009)。不規(guī)則形狀的磁敏感血栓征能獨立預(yù)測溶栓后24小時大腦中動脈無再通(OR=6.153,95%CI1.515-24.993,P=0.011),優(yōu)于血栓征長度(OR=1.095,95%CI0.970-1.236,P=0.142),但不能預(yù)測溶栓后出血轉(zhuǎn)化(OR=0.762,95%CI0.177～3.280,P=0.715)與3月不良神經(jīng)功能結(jié)局(OR=1.570,95%CI0.377～6.529,P=0.535). 研究結(jié)論 血糖與INR水平影響了急性缺血性卒中患者大腦中動脈磁敏感血栓征的形成。單純磁敏感血栓征無法預(yù)測溶栓后大腦中動脈再通情況、溶栓后出血轉(zhuǎn)化及3月神經(jīng)功能結(jié)局。不規(guī)則形狀的磁敏感血栓征能獨立預(yù)測溶栓后24小時大腦中動脈再通情況,但不能預(yù)測溶栓后出血轉(zhuǎn)化及3月神經(jīng)功能結(jié)局。
[Abstract]:Background of the study

Cerebral vascular disease is one of the most common neurological diseases threatening the life of human life . According to the latest epidemiological investigation , the cause of death and death of cerebral artery in the adult of our country has been rising . With the development of internal mechanical thrombectomy , it is found that all the thrombus contains fibrin , platelets , nucleated cells ( neutrophils / monocytes ) and red blood cells , but the proportion of various components in different thrombosis is different . In the model of femoral artery thrombosis , the white thrombus rich in platelets shows a certain impedance to the intravenous rt - PA thrombolytic therapy , while red blood cells rich in red blood cells show a more rapid drug reaction .

The middle cerebral artery ( MCA ) is one of the most common intracranial vascular occlusion sites in the clinic . gradient echo sequence ( GRE ) provides a specific and sensitive method for displaying thrombus . GRE sequences are very sensitive to deoxyhemoglobin , and the magnetic susceptibility of the middle cerebral artery may indicate that there are more red blood cells in the thrombus .

In the treatment of thrombolytic therapy or intravenous recombinant tissue type plasminogen activator ( rt - PA ) , the volume or length of thrombus in a responsible vessel is an important factor influencing the re - opening and prognosis of blood vessels .

Purpose of study

To investigate the factors affecting the occurrence of magnetic susceptibility in the middle cerebral artery , and to clarify the effect of magnetic susceptibility of middle cerebral artery on the re - opening , bleeding and neurological outcome of the middle cerebral artery after thrombolytic therapy in patients with acute ischemic stroke .

Research Methods

The clinical data of patients with acute ischemic stroke treated with intravenous rt - PA thrombolytic therapy were collected , and the clinical data were analyzed . The volume , length and morphology of thrombus were assessed on the magnetic sensitive sequences .

Results of the study

Of the 72 patients , the mean age was ( 66.14 鹵 13.19 ) years old , and 22 cases ( 36.6 % ) of female were divided into two groups ( OR = 0.157 , 95 % CI 0.031 锝，

本文編號：2059703