目的 探讨急性大血管闭塞性卒中患者在成功行早期血管内治疗(EVT)后，收缩压下降幅度(SBPr)与术后90d临床预后及术后24h症状性颅内出血(sICH)的关系。方法 回顾性、序贯性纳入2015年7月至2023年4月于皖南医学院第一附属医院(弋矶山医院)因前循环急性大血管闭塞行EVT并获得成功再通的患者。收集所有患者的人口学资料、既往史(高血压病、糖尿病)、急性卒中Org 10172治疗试验(TOAST)分型、基线美国国立卫生研究院卒中量表(NIHSS)评分及基线Alberta卒中项目早期CT(ASPECT)评分，收集手术相关参数[包括发病至置鞘时间、发病至再通时间、闭塞部位(颈内动脉、大脑中动脉M1段、大脑中动脉M2段)、脑侧支循环状态(术前闭塞血管造影显示闭塞血管区域软脑膜侧支循环回流范围≥50％定义为侧支循环良好，回流范围＜50％定义为侧支循环不良)]、术后即刻再通状态[采用改良脑梗死溶栓(mTICI)分级进行评估，成功再通定义为mTICI分级为2b～3级]、术后24 h sICH、术后90 d预后(以术后90 d改良Rankin量表评分评估，评分≤2分为预后良好，评分＞2分为预后不良)。根据EVT后24h内SBPr，将SBPr分成5 类，即 SBPr＜-10％、-10％～10％、＞10％～20％、＞20％～30％和＞30％。根据术后 90 d 预后以及术后24hsICH发生情况，将所有纳入患者分为预后良好组与预后不良组以及sICH组与无sICH组。SBPr与术后90d临床预后和术后24h sICH的关系采用二分类多因素Logistic回归分析模型分析。根据有无高血压病史、有无持续静脉降压、基线ASPECT评分(3～5分和6～10分)及侧支循环状态(良好与不良)进行亚组分析。利用限制性立方图描绘SBPr与术后24 h sICH及术后90 d临床预后的关系。结果 (1)共纳入731例患者，中位年龄71(62，77)岁，男性患者占58。0％(424/731)，中位基线NIHSS评分为14(12，18)分，中位基线ASPECT评分9(7，10)分;405例(55。4％)患者术后90d预后良好，35例(4。8％)患者术后24 h发生sICH。(2)多因素分析结果显示，年龄越大(OR=1。036，95％CI:1。017～1。056)，基线 NIHSS 评分越高(OR=1。095，95％CI:1。049～1。144)，基线 ASPECT 评分越低(OR=0。704，95％CI:0。636～0。780)，患有糖尿病(OR=1。729，95％CI:1。084～2。758)，侧支循环不良(侧支循环良好比不良，OR=0。481，95％CI:0。332～0。696)以及SBPr＞30％(以SBPr-10％～10％作为参照，OR=2。238，95％CI:1。230～4。071)，术后90 d预后不良风险越高(均P＜0。05)。持续静脉降压为术后24 h sICH发生的危险因素(OR=2。278，95％CI:1。047～4。953;P=0。038)，而SBPr 20％～30％与较低的术后24h sICH发生风险相关(以SBPr-10％～10％作为参照，OR=0。362，95％CI:0。131～0。998;P=0。049)。(3)限制性立方图显示，EVT 后 SBPr 与术后 90 d预后不良存在U形关系，而与sICH的发生存在近线性关系，下降越多，sICH发生率越低。(4)亚组分析显示，在无高血压病病史和良好侧支循环状态亚组中，SBPr＞30％较SBPr-10％～10％均具有更高的不良预后风险[OR值及 95％CI 分别为 2。921(1。000～8。528)、2。363(1。078～5。183)，P=0。05和P＜0。05];在EVT后接受持续静脉降压组和基线ASPECT评分6～10分组，SBPr＞30％与术后90 d不良预后相关[以SBPr-10％～10％作为参照，OR值和95％CI分别为2。646(1。168～5。993)、2。481(1。360～4。527)，均P＜0。05]。SBPr与较低的sICH发生风险的相关性仅存在于不良脑侧支循环状态亚组中(以SBPr-10％～10％为参照，SBPr＞20％～30％:OR=0。133，95％CI:0。027～0。652;SBPr＞30％:OR=0。104，95％CI:0。013～0。864;均P＜0。05)。结论 对于急性前循环大血管闭塞性卒中EVT后血管再通患者，术后SBPr可能与术后90 d预后不良及术后24 h sICH发生相关，但这种相关性存在显著的个体化差异。基线ASPECT评分、既往高血压病史、脑侧支循环状态以及EVT后持续静脉降压的使用在EVT后个体化血压管理中需谨慎对待。
Association between the magnitude of systolic blood pressure reduction after successful endovascular thrombectomy with outcomes and post-procedure symptomatic intracranial hemorrhage in acute large vessel occlusion stroke patients
Objective To explore the association of the magnitude of systolic blood pressure reduction(SBPr)with post-procedure 24 h symptomatic intracranial hemorrhage(sICH)and 90-day clinical outcomes in patients with successful endovascular thrombectomy(EVT).Methods Consecutively registered patients with EVT caused by anterior circulation large vessel occlusion stroke(LVOS)in the First Affiliated Hospital of Wannan Medical College(Yijishan Hospital)between July 2015 and April 2023 and patients with successful reperfusion were analyzed.Demographic data,medical history(hypertension,diabetes),the trial of Org 10172 in acute stroke treatment(TOAST)classification,the baseline National Institutes of Health Stroke Scale(NIHSS)score and the baseline Alberta stroke early CT(ASPECT)score of patients were collected.And procedure related parameters(including time from onset to puncture,time from onset to reperfusion,occluded site[internal carotid artery,M1 segment of middle cerebral artery,M2 segment of middle cerebral artery],collateral circulation status[determined based on preoperative occluded angiography showing the range of collateral circulation in the occluded vessel area,defined as good collateral circulation with a reflux range of ≥ 50％and poor collateral circulation with a reflux range of＜50％]),immediate postoperative reperfusion status(evaluated using the modified thrombolysis for cerebral infarction[mTICI]grading,successful reperfusion