心电图or颅脑MRA?更能找出预后不良的癌症合并卒中患者?

2021-11-13 LILYMED MedSci原创

PLOS ONE:颅内动脉粥样硬化和心房颤动对活动性癌症患者缺血性中风的预后的影响

癌症和缺血性中风是全世界残疾和死亡的主要原因。这两种疾病密切相关,活动性癌症已被确认为缺血性中风的独立危险因素。缺血性中风在癌症患者中很常见,多达15%的患者在癌症治疗中经历过缺血性中风。 此外,癌症患者的缺血性中风成因复杂,因为癌症特异性和常规中风机制都涉及其中。因此,与其他患者相比,他们发生的卒中更严重,复发更频繁,预后更差

随着癌症患者预期寿命的大幅提高,其长期生活质量已成为一个重要问题。因此,癌症患者缺血性中风这一可导致永久性残疾或死亡的疾病已被广泛研究。颅内动脉粥样硬化(ICAS)、心房颤动(AF)和癌症具有共同的危险因素,且ICAS和AF常见于晚期癌症患者。在本研究旨在厘清活动性癌症患者的ICAS和AF与缺血性卒中预后的关系。

本次共有116例缺血性脑卒中患者(平均年龄71±11岁;男性,61.2%;NIHSS初始平均评分为9±7)。32例(27.6%)患者发生早期神经功能恶化(END)事件,50例(43.1%)患者预后不佳。21例(18.1%)患者检出AF, 37例(31.9%)患者检出ICAS,其中26例(22.4%)有狭窄,11例(9.5%)有闭塞。

单因素分析中,END与NIHSS初始评分、溶栓治疗、ICAS的相关性有统计学意义(表1)。在多变量logistic回归分析中,在调整混杂因素后,ICAS(aOR= 4.56, 95%CI : 1.52-13.70)和多区域病变(aOR = 2.90, 95% CI: 1.05-7.97)仍具有显著性。ICAS与END根据狭窄程度呈定量正相关(狭窄组:aOR = 4.24, 95% CI: 1.31-13.72;闭塞组:aOR = 5.74, 95% CI: 1.05-31.30)。AF与END呈正相关,但统计学意义不大(aOR = 3.31, 95% CI: 0.97-11.32;表2)。

不良结局与全身转移、NIHSS初始评分、溶栓治疗、白细胞(WBC)计数、hs-CRP、D-二聚体、MRI病变类型、DWI病变体积和ICAS相关,且糖尿病和AF密切相关(表3)。在多变量分析中,在调整混杂因素后,ICAS (aOR = 6.33, 95% CI: 1.15-34.79)仍然显著。NIHSS初始评分(aOR = 1.22, 95% CI: 1.09-1.37)和多区域病变(aOR = 19.31, 95% CI: 3.61-103.32)也与不良预后显著相关,独立于ICAS。房颤与不良预后没有统计学意义的相关性(表4)。

根据ICAS病变负荷比较预后时,狭窄程度与NIHSS初始评分(趋势P< 0.001)、DWI病变体积(趋势P = 0.001)、END ( 趋势P= 0.001)、不良结局(趋势P <0.001)呈正相关(图1)。

此外,通过比较四组的特点,研究个体和协同作用对ICAS和AF预后的影响。与其他组相比,AF组和ICAS组的END和不良结局发生率更高,NIHSS初始评分、WBC计数、hs-CRP和DWI病变体积更高。这些趋势从大到小依次为[AF和ICAS组]、[仅ICAS组]、[仅AF组]和[隐源组]。四组间D -二聚体水平或多发性脑损伤似乎没有显著差异(表5)。

综上,本研究发现ICAS与活动性癌症的缺血性卒中患者END和不良结局相关,且这些相关性与ICAS狭窄程度成正比。严重ICAS损伤的患者脑卒中面积大、严重程度高。相比之下,房颤患者预后较差,但差异无统计学意义。

总的来说,本研究证实ICAS与活动性癌症患者合并急性至亚急性期缺血性卒中的与不良预后密切相关。这种关联似乎与合并ICAS时形成大而严重的初始脑卒中病变的倾向有关。因此,通过共同进行初始MRA,可以帮助我们在后期对预后不良的高危人群进行分类。

原文来源:

Ki-Woong Nam, et al. Effects of intracranial atherosclerosis and atrial fibrillation on the prognosis of ischemic stroke with active cancer..

PLOS ONE | https://doi.org/10.1371/journal.pone.0259627 November 5, 2021

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    2021-11-13 JZ Yang

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