Das Suman, Mondal Gourango Prosad, Bhattacharya Ramesh, Ghosh Kartick Chandra, Das Sarbajit, Pattem Hema Krishna, Paul Shabir Ahmed, Patra Chandrakanta
Department of Neurology, Calcutta National Medical College, Kolkata, India.
J Neurosci Rural Pract. 2020 Apr;11(2):315-324. doi: 10.1055/s-0040-1709946. Epub 2020 May 2.
Thrombolysis improves the outcome in acute ischemic stroke (AIS), albeit with an increased risk of symptomatic intracranial hemorrhage (sICH). Biomarkers to find patients at risk of sICH, and guide treatment and prognosis would be valuable. Consecutive patients of AIS thrombolysed between February 2017 and September 2019 at Calcutta National Medical College were studied prospectively for sICH and outcome at 6-month follow-up. We identified the independent risk factors for unfavorable outcomes, mortality, and sICH using multivariate analysis. Prethrombolysis and 24-hour postthrombolysis fibrinogen levels were estimated to evaluate its biomarker role. Out of 180 AIS patients admitted during the study period, 60 patients were thrombolysed. Door to needle time was <3 hours among 24 patients and 3 to 4.5 hours among 36 patients. Favorable outcomes occurred among 76.67% and sICH occurred among 13.33% patients. Upper tertile of National Institute of Health Stroke Scale (NIHSS) had the highest adjusted odds for sICH (17.5 [95% confidence intervals=1.7-178.44]). Total anterior circulation stroke had the highest adjusted odds for unfavorable outcome (19.11 [3.9-92.6]). Following thrombolysis, the mean (standard deviation) fibrinogen level of 449.27 (32.87) decreased 7% to postthrombolysis level of 420 (20.5; p< 0.0001). Higher tertiles of fibrinogen levels had progressively increasing odds for morbidity and sICH. Congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke (double weight), i.e., CHADS2 score >2, low ejection fraction, the occurrence of total anterior circulation stroke and higher mean arterial blood pressure, blood glucose level, NIHSS score, and fibrinogen at admission were the common risk factors significantly predicting postthrombolysis sICH and morbidity. Antiplatelet and anticoagulant therapy, lower ASPECT (Alberta Stroke Program Early CT Score), and higher SEDAN scores also predicted sICH . Fibrinogen levels were significantly higher among those developing sICH and having unfavorable outcome. The performance of thrombolysis within 3 hours or between 3 and 4.5 hours after symptom onset did not affect morbidity, mortality, or the occurrence of sICH.
溶栓治疗可改善急性缺血性卒中（AIS）的预后，尽管有症状性颅内出血（sICH）风险增加。寻找有sICH风险的患者、指导治疗和判断预后的生物标志物将很有价值。对2017年2月至2019年9月在加尔各答国立医学院接受溶栓治疗的AIS连续患者进行前瞻性研究，观察6个月随访时的sICH情况和预后。我们使用多变量分析确定了不良预后、死亡率和sICH的独立危险因素。估计溶栓前和溶栓后24小时的纤维蛋白原水平，以评估其作为生物标志物的作用。在研究期间收治的180例AIS患者中，60例接受了溶栓治疗。24例患者的门到针时间<3小时，36例患者的门到针时间为3至4.5小时。76.67%的患者预后良好，13.33%的患者发生了sICH。美国国立卫生研究院卒中量表（NIHSS）评分处于上三分位数的患者发生sICH的调整后比值最高（17.5 [95%置信区间=1.7-178.44]）。完全前循环卒中患者出现不良预后的调整后比值最高（19.11 [3.9-92.6]）。溶栓后，平均（标准差）纤维蛋白原水平从449.27（32.87）降至溶栓后水平420（20.5；p<0.0001），下降了7%。纤维蛋白原水平较高的三分位数患者发生发病和sICH的几率逐渐增加。充血性心力衰竭、高血压、年龄≥75岁、糖尿病、卒中（双倍权重），即CHADS2评分>2、低射血分数、完全前循环卒中的发生以及入院时较高的平均动脉血压、血糖水平、NIHSS评分和纤维蛋白原是显著预测溶栓后sICH和发病的常见危险因素。抗血小板和抗凝治疗、较低的阿尔伯塔卒中项目早期CT评分（ASPECT）以及较高的SEDAN评分也可预测sICH。发生sICH和预后不良的患者纤维蛋白原水平显著更高。症状发作后3小时内或3至4.5小时内进行溶栓治疗对发病率、死亡率或sICH的发生没有影响。