defined as mTICI grading of 2b-3),24 hours sICH,and 90 days clinical outcomes(evaluated using the modified Rankin scale score at 90days after EVT,with a score ≤ 2indicating a good prognosis and a score＞2indicating a poor prognosis).SBPr was defined as(baseline SBP-mean SBP)/baseline SBP x 100％.According to the the magnitude of SBPr,SBPr is divided into 5 categories(＜-10％,-10％-10％,＞10％-20％,＞20％-30％and＞30％).Based on the clinical outcomes at 90 days and the occurrence of sICH at 24 hours after EVT,patients were divided into a good prognosis group and a poor prognosis group,as well as an sICH group and a non-sICH group.The relationship between SBPr and postoperative 90 days clinical prognosis or sICH was analyzed using a binary Logistic regression model.Subgroup analysis was conducted based on a history of hypertension(yes and no),continuous intravenous hypotensive therapy(yes and no),baseline ASPECT scores(3-5 and 6-10),and collateral circulation status(good and bad).Using a restricted cubic plot to depict the relationship between SBPr and sICH and clinical prognosis at 90days.Results(1)In total,731 patients were included.The median age was 71(62,77)years and 424(58.0％)were men.The median baseline NIHSS score was 14(12,18),the median baseline ASPECT was 9(7,10),405(55.4％)patients achieved 90-day modified Rankin scale score 0-2,and 35 patients(4.8％)developed sICH.(2)Multivariate analysis showed that the older age(OR,1.036,95％CI 1.017-1.056),the higher baseline NIHSS score(OR,1.095,95％CI1.049-1.144),the lower baseline ASPECT score(OR,0.704,95％CI 0.636-0.780),diabetes(OR,1.729,95％CI 1.084-2.758),bad collateral circulation(good collateral circulation vs.bad collateral circulation,OR,0.481,95％CI 0.332-0.696)and SBPr＞30％(SBPr-10％-10％as a reference,OR,2.238,95％CI 1.230-4.071),the higher the risk of poor clinical outcomes at 90 days(all P＜0.05).Continuous intravenous hypotensive therapy is a risk factor for postoperative 24 h sICH(OR,2.278,95％CI 1.047-4.953;P=0.038),while SBPr 20％-30％is associated with a lower risk of postoperative 24 h sICH(SBPr-10％-10％as a reference,OR,0.362,95％CI0.131-0.998;P=0.049).(3)The restrictive cube plot shows that there is a U-shaped relationship between SBPr after EVT and poor clinical outcomes at 90 days,while there is a nearly linear relationship with the occurrence of sICH.The more SBP reduction,the lower the incidence of sICH.(4)In the subgroup analyses,in the non-hypertension history and the good collateral circulation group,SBPr＞30％has a higher risk of poor clinical outcomes compared to SBPr-10％-10％(OR and 95％CI were 2.921[1.000-8.528]and 2.363[1.078-5.183],respectively,with P=0.05 or P＜0.05);After EVT,the group receiving continuous intravenous hypotensive therapy and the baseline ASPECT score 6-10 groups showed a significant correlation between SBPr＞30％and poor clinical outcomes at 90 days(SBPr-10％-10％as a reference,OR and 95％CI were 2.646[1.168-5.993]and 2.481[1.360-4.527],respectively,with P＜0.05).The correlation between SBPr and lower incidence of sICH was only found in the subgroup of poor collateral circulation(SBPr-10％-10％as a reference,SBPr＞20％-30％:OR,0.133,95％CI 0.027-0.652;SBPr＞30％:OR,0.104,95％CI 0.013-0.864;all P＜0.05).Conclusions Among patients who achieved successful reperfusion with EVT,SBPr might be related to a worse functional outcome at 90 days and sICH 24 h after operation.However,the relationship may exhibit significant heterogeneity across different subgroups.Baseline ASPECT score,history of hypertension,collateral circulation,and the use of continuous venous hypertension after EVT have been highlighted in individualized blood pressure management after EVT.
万方数据
维普
