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中华卫生应急电子杂志 ›› 2022, Vol. 08 ›› Issue (04) : 193 -198. doi: 10.3877/cma.j.issn.2095-9133.2022.04.001

论著

非溶栓急性缺血性卒中患者早期神经功能恶化的影响因素分析
姚富远1, 陈芳兰2, 邓哲3,†()   
  1. 1. 515041　广东汕头，汕头大学医学院
    2. 518035　广东深圳，深圳市第二人民医院重症医学科
    3. 518035　广东深圳，深圳市第二人民医院急诊科
  • 收稿日期:2022-06-27 出版日期:2022-08-18
  • 通信作者: 邓哲

Risk factors for early neurological deterioration in non-thrombolysed patients with acute ischemic stroke

Fuyuan Yao1, Fanglan Chen2, Zhe Deng3,†()   

  1. 1. Shantou University Medical School, Shantou 515041, China
    2. Department of Critical Care Medicine, the Second Peopletical Care Medicinenon-, Shenzhen 518035, China
    3. Department of Emergency Medicine, the Second Peoplergency Medicinecinenon-, Shenzhen 518035, China
  • Received:2022-06-27 Published:2022-08-18
  • Corresponding author: Zhe Deng
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姚富远, 陈芳兰, 邓哲. 非溶栓急性缺血性卒中患者早期神经功能恶化的影响因素分析[J/OL]. 中华卫生应急电子杂志, 2022, 08(04): 193-198.

Fuyuan Yao, Fanglan Chen, Zhe Deng. Risk factors for early neurological deterioration in non-thrombolysed patients with acute ischemic stroke[J/OL]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2022, 08(04): 193-198.

目的

探讨脱水指标血尿素氮/肌酐(BUN/Cr)对非溶栓急性缺血性卒中患者早期神经功能恶化(END)的预测价值。

方法

采用回顾性病例系列研究分析2016年1月至2019年12月期间深圳市第二人民医院急诊科收治的发病24 h内急性缺血性卒中患者624例，其中END组69例，非END组555例。END定义为入院后72 h内美国国立卫生研究院卒中量表(NIHSS)评分较基线增加≥2分。比较END组与非END组的人口统计学、基线临床资料以及实验室检查结果。采用多变量logistic回归分析确定END的独立危险因素。采用受试者工作特征(ROC)曲线分析BUN/Cr对END的预测价值。

结果

END组患者糖尿病比例，基线NIHSS评分、血压、血糖、白细胞、D-二聚体、红细胞沉降率(ESR)、BUN/Cr、血浆渗透压、住院时间及出院时mRS评分均显著高于非END组(P<0.05)。多因素logistic回归分析显示基线NIHSS评分(OR＝1.175，95%CI 1.075~1.284；P<0.001)、收缩压(OR＝1.021，95%CI 1.002~1.040；P＝0.029)、BUN/Cr(OR＝1.091，95%CI 1.023~1.163；P＝0.008)、ESR(OR＝1.031，95%CI 1.010~1.052；P＝0.004)是非溶栓AIS患者发生END的独立危险因素。ROC曲线分析显示，BUN/Cr预测END的ROC曲线下面积为0.652(95%CI 0.588~0.715；P<0.001)，最佳截断值为16.6，敏感度和特异度分别为75%和54%。使用预测方程0.087×BUN/Cr + 0.03×ESR + 0.161×基线NIHSS评分+0.021×收缩压-8.036对END具有较好的预测价值，其ROC曲线下面积为0.835(95% CI 0.776~0.894；P<0.001)，敏感度和特异度分别为86%和71%。

结论

BUN/Cr作为脱水指标与非溶栓AIS患者发生END的风险相关，对END具有一定的预测价值。血浆渗透压水平与END的发生无关。

关键词: 脱水, 急性缺血性卒中, 早期神经功能恶化, 危险因素
Objective

To investigate the predictive value of dehydration for the early neurological deterioration (END) in non-thrombolysed patients with acute ischemic stroke (AIS).

Methods

With a retrospective case series study, 624 patients with AIS within 24 h of onset admitted to the Department of Emergency Medicine, the Second People’s Hospital of Shenzhen between January 2016 and December 2019 were enrolled, including 69 in the END group and 555 in the non-END group. END was defined as an increase ≥ND was defined as an increaseEND group and 555 in t(NIHSS) score during the first 72 h of hospitalization. The demographics, baseline clinical data and laboratory findings between the END and non-END groups were compared. Multivariate logistic regression analysis was used to determine the independent risk factors for END. Receiver operating characteristic(ROC)curve was used to analyze the predictive value of BUN/Cr for END.

Results

There were significant differences in the proportion diabetes mellitus, baseline NIHSS score, blood pressure, blood glucose, white blood cell, D-dimer, erythrocyte sedimentation rate(ESR), BUN/Cr, plasma osmolality, hospital stay and modified Rankin scale(mRS) score on discharge between the END group and the non-END group(all P<0.05). Multivariate logistic regression analysis showed that baseline NIHSS score(odds ratio OR =1.175, 95% CI 1.075-1.284; P<0.001), systolic blood pressure(OR=1.021, 95% CI 1.002-1.040; P=0.029), BUN/Cr(OR=1.091, 95% CI 1.023-1.163; P=0.008), and ESR(OR =1.031, 95% CI 1.010-1.052; P=0.004) were the independent risk factors for END. ROC curve analysis showed that the area under the curve of BUN/Cr predicting END was 0.652(95% CI 0.588-0.715; P<0.001), the optimal cut-off value was 16.6, and the sensitivity and specificity were 75% and 54% respectively. ROC curve analysis showed that the prognostic equation(0.087×BUN/Cr+ 0.03×ESR+ 0.161×NIHSS+ 0.021×systolic blood pressure - 8.036)had a better predictive value for END, and the area under the curve was 0.835(95% CI 0.776-0.894; P<0.001), the sensitivity and specificity were 86% and 71% respectively.

