Please wait a minute...
浙江大学学报（医学版）
浙江大学学报（医学版）  2017, Vol. 46 Issue (4): 384-389    DOI: 10.3785/j.issn.1008-9292.2017.08.07
缺血性卒中专题     
静脉溶栓获益的最大梗死体积阈值与急性缺血性卒中患者发病时间的关系
张美霞, 周颖, 张睿婷, 张圣, 楼敏
浙江大学医学院附属第二医院神经内科, 浙江 杭州 310009
Maximal infarct volume to benefit from intravenous thrombolysis and its relation with onset to treatment time
ZHANG Meixia, ZHOU Ying, ZHANG Ruiting, ZHANG Sheng, LOU Min
Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
 全文: PDF(1015 KB)   HTML ( ) 
摘要：

目的：探究静脉溶栓治疗获益的最大梗死体积阈值及其与急性缺血性卒中患者发病时间的关系。方法：回顾性分析2009年5月至2016年6月发病9 h内在浙江大学医学院附属第二医院接受静脉溶栓治疗的急性缺血性卒中患者的临床及影像学资料。按起病至静脉溶栓时间（ONT）将患者分成时间窗内组（ONT ≤ 4.5 h）和超时间窗组（ONT>4.5 h），三个月临床预后采用改良Rankin评分（mRS）评估，mRS ≤ 2定义为预后良好，mRS>2定义为预后不良。利用受试者工作特征（ROC）曲线计算静脉溶栓治疗获益的最大梗死体积阈值。结果：共纳入587例急性缺血性卒中患者，时间窗内465例，超时间窗122例。相对于临床预后良好者，临床预后不良者基线梗死体积较大（Z=-9.766，P<0.01）。校正年龄、ONT、基线美国国立卫生研究院卒中量表（NIHSS）评分、心房颤动后，较大基线梗死体积是预后不良的独立影响因素（OR=1.014，95%CI：1.008~1.020，P<0.01）。根据ROC曲线，时间窗内患者和超时间窗患者静脉溶栓获益的最大梗死体积阈值分别为152 mL（曲线下面积为0.733，95%CI：0.686~0.779，P<0.01）和71 mL（曲线下面积为0.732，95%CI：0.644~0.820，P<0.01）。随着ONT延长，梗死体积阈值减小（ρ=-0.691，P<0.05）。结论：相对于超时间窗的缺血性卒中患者，时间窗内的患者从静脉溶栓中获益的梗死体积阈值更高，其阈值随时间延长而减小。
关键词： 急性病;  脑缺血/治疗;  卒中/治疗;  血栓溶解疗法/方法;  侧支循环;  预后;  治疗结果    
Abstract:

Objective:To investigate the relationship between maximal infarct volume to benefit from intravenous thrombolysis (IVT) and onset to needle time (ONT). Methods:The clinical and image data of acute ischemic stroke patients who received IVT in the second Affiliated Hospital, Zhejiang University School of Medicine during May 2009 to June 2016 were retrospectively reviewed. Patients were classified into within-time-window group (ONT ≤ 4.5 h) and beyond-time-window group (ONT>4.5 h). Good and poor outcome were defined as modified Rankin scale (mRS) ≤ 2 or >2 at 3 months, respectively. The maximal infarct volume was analyzed by receiver operating characteristic (ROC) curve. Results:Among 587 patients (465 cases were within-time-window, 122 cases were beyond-time-window), baseline core volume was 15(2-46)mL,and 324 (55.2%) patients achieved good outcome. Compared with the good-outcome group, the baseline core volume was larger in the poor-outcome group (32 mL vs 5 mL,Z=-9.766,P<0.01). After adjusting age, ONT, baseline National Institutes of Health Stroke Scale (NIHSS) and atrial fibrillation, baseline infarct core volume independently predicted poor outcome (OR=1.014, 95% CI:1.008-1.020, P<0.01). The ROC curve analysis showed that the maximal infarct core volume for achieving good outcome in the within-time-window group and beyond-time-window group were 152 mL and 71mL, respectively. The maximal infarct volume to benefit from IVT diminished with the increasing delayed ONT of every 30 min (ρ=-0.691, P<0.05). Conclusion:The maximal infarct volume to benefit from thrombolysis is larger in patients treated within time window than those beyond the time window, and that volume diminishes with ONT delay.
Key words: Acute disease    Brain ischemia/therapy    Stroke/therapy    Thrombolytic therapy/methods    Collateral circulation    Prognosis    Treatment outcome
收稿日期: 2017-02-10 出版日期: 2017-08-25
CLC:  R743.3  
基金资助:

