摘要
目的 探讨经阿替普酶(alteplase,rt-PA)静脉溶栓后48h内出现血管再闭塞的急性脑梗死(acute cerebral infarction,ACI)患者桥接静脉给予替罗非班的安全性及有效性.方法 选取2019年5月至2022年5月解放军第九六〇医院神经内科收治的74例经rt-PA静脉溶栓48h内出现血管再闭塞情况的ACI患者[美国国立卫生研究院卒中量表(national institute of health stroke scale,NIHSS)评分提高≥2分]作为研究对象,依据中国缺血性卒中亚型(Chinese ischemic stroke sub-classification,CISS)分为大动脉粥样硬化组(large artery atherosclerosis,LAA)41例和穿支动脉病变组(penetrating artery disease,PAD)33例.两组患者在发病后均给予rt-PA静脉溶栓治疗,在溶栓48h内出现神经系统症状加重时复查头颅CT,排除出血后给予静脉泵入替罗非班,持续泵入约48h;结束替罗非班前2 h衔接使用阿司匹林肠溶片100 mg+硫酸氢氯吡格雷片75 mg,双重抗血小板药物序贯治疗21d后,停用硫酸氢氯吡格雷片;单独使用阿司匹林肠溶片100 mg持续 90d.记录两组患者在静脉溶栓前、溶栓后1h、症状加重时、应用替罗非班 48h后、发病 14d后及发病 90d后NIHSS评分;静脉溶栓前、发病后 90d时Rankin量表(modified Rankin scale,mRS)评分.详细记录治疗时及住院期间不良事件发生情况.结果 对于rt-PA静脉溶栓后出现血管再闭塞的ACI患者采用替罗非班强化治疗后,两组溶栓前、溶栓后1h、症状加重时及应用替罗非班48h后NIHSS评分比较,差异无统计学意义(P>0.05);两组在发病 14、90 d时NIHSS评分比较,差异有统计学意义(P<0.05),LAA组NIHSS评分高于PAD组.两组脑梗死14、90 d时NIHSS评分均较症状加重时显著下降,LAA组分别下降(3.46±2.22)、(4.17±2.25)分,PAD组分别下降(4.73±2.32)、(5.36±2.61)分,两组评分下降情况比较,差异有统计学意义(P<0.05).LAA组和PAD组溶栓前和发病90d 时mRS评分比较,差异无统计学意义(P>0.05);在发病90d时LAA组和PAD组mRS评分分别为(1.41±0.81)、(1.06±1.03)分,均较本组溶栓前明显降低,差异有统计学意义(P<0.05).两组治疗期间不良反应发生率比较,差异无统计学意义(P>0.05).LAA组预后良好36例(87.80%),预后不良5例(12.20%);PAD组预后良好30例(90.91%),预后不良3例(9.09%),两组预后情况比较,差异无统计学意义(P>0.05).结论 替罗非班应用于经rt-PA静脉溶栓后出现的血管再闭塞ACI患者是安全、有效的;在 CISS分型中,PAD型临床疗效及远期预后优于LAA型.
Abstract
Objective To determine the safety and efficacy of tirofiban in patients with acute cerebral infarc-tion(ACI)andvascular re-occlusion within 48 h after intravenous thrombolysis with alteplase(rt-PA).Methods A retrospective analysis was conducted involving 74 patients with vascular re-occlusion and an increase in the national institute of health stroke scale(NIHSS)score≥2 points within 48 h after rt-PA thrombolysis in the Department of Neurology at the 960 Hospital of the People's Liberation Army from May 2019 to May 2022.According to the Chinese ischemic stroke sub-classification(CISS),the patients were divided into the following two groups:large artery atherosclerosis group(LAA;n=41);and penetrating artery disease group(PAD;n=33).Bolytic therapy was initiated after the onset of the disease.When the neurologic symptoms were aggravated within 48 h after thrombolytic therapy,ahead computed tomography was obtained,and tirofiban was infused intravenously for approximately 48 h after exclusion of hemorrhage.Aspirin tablets(100 mg)and clopidogrel bisulfate tablets(75)mg were used 2 h before the tirofiban infu-sion was completed.After sequential treatment with dual antiplatelet drug for 21 days,clopidogrel bisulfate tablets were discontinued and aspirin tablets(100 mg)were continued for 90 days.The NIHSS and modi-fied Rankin scale(mRS)scores were recorded before and 1 h after intravenous thrombolysis,at the time of symptom aggravation,48 h after tirofiban administration,14 days after onset,and 90 days after onset in both groups.Results There was no significant difference in NIHSS scores before thrombolysis,1 h after throm-bolysis,when symptoms were aggravated,and 48 h after tirofiban administration in ACI patients with vas-cular re-occlusion after intravenous thrombolysis with rt-PA,but there was a significant difference in NI-HSS scores between the two groups on the 14th and 90th days after onset,and the NIHSS score was higher in the LAA group than the PAD group.On the 14th and 90th days after cerebral infarction,the NIHSS scores of the two groups were significantly lower than the patients with exacerbation of symptoms.The LAA and PAD group scores decreased significantly.There was no significant difference in mRS scores be-tween the LAA and PAD groups before thrombolysis and 90 days after onset,but on the 90th day after onset the mRS scores in the LAA and PAD groups were significantly lower than before thrombolysis.There was no significant difference in the incidence of adverse reactions between the two groups during treatment(P>0.05).The prognosis was good in 36 patients(87.80% )and poor in 5 patients(12.20% )in the LAA group.In PAD group,the prognosis was good in 30 patients(90.91% )and poor in 3 patients(9.09% )in the PAD group.There was no significant difference in prognosis between the two groups(P>0.05).Conclusions Tirofiban is shown to be safe and effective in ACI patients with vascular re-occlusion after intravenous thrombolysis with rt-PA.Based on the CISS classification,the clinical efficacy and long-term prognosis of the PAD type is better than the LAA type.
维普
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