摘要
目的：观察重组组织型纤溶酶原激活物（rt-PA）在急性脑梗死溶栓治疗中的疗效及安全性，并分析影响溶栓的预后因素。方法回顾性分析杭州市中医院急诊科2009年1月至2013年11月60例脑梗死患者的临床资料；其中30例接受溶栓治疗者为溶栓组，患者于发病4.5 h内给予0.9 mg/kg rt-PA治疗，总剂量最高不超过90 mg，其中10%静脉推注，剩余的90%在60 min内缓慢静脉滴注（静滴）；30例未溶栓治疗者为对照组，患者采用拜阿司匹林等抗血小板聚集常规治疗。观察两组溶栓前及溶栓后1 h、24 h和14 d患者的美国国立卫生研究院卒中量表（NIHSS）评分及两组溶栓前及溶栓后0.5、1.0、1.5 h患者的Barthel指数（BI）评分；观察溶栓组不同年龄、合并症及NIHSS评分患者的出血转化、症状性出血及3个月改良Rankin量表（mRS）评分情况。结果对照组和溶栓组治疗前NIHSS评分（分：15.2±3.6比15.5±3.3）、BI评分（分：45.0±8.8比44.1±7.6）比较差异均无统计学意义（均P＞0.05）；治疗后随时间延长NIHSS评分逐渐降低，溶栓后14 d为最低，BI逐渐升高，溶栓后1.5 h为最高，且以溶栓组的变化更显著〔NIHSS评分（分）：9.7±2.6比12.8±4.2，BI评分（分）：82.6±7.8比69.6±9.8，均P＜0.05〕。溶栓组脑出血转化2例，牙龈出血3例，皮肤出血1例，血尿1例，黑便1例；对照组脑出血转化1例；两组均无明显的全身性出血。30例溶栓组患者中，年龄＞80岁者基线NIHSS评分高于年龄≤80岁者（15分比12分）；合并房颤者的年龄（岁：71.0±4.1比61.5±2.6）、基线NIHSS评分（14分比11分）、出血转化率〔37.50%（3/8）比18.18%（4/22）〕均高于未合并房颤者；国际标准化比值（INR）升高者基线NIHSS评分较未升高者低（11分比14分）；NIHSS评分≤4分者出血转化率低于NIHSS评分＞4分者〔16.67%（1/6）比29.17%（7/24）〕；NIHSS评分≥20分者3个月mRS评分高于NIHSS评分＜20分者（4分比2分）、3个月mRS评分≤2分的比例低于NIHSS评分＜20分者〔11.11%（1/9）比52.38%（11/21），均P＜0.05〕。两组病死率均为3.33%。结论 rt-PA溶栓治疗能明显促进急性脑梗死患者神经功能缺损的早期恢复，改善其预后，且安全性较好，对年龄＞80岁、合并房颤、INR升高及轻型或重型患者同样有效。
Objective To observe the therapeutic efficacy and safety of recombinant tissue plasminogen activator （rt-PA） for treatment of patients with acute cerebral infarction and investigate the prognostic factors of thrombolysis. Methods The clinical data of 60 patients with acute cerebral infarction from January 2009 to November 2013 in Department of Emergency, Hangzhou Traditional Chinese Medicine Hospital were retrospectively analyzed;of them, 30 cases received intravenous rt-PA thrombolytic treatment, being in the thrombolytic group, 0.9 mg/kg rt-PA was given to the patient within 4.5 hours after the disease onset, the total dosage could not exceed 90 mg, in which 10%was intravenously injected and the rest 90%was intravenously dripped slowly within 60 minutes. That another 30 cases did not undergo thrombolytic therapy was assigned as the control group, and they took aspirin, etc anti-platelet aggregation routine treatment. Before and after thrombolytic treatment for 1 hour, 24 hours and 14 days, the National Institutes of Health Stroke Scale （NIHSS） score was evaluated in the two groups;before and after thrombolytic therapy for 0.5, 1.0, and 1.5 hours, the patient＆#39;s scores of Barthel index （BI） were observed in the two groups. In thrombolytic group, the situations of hemorrhage transformation, symptomatic hemorrhage and modified Rankin scale （mRS） score in 3 months of the patients with different ages, complications and NIHSS scores were observed. Results Before treatment, no statistically significant differences were found in the NIHSS score （15.2±3.6 vs. 15.5±3.3） and BI score （45.0±8.8 vs. 44.1±7.6） between the control group and thrombolytic group （both P〉0.05）;after treatment with the extension of time, the NIHSS score was gradually reduced, reaching the lowest level on the 14th day after thrombolytic treatment, while the BI score was gradually increased, reaching its peak at 1.5 hours after thrombolytic treatment, the changes being more prominent in thrombolytic group （NIHSS score：9.7±2.6 vs. 12.8±4.2, BI score：82.6±7.8 vs. 69.6±9.8, both P〈0.05）. In thrombolytic group, there were cerebral hemorrhage transformation 2 cases, gum bleeding 3 cases, skin bleeding 1 case, urethral bleeding 1 case, gastrointestinal bleeding and black stool 1 case. In control group, cerebral hemorrhage transformation was seen in 1 case. There was no obvious systemic hemorrhage in the two groups. In the 30 cases in thrombolytic group, the baseline NIHSS score of patients〉80 years old was higher than that in cases≤80 years old （15 vs. 12）; the age （years： 71.0±4.1 vs. 61.5±2.6）, baseline NIHSS score （14 vs. 11） and bleeding conversion rate [37.50% （3/8） vs. 18.18% （4/22）] of cases with atrial fibrillation were higher than those not complicated with atrial fibrillation; the NIHSS score of cases with elevated international normalized ratio （INR） was lower than those without elevated INR （11 vs. 14）;The bleeding conversion rate [16.67%（1/6） vs. 29.17%（7/24）] with NIHSS score≤4 were lower than those with NIHSS score〉4;the mRS score in 3 months （4 vs. 2）, and percentage of 3-month mRS score≤2 [11.1%（1/9） vs. 52.38%（11/21）] in cases with NIHSS score≥20 was higher than that in cases with NIHSS score〈20 （all P〈0.05）. The fatality rate of two groups was 3.33%. Conclusions The intravenous rt-PA thrombolytic treatment can significantly promote the early recovery of neurologic impairment for patients with acute cerebral infarction. The therapy can improve the prognosis and its safety is relatively good. Meanwhile it is similarly effective for cases over 80, with complications such as atrial fibrillation, raised INR, and with different degrees of severity.
出处
《中国中西医结合急救杂志》
CAS
北大核心
2015年第2期160-163,共4页
Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care
基金
浙江省中医药科技计划项目（2009YA018）
关键词
重组组织型纤溶酶原激活物
脑梗死
疗效
安全性
Recombinant tissue plasminogen activator
Cerebral infarction
Therapeutic efficacy
Safety
作者简介
通讯作者：王瑞明，Email：15967193738@126.com