国家自然科学基金（81471170，81622017）
通讯作者: 楼敏(1976-),女,博士,主任医师,教授,博士生导师,主要从事神经病学研究;E-mail:lm99@zju.edu.cn;http://orcid.org/0000-0002-6627-064X     E-mail: lm99@zju.edu.cn
作者简介: 张美霞(1993-),女,硕士研究生,主要从事神经病学研究;E-mail:15858186690@163.com;http://orcid.org/0000-0002-9588-2733
服务　　
把本文推荐给朋友
加入引用管理器
E-mail Alert
RSS
作者相关文章　　

引用本文:

张美霞 等. 静脉溶栓获益的最大梗死体积阈值与急性缺血性卒中患者发病时间的关系[J]. 浙江大学学报（医学版）, 2017, 46(4): 384-389.

ZHANG Meixia, ZHOU Ying, ZHANG Ruiting, ZHANG Sheng, LOU Min. Maximal infarct volume to benefit from intravenous thrombolysis and its relation with onset to treatment time. Journal of ZheJiang University(Medical Science), 2017, 46(4): 384-389.

链接本文:

http://www.zjujournals.com/med/CN/10.3785/j.issn.1008-9292.2017.08.07    或    http://www.zjujournals.com/med/CN/Y2017/V46/I4/384

