静脉注射组织型纤溶酶原激活剂治疗是颈动脉内膜切除术后症状性脑出血的独立危险因素。
Intravenous tissue-type plasminogen activator therapy is an independent risk factor for symptomatic intracerebral hemorrhage after carotid endarterectomy.
作者信息
Vellimana Ananth K, Yarbrough Chester K, Blackburn Spiros, Strom Russell G, Pilgram Thomas K, Lee Jin-Moo, Grubb Robert L, Rich Keith M, Chicoine Michael R, Dacey Ralph G, Derdeyn Colin P, Zipfel Gregory J
机构信息
*Department of Neurological Surgery, ‡Mallinckrodt Institute of Radiology, and §Department of Neurology, Washington University School of Medicine, St. Louis, Missouri; ‖Department of Neurosurgery, University of Florida, Gainesville, Florida.
出版信息
Neurosurgery. 2014 Mar;74(3):254-61. doi: 10.1227/NEU.0000000000000261.
BACKGROUND
Carotid endarterectomy (CEA) for symptomatic carotid artery stenosis and intravenous tissue-type plasminogen activator (IV-tPA) for acute ischemic stroke are proven therapies; however, the safety of CEA in stroke patients who recently received IV-tPA has not been established.
OBJECTIVE
To evaluate the safety of CEA in stroke patients who recently received IV-tPA.
METHODS
A retrospective review of patients who underwent CEA for symptomatic carotid artery stenosis was performed. The primary end point was postoperative symptomatic intracerebral hemorrhage (sICH). A univariate analysis of potential risk factors for sICH, including IV-tPA therapy, timing of CEA, degree of stenosis, and stroke severity, was performed. Factors with a value of P < .1 on univariate analysis were tested further.
RESULTS
Among 142 patients, 3 suffered sICH after CEA: 2 of 11 patients treated with IV-tPA (18.2%) and 1 of 131 patients not treated with IV-tPA (0.8%). Both IV-tPA patients suffering sICH underwent CEA within 3 days of tPA administration. On univariate analysis, IV-tPA (P = .02), female sex (P = .09), shorter time between ischemic event and CEA (P = .06), and lower mean arterial pressure during the first 48 hours of admission (P = .08) were identified as risk factors for sICH. On multivariate analysis, IV-tPA was the only significant risk factor (P = .002 by stepwise logistic regression; P = .03 by nominal logistic regression).
CONCLUSION
This study indicates that IV-tPA is an independent risk factor for sICH after CEA. This suggests that CEA should be pursued cautiously in patients who recently received IV-tPA. Early surgery may be associated with an increased risk for sICH.
ABBREVIATIONS
CEA, carotid endarterectomyIV-tPA, intravenous recombinant tissue-type plasminogen activatorMAP, mean arterial pressureNASCET, North American Symptomatic Carotid Endarterectomy TrialNIHSS, National Institutes of Health Stroke ScaleNINDS, National Institute of Neurological Disorders and StrokesICH, symptomatic intracerebral hemorrhageTIA, transient ischemic attack.
背景
对于有症状的颈动脉狭窄行颈动脉内膜切除术（CEA）以及对于急性缺血性卒中使用静脉注射组织型纤溶酶原激活剂（IV-tPA）都是已被证实的治疗方法；然而，在近期接受IV-tPA治疗的卒中患者中CEA的安全性尚未确立。
目的
评估在近期接受IV-tPA治疗的卒中患者中CEA的安全性。
方法
对因有症状的颈动脉狭窄而接受CEA的患者进行回顾性研究。主要终点是术后有症状性脑出血（sICH）。对sICH的潜在危险因素进行单因素分析，包括IV-tPA治疗、CEA的时机、狭窄程度和卒中严重程度。对单因素分析中P值<0.1的因素进行进一步检验。
结果
在142例患者中，3例在CEA术后发生sICH：11例接受IV-tPA治疗的患者中有2例（18.2%），131例未接受IV-tPA治疗的患者中有1例（0.8%）。2例发生sICH的接受IV-tPA治疗的患者在给予tPA后3天内接受了CEA。单因素分析显示，IV-tPA（P = 0.02）、女性（P = 0.09）、缺血事件与CEA之间的时间较短（P = 0.06）以及入院后最初48小时内平均动脉压较低（P = 0.08）被确定为sICH的危险因素。多因素分析显示，IV-tPA是唯一显著的危险因素（逐步逻辑回归P = 0.002；名义逻辑回归P = 0.03）。
结论
本研究表明IV-tPA是CEA术后发生sICH的独立危险因素。这表明在近期接受IV-tPA治疗的患者中应谨慎进行CEA。早期手术可能与sICH风险增加有关。
缩写
CEA，颈动脉内膜切除术；IV-tPA，静脉注射重组组织型纤溶酶原激活剂；MAP，平均动脉压；NASCET，北美症状性颈动脉内膜切除术试验；NIHSS，美国国立卫生研究院卒中量表；NINDS，美国国立神经疾病和卒中研究所；ICH，有症状性脑出血；TIA，短暂性脑缺血发作
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