目的 构建预测行血管内介入治疗的急性脑梗死患者预后不良的列线图模型,探讨其在预后评估中的价值.方法 2020年3月-2023年3月南阳市中心医院诊治急性脑梗死患者167例,均行血管内介入治疗,术后3个月采用改良Rankin量表评分(mRS)评估患者预后,其中mRS＜3分者66例为预后良好组,mRS≥3分者101例为预后不良组.比较2组年龄、术后并发症、术后24 h美国国立卫生研究院卒中量表(NIHSS)评分及术后纤维蛋白原/白蛋白比值(FAR)、血管内皮生长因子(VEGF)、D-二聚体水平等临床资料.采用多因素logistic回归分析行血管内介入治疗的急性脑梗死患者预后不良的影响因素;根据影响因素构建预测行血管内介入治疗的急性脑梗死患者预后不良的列线图模型.绘制校准曲线,采用Hosmer-Lemeshow拟合优度检验评价模型的校准度;绘制ROC曲线,评估模型的预测效能;采用一致性指数评估模型的区分度,采用Bootstrap法进行内部验证.结果 167例患者预后不良发生率为60.48％.预后不良组年龄≥60岁、术后严重脑水肿、出血转化比率(73.27％、58.42％、49.50％),术后24 h NIHSS评分[(19.42±3.24)分]、FAR(0.09±0.02)及 VEGF[(351.49±30.75)ng/L]、D-二聚体[(448.75±46.75)μg/L]水平均高于预后良好组[42.42％、18.18％、30.30％、(11.24±2.75)分、0.07±0.01、(256.54±21.38)ng/L、(226.74±15.76)μg/L](x2=15.973、24.439、6.045,t=16.909、7.527、21.859、37.190;P 均＜0.05).年龄(OR=3.374,95％CI:1.620～5.127,P＜0.001)、术后 24 h NIHSS 评分(OR=3.747,95％CI:1.456～6.038,P＜0.001)、术后严重脑水肿(OR=4.963,95％CI:2.581～7.345,P＜0.001)、FAR(OR=2.707,95％CI:1.100～4.315,P＜0.001)、VEGF(OR=4.242,95％CI:2.276～6.028,P＜0.001)、D-二聚体(OR=5.948,95％CI:3.383～8.512,P＜0.001)是行血管内介入治疗的急性脑梗死患者预后不良的影响因素.列线图模型的校准曲线接近理想曲线,拟合良好(x2=3.526,P=0.752).列线图模型预测行血管内介入治疗的急性脑梗死患者预后不良的AUC为0.827(95％CI:0.618～0.969,P＜0.001),灵敏度为90.80％,特异度为78.50％.列线图模型的一致性指数为0.857(95％CI:0.785～0.952,P＜0.001),区分度较好.结论 行血管内介入治疗的急性脑梗死患者中年龄≥60岁、术后严重脑水肿及术后24 h NIHSS评分、FAR、VEGF、D-二聚体升高者预后不良的风险较大,基于上述影响因素构建的列线图模型预测患者预后不良有较高价值.
Construction and verification of nomogram model for predicting poor prognosis of patients with acute cerebral infarction after endovascular intervention
Objective To construct a nomogram model to predict the poor prognosis of patients with acute cerebral infarction after endovascular intervention,and to investigate its predictive value.Methods A total of 167 patients with acute cerebral infarction received endovascular intervention in Nanyang Central Hospital from March 2020 to March 2023,and were divided into 66 patients with modified Rankin scale(mRS)＜3(good prognosis group)and 101 patients with mRS≥3(poor prognosis group)according to the prognosis 3 months after operation.The clinical data as age,postoperative complications,National Institutes of Health Stroke Scale(NIHSS)score 24 h postoperatively,fibrinogen to albumin ratio(FAR),vascular endothelial growth factor(VEGF),and D-dimer level were compared between two groups.Multivariate logistic regression was used to analyze the influencing factors of poor prognosis in patients with acute cerebral infarction after endovascular interventional therapy.A nomogram model was constructed based on these influencing factors to predict the poor prognosis.The calibration curve was drawn,and the Hosmer-Lemeshow goodness of fit test was used to evaluate the calibration degree of the model.ROC curve was drawn to evaluate the predictive efficiency of the model.Consistency index was used to evaluate the differentiation of the model,and Bootstrap method was used for internal verification.Results The poor prognosis rate of 167 patients was 60.48％.The proportions of patients aged≥60 years old,postoperative severe cerebral edema and hemorrhagic conversion,NIHSS score 24 h postoperatively,FAR,and levels of VEGF and D-dimer were higher in poor prognosis group[73.27％,58.42％,49.50％,19.42±3.24,0.09±0.02,(351.49±30.75)ng/L,(448.75±46.75)μg/L]than those in good prognosis group[42.42％,18.18％,30.30％,11.24±2.75,0.07±0.01,(256.54±21.38)ng/L,(226.74±15.76)μg/L](x2=15.973,x2=24.439,x2=6.045,t=16.909,t=7.527,t=21.859,t=37.190;all P values＜0.05).Age(OR=3.374,95％CI:1.620-5.127,P＜0.001),NIHSS score 24 h postoperatively(OR=3.747,95％CI:1.456-6.038,P＜0.001),postoperative servere cerebral edema(OR=4.963,95％CI:2.581-7.345,P＜0.001),FAR(OR=2.707,95％CI:1.100-4.315,P＜0.001),VEGF(OR=4.242,95％CI:2.276-6.028,P＜0.001)and D-dimer(OR=5.948,95％CI:3.383-8.512,P＜0.001)were the influencing factors of poor prognosis of patients with acute cerebral infarction after endovascular intervention.The calibration curve of nomogram model was close to the ideal curve,showing a good fitting(x2=3.526,P=0.752).The AUC of nomogram model to predict poor prognosis was 0.827(95％CI:0.618-0.969,P＜0.001),with a sensitivity of 90.80％,and a specificity of 78.50％.The consistency index of the nomogram model was 0.857(95％CI:0.785-0.952,P＜0.001),indicating a good differentiation.Conclusion Age of 60 years or older,postoperative severe cerebral edema,and elevated NIHSS score,FAR,VEGF and D-dimer levels 24 h postoperatively indicate a high risk of poor prognosis of patients with acute cerebral infarction after endovascular intervention,and the nomogram model based on the above influencing factors has a high predictive value to the poor prognosis.
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