Petty G W, Brown R D, Whisnant J P, Sicks J D, O'Fallon W M, Wiebers D O
Division of Cerebrovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
Stroke. 2000 May;31(5):1062-8. doi: 10.1161/01.str.31.5.1062.
There is scant population-based information on functional outcome, survival, and recurrence for ischemic stroke subtypes.
We identified all residents of Rochester, Minnesota, with a first ischemic stroke from 1985 through 1989 using the resources of the Rochester Epidemiology Project medical records linkage system. After reviewing medical records and imaging studies, we assigned patients to 4 major ischemic stroke categories based on National Institute of Neurological Diseases and Stroke Data Bank criteria: large-vessel cervical or intracranial atherosclerosis with stenosis (ATH, n=74), cardioembolic (CE, n=132), lacunar (LAC, n=72), and infarct of uncertain cause (IUC, n=164). We used the Rankin disability score to assess functional outcome and the Kaplan-Meier product-limit method and Cox proportional hazards regression analysis with bootstrap validation to estimate rates and identify predictors of survival and recurrent stroke among these patients.
Rankin disabilities were different across stroke subtypes at the time of stroke and 3 months and 1 year later (P=0.001). LAC was associated with milder deficits compared with other subtypes. Mean follow-up among the 442 patients in the cohort was 3.2 years. Estimated rates of recurrent stroke at 30 days were significantly different (P<0.001): ATH, 18.5% (95% CI 9.4% to 27.5%); CE, 5.3% (95% CI 1.2% to 9.6%); LAC, 1.4% (95% CI 0.0% to 4.1%); and IUC, 3. 3% (95% CI 0.4% to 6.2%). After adjusting for age, sex, and stroke severity, infarct subtype was an independent determinant of recurrent stroke within 30 days (P=0.0006; eg, risk ratio for ATH compared with CE=3.3, 95% CI 1.2 to 9.3) but not long term (P=0.07). Four of 25 recurrent strokes within 30 days were procedure-related, each in patients with ATH. Five-year death rates were significantly different (P<0.001): ATH, 32.2% (95% CI 21.1% to 43.2%); CE, 80.4% (95% CI 73.1% to 87.6%); LAC, 35.1% (95% CI 23.6% to 46.0%); and IUC, 48.6% (95% CI 40.5% to 56.7%). With adjustment for age, sex, cardiac comorbidity, and stroke severity, the subtype of ischemic stroke was an independent determinant of long-term (P=0.018; eg, risk ratio for ATH compared with cardioembolic=0.47, 95% CI 0.29 to 0.77) but not 30-day survival (P=0.2).
Early recurrence rates for ischemic stroke caused by ATH are higher than those for other subtypes and higher than previous non-population-based studies have reported. Some of the increased risk of early recurrence among patients with ATH may be iatrogenic. Patients with LAC have better poststroke functional status than those with other subtypes. Survival is poorest among those with ischemic stroke with a cardiac source of embolism.
关于缺血性卒中亚型的功能转归、生存率及复发情况，基于人群的信息较少。
我们利用罗切斯特流行病学项目医疗记录链接系统的资源，确定了1985年至1989年期间明尼苏达州罗切斯特市所有首次发生缺血性卒中的居民。在查阅医疗记录和影像学研究后，我们根据美国国立神经疾病和卒中数据库标准将患者分为4种主要缺血性卒中类型：伴有狭窄的大血管颈部或颅内动脉粥样硬化（ATH，n = 74）、心源性栓塞（CE，n = 132）、腔隙性（LAC，n = 72）以及病因不明的梗死（IUC，n = 164）。我们使用Rankin残疾评分评估功能转归，并采用Kaplan-Meier乘积限界法和Cox比例风险回归分析及自助法验证来估计这些患者的生存率和复发性卒中发生率，并确定其预测因素。
卒中时、3个月及1年后，不同卒中亚型的Rankin残疾程度不同（P = 0.001）。与其他亚型相比，LAC与较轻的功能缺损相关。该队列中442例患者的平均随访时间为3.2年。30天时复发性卒中的估计发生率有显著差异（P<0.001）：ATH为18.5%（95%CI 9.4%至27.5%）；CE为5.3%（95%CI 1.2%至9.6%）；LAC为1.4%（95%CI 0.0%至4.1%）；IUC为3.3%（95%CI 0.4%至6.2%）。在调整年龄、性别和卒中严重程度后，梗死亚型是30天内复发性卒中的独立决定因素（P = 0.0006；例如，ATH与CE相比的风险比=3.3，95%CI 1.2至9.3），但不是长期复发性卒中的独立决定因素（P = 0.07）。30天内25例复发性卒中中有4例与手术相关，均为ATH患者。5年死亡率有显著差异（P<0.001）：ATH为32.2%（95%CI 21.1%至43.2%）；CE为80.4%（95%CI 73.1%至87.6%）；LAC为35.1%（95%CI 23.6%至46.0%）；IUC为48.6%（95%CI 40.5%至56.7%）。在调整年龄、性别、心脏合并症和卒中严重程度后，缺血性卒中亚型是长期生存的独立决定因素（P = 0.018；例如，ATH与心源性栓塞相比的风险比=0.47，95%CI 0.29至0.77），但不是30天生存率的独立决定因素（P = 0.2）。
ATH所致缺血性卒中的早期复发率高于其他亚型，且高于以往非基于人群的研究报道。ATH患者早期复发风险增加的部分原因可能是医源性的。LAC患者卒中后的功能状态优于其他亚型患者。心源性栓塞性缺血性卒中患者的生存率最差。