Conclusion

BUN/Cr as a dehydration marker is related to the risk of END in non-thrombolysed patients with AIS, and has a certain predictive value for END. Plasma osmolality is not significantly associated with the risk for END.

Key words: Acute ischemic stroke, Early neurological deterioration, Risk factors
表1 两组患者的人口统计学和基线资料[例(%)]
组别 例数 年龄(岁，±s) 男性 血管因素
高血压 高脂血症 糖尿病 缺血性心脏病 心房颤动 既往卒中 吸烟 饮酒
END组 69 64.14±14.40 41(50.42) 48(69.57) 11(15.94) 27(39.13) 10(14.49) 6(8.70) 26(37.68) 30(43.48) 19(27.54)
非END组 555 65.25±12.59 320(57.66) 366(65.95) 58(10.45) 153(27.57) 58(10.45) 39(7.03) 168(30.27) 190(34.23) 118(21.26)
χ2/t/Z值   0.68 0.08 0.36 1.88 4.00 1.03 0.07 1.57 2.30 1.41
P值   >0.05 >0.05 >0.05 >0.05 <0.05 >0.05 >0.05 >0.05 >0.05 >0.05
表2 两组患者临床资料及转归比较(±s)
组别 例数 基线NIHSS [分，M(Q1~Q3)] OCSP分型[例(%)] 血压(mmHg，±s)
完全前循环 部分前循环 后循环 腔隙性梗死 收缩压 舒张压
END组 69 5(2~10) 20(28.99%) 29(42.03%) 11(15.94%) 9(13.04%) 151.35±25.31 88.51±16.95
非END组 555 2(1~4) 62(11.17%) 170(30.63%) 115(20.72%) 208(37.48%) 144.73±21.57 83.85±13.08
T值、Z值或χ2值   －5.46 28.55 2.35 2.69
P值   <0.001 <0.001 <0.05 <0.05
组别 例数 实验室检查
总胆固醇[mmol/L，M(Q1~Q3)] 三酰甘油[mmol/L，M(Q1~Q3)] 高密度脂蛋白[mmol/L，M(Q1~Q3)] 低密度脂蛋白[mmol/L，M(Q1~Q3)] 血糖[mmol/L，M(Q1~Q3)] WBC(×109/L，±s) PLT(×109/L，±s)
END组 69 4.02(3.46~5.03) 1.25(0.96~1.64) 1.12(0.93~1.31) 2.38(1.83~3.30) 6.03(4.82~7.21) 8.30±2.63 244.97±80.51
非END组 555 4.25(3.57~4.86) 1.32(0.99~1.82) 1.11(0.94~1.29) 2.63(2.04~3.20) 5.31(4.80~6.20) 7.40±2.23 229.12±64.80
T值、Z值或χ2值   －0.71 －1.08 －0.21 －0.96 －2.38 3.10 1.57
P值   >0.05 >0.05 >0.05 >0.05 <0.05 <0.05 >0.05
组别 例数 实验室检查
Fib[mg/L，M(Q1~Q3)] D-二聚体[mg/L，M(Q1~Q3)] hs-CRP[mg/L，M(Q1~Q3)] ESR[mm/h,M(Q1~Q3)] BUN(mmol×L－1) BUN/Cr 血浆渗透压[mOsm/kg，M(Q1~Q3)]
END组 69 2.96 (2.45~3.43) 0.74(0.32~0.92) 3.33(1.31~12.48) 19.5(9.25~45.25) 5.28±1.41 19.41±4.33 303.10(299.43~307.00)
非END组 555 2.77 (2.31~3.24) 0.52(0.27~0.82) 3.82(1.35~7.48) 13.00(7.00~20.00) 4.90±1.44 17.32±5.44 300.51(296.90~304.30)
T值、Z值或χ2值   －1.35 －1.99 －1.27 －2.79 2.06 3.07 －3.39
P值   >0.05 <0.05 >0.05 <0.05 <0.05 <0.05 <0.05
组别 例数 实验室检查
BUN/Cr>15(例，%) 住院天数[d，M(Q1~Q3)] 出院时mRS[分，M(Q1~Q3)]
END组 69 58(84.06) 11(9~14) 4(2~5)
非END组 555 377(67.93) 10(8~12) 1(1~2)
T值、Z值或χ2值   7.56 －2.67 －8.58
P值   <0.05 <0.05 <0.001
表3 END危险因素的多因素logistic回归分析
自变量 优势比(95%可信区间) P值
基线NIHSS评分 1.175(1.075~1.284) <0.001
收缩压 1.021(1.002~1.040) <0.05
BUN/Cr 1.091(1.023~1.163) <0.05
ESR 1.031(1.010~1.052) <0.05
图1 BUN/Cr预测非溶栓患者卒中早期神经功能恶化的受试者工作特征曲线
图2 联合方程预测非溶栓患者卒中早期神经功能恶化的受试者工作特征曲线
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