[1] SAVER J L. Time is brain-quantified[J]. Stroke,2006,37(1):263-266.
[2] LUBY M, WARACH S J, NADAREISHVILI Z, et al. Immediate changes in stroke lesion volumes post thrombolysis predict clinical outcome[J]. Stroke,2014,45(11):3275-3279.
[3] PICANCO M R, CHRISTENSEN S, CAMPBELL B C, et al. Reperfusion after 4.5 hours reduces infarct growth and improves clinical outcomes[J]. Int J Stroke,2014,9(3):266-269.
[4] CHO K H, KWON S U, LEE D H, et al. Early infarct growth predicts long-term clinical outcome after thrombolysis[J]. J Neurol Sci,2012,316(1-2):99-103.
[5] LEES K R, BLUHMKI E, VON KUMMER R, et al. Time to treatment with intravenous alteplase and outcome in stroke:an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials[J]. Lancet,2010,375(9727):1695-1703.
[6] NEUMANN-HAEFELIN T, WITTSACK H J, WENSERSKI F, et al. Diffusion-and perfusion-weighted MRI. The DWI/PWI mismatch region in acute stroke[J]. Stroke,1999,30(8):1591-1597.
[7] SCHAEFER P W, PULLI B, COPEN W A, et al. Combining MRI with NIHSS thresholds to predict outcome in acute ischemic stroke:value for patient selection[J]. AJNR Am J Neuroradiol,2015,36(2):259-264.
[8] YOO A J, BARAK E R, COPEN W A, et al. Combining acute diffusion-weighted imaging and mean transmit time lesion volumes with National Institutes of Health Stroke Scale Score improves the prediction of acute stroke outcome[J]. Stroke,2010,41(8):1728-1735.
[9] 中华医学会神经病学分会脑血管病学组急性缺血性脑卒中诊治指南撰写组.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志,2014,48(4):246-257. Cerebrovascular Disease Study Group, Chinese Medical Association Branch of Neurology. Chinese guidelines for acute ischemic stroke treatment 2014[J]. Chinese Journal of Neurology,2014,48(4):246-257. (in Chinese)
[10] JAUCH E C, SAVER J L, ADAMS H P JR, et al. Guidelines for the early management of patients with acute ischemic stroke:a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke,2013,44(3):870-947.
[11] DEL ZOPPO G J, SAVER J L, JAUCH E C, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator:a science advisory from the American Heart Association/American Stroke Association[J]. Stroke,2009,40(8):2945-2948.
[12] VOGT G, LAAGE R, SHUAIB A, et al. Initial lesion volume is an independent predictor of clinical stroke outcome at day 90:an analysis of the Virtual International Stroke Trials Archive (VISTA) database[J]. Stroke,2012,43(5):1266-1272.
[13] PARSONS M W, CHRISTENSEN S, MCELDUFF P, et al. Pretreatment diffusion-and perfusion-MR lesion volumes have a crucial influence on clinical response to stroke thrombolysis[J]. J Cereb Blood Flow Metab,2010,30(6):1214-1225.
[14] WIJDICKS E F, SHETH K N, CARTER B S, et al. Recommendations for the management of cerebral and cerebellar infarction with swelling:a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke,2014,45(4):1222-1238.
[15] HACKE W, SCHWAB S, HORN M, et al. ‘Malignant’ middle cerebral artery territory infarction:clinical course and prognostic signs[J]. Arch Neurol,1996,53(4):309-315.
[16] MINNERUP J, WERSCHING H, RINGELSTEIN E B, et al. Prediction of malignant middle cerebral artery infarction using computed tomography-based intracranial volume reserve measurements[J]. Stroke,2011,42(12):3403-3409.
[17] MA H, PARSONS M W, CHRISTENSEN S, et al. A multicentre, randomized, double-blinded, placebo-controlled Phase Ⅲ study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND)[J]. Int J Stroke,2012,7(1):74-80.
[18] THOMALLA G, FIEBACH J B, ØSTERGAARD L, et al. A multicenter, randomized, double-blind, placebo-controlled trial to test efficacy and safety of magnetic resonance imaging-based thrombolysis in wake-up stroke (WAKE-UP)[J]. Int J Stroke,2014,9(6):829-836.
[1] 丁元 等. 腹腔镜胰体尾切除术患者围手术期加速康复管理及效果评估[J]. 浙江大学学报（医学版）, 2017, 46(6): 625-629.
[2] 陆薇 等. 改良侧壁开窗式上颌窦底提升术治疗上颌后牙区缺牙伴重度骨萎缩患者临床观察[J]. 浙江大学学报（医学版）, 2017, 46(6): 630-636.
[3] 祝子逸 等. 内镜引导下吻合口瘘冲洗治疗食管胃吻合口瘘合并瘘旁脓肿临床疗效观察[J]. 浙江大学学报（医学版）, 2017, 46(6): 637-642.
[4] 张思影 等. CT和磁共振参数反应图在肿瘤精准疗效评估中的研究进展[J]. 浙江大学学报（医学版）, 2017, 46(5): 468-472.
[5] 潘瑶 等. 胰腺癌的影像学精准诊断与评估[J]. 浙江大学学报（医学版）, 2017, 46(5): 462-467.
[6] 李爱静 等. 动态增强磁共振成像参照物模型定量参数与乳腺癌预后因素及分子病理分型的关系[J]. 浙江大学学报（医学版）, 2017, 46(5): 505-510.
[7] 胡静 等. 记忆T细胞在行放射治疗的非小细胞肺癌患者中的表达及其预后预测价值[J]. 浙江大学学报（医学版）, 2017, 46(5): 523-528.
[8] 潘静颖 等. PET-CT与乳腺癌分子病理分型、治疗反应及预后的相关性研究进展[J]. 浙江大学学报（医学版）, 2017, 46(5): 473-480.
[9] 赖针珍 等. 动态CT血管造影评估急性基底动脉闭塞患者侧支血流与再灌注治疗预后的关系[J]. 浙江大学学报（医学版）, 2017, 46(4): 371-376.
[10] 冯学问 等. 急性缺血性卒中患者血管内治疗后应用替罗非班的安全性及预后分析[J]. 浙江大学学报（医学版）, 2017, 46(4): 397-404.
[11] 王庆松 等. 基于CT灌注成像的侧支评分预测急性前循环大血管闭塞患者动脉取栓治疗预后的价值[J]. 浙江大学学报（医学版）, 2017, 46(4): 377-383.
[12] 邹丽霞 等. 人源化白细胞介素-6受体抗体治疗全身型幼年特发性关节炎的疗效及安全性[J]. 浙江大学学报（医学版）, 2017, 46(4): 421-426.
[13] 张晓群 等. 不同药物洗脱支架对冠状动脉小血管病变患者预后影响的meta分析[J]. 浙江大学学报（医学版）, 2017, 46(3): 305-314.
[14] 姚国荣,傅云峰,李艳丽,周彩云,吕卫国. 卵巢上皮性癌组织中DNAJB11的表达及临床意义[J]. 浙江大学学报（医学版）, 2017, 46(2): 173-178.
[15] 姚国荣 等. 卵巢上皮性癌组织中DNAJB11的表达及临床意义[J]. 浙江大学学报（医学版）, 2017, 46(2): 173-178.