發(fā)布時(shí)間：2018-06-24 03:01

  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(jiàn)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(guó)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(shì)。隨著動(dòng)脈內(nèi)機(jī)械取栓技術(shù)的發(fā)展,分析急性缺血性卒中顱內(nèi)動(dòng)脈新鮮血栓的組織病理學(xué)變成可能。在一項(xiàng)大腦中動(dòng)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(dòng)脈血栓形成模型中,富含血小板的白色血栓對(duì)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(dòng)脈(middle cerebral artery, MCA)是臨床上最為常見(jiàn)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(gè)特異性和敏感性高的顯示血栓的方法。GRE序列對(duì)脫氧血紅蛋白非常敏感,大腦中動(dòng)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(xiàng)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(dòng)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(cè)血管再通及臨床預(yù)后的潛在價(jià)值。 在動(dòng)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(zhǎng)度是血管是否再通和預(yù)后的重要影響因素。一項(xiàng)最新的機(jī)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(dòng)脈主干的Merci取栓后再通成功率。靜脈rt-PA溶栓治療與動(dòng)脈取栓不同rt-PA需將纖溶酶原激活成纖溶酶,通過(guò)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(dòng)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(dòng)脈磁敏感血栓征出現(xiàn)的因素,明確大腦中動(dòng)脈磁敏感血栓征對(duì)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(dòng)脈的再通、出血轉(zhuǎn)化以及3個(gè)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(dòng)脈閉塞患者,分析其臨床資料,在磁敏感序列上評(píng)價(jià)血栓征體積、長(zhǎng)度及形態(tài),利用動(dòng)脈閉塞病灶(Arterial Occlusive Lesion,AOL)量表評(píng)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(píng)定,改良Rankin評(píng)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(shí)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(shí)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(guó)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(dú)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(jì)學(xué)差異(OR=0.741,95%CI0.562-0.977,P=0.033)。相對(duì)于初次診斷的房顫來(lái)說(shuō),慢性房顫有更容易出現(xiàn)磁敏感血栓征的趨勢(shì)(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(wú)法預(yù)測(cè)溶栓后無(wú)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(zhǎng)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(zhǎng)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(shí)大腦中動(dòng)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(dú)立預(yù)測(cè)溶栓后24小時(shí)大腦中動(dòng)脈無(wú)再通(OR=6.153,95%CI1.515-24.993,P=0.011),優(yōu)于血栓征長(zhǎng)度(OR=1.095,95%CI0.970-1.236,P=0.142),但不能預(yù)測(cè)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(dòng)脈磁敏感血栓征的形成。單純磁敏感血栓征無(wú)法預(yù)測(cè)溶栓后大腦中動(dòng)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(dú)立預(yù)測(cè)溶栓后24小時(shí)大腦中動(dòng)脈再通情況,但不能預(yù)測(cè)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(hào)：2059703