急性脑梗死患者阿替普酶静脉溶栓后脂蛋白相关磷脂酶A2变化特点及对认知功能恢复的影响

doi:10.3969/j.issn.1006-6233.2023.09.016

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摘要 目的: 探讨急性脑梗死患者阿替普酶静脉溶栓后脂蛋白相关磷脂酶A2变化特点及对认知功能恢复的影响。方法: 选取2022年1月至2023年2月于本院就诊行阿替普酶静脉溶栓的128例急性脑梗死患者。根据静脉溶栓后MoCA量表的评价结果,将MoCA评分<26的患者纳入恢复不良组(18例),将MoCA评分≥26的患者纳入恢复良好组(110例),并将恢复不良组随机分为训练集和验证集。对比两组治疗前后Lp-PLA2的变化趋势及临床特征等资料比较及多因素Logistic回归分析明确各变量与结局事件(认知功能恢复不良)的关系,基于危险因素绘制预测列线图及评价。再通过X-tile软件根据列线图风险得分将该模型分层,进一步探讨该模型的临床应用价值。结果: 两组患者的Lp-PLA2在阿替普酶静脉溶栓治疗后均下降,但恢复良好组(223.45±102.35μg/L)的下降幅度高于恢复不良组(289.36±110.23μg/L),两组比较差异具有统计学意义(P<0.05)。恢复不良组的年龄≥65岁、梗死部位(额叶)、溶栓前高血糖、纤维蛋白原、白细胞计数、Lp-PLA2、代谢综合症、APTT、溶栓时间均高于恢复良好组,而治疗后NIHSS评分和MESSS评分均低于恢复良好组(P<0.05)。梗死部位(额叶)、溶栓前高血糖、纤维蛋白原≥2.89g/L、白细胞计数≥8.00×10⁹L^-1、Lp-PLA2≥291.36ng/mL、代谢综合症、APTT≥31.50s、溶栓时间≥4.50s、NIHSS评分≥15.00分、MESSS评分≥12.00分是患者阿替普酶静脉溶栓后认知功能恢复不良的危险因素(P<0.05)。风险预测模型列线图评价的结果显示,训练集和验证集的C-index分别为0.862、0.826;两集的校正曲线均与理想曲线拟合反映良好;训练集和验证集的ROC曲线下面积(AUC)分别为0.864(95%CI:0.789~0.898,P<0.001)和0.834(95%CI:0.774~0.877,P<0.001);决策曲线显示阈值概率在0.01~0.91时,净获益率>0,具有较高的净获益值,安全可靠,实用性强。高风险组恢复不良的发生率明显高于中风险组和低风险组(χ²=6.266,P=0.013)。结论: 基于这种理想和实用的预测模型,我们可以早识别并积极干预静脉溶栓后急性脑梗死患者,以改善其预后。

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关键词 ：急性脑梗死, 阿替普酶, 静脉溶栓, 脂蛋白相关磷脂酶A2, 认知功能

Abstract：Objective: To investigate the characteristics of changes in lipoprotein-related phospholipase A2 after intravenous thrombolysis with alteplase in patients with acute cerebral infarction and the effect on cognitive function recovery. Methods: One hundred and twenty-eight patients with acute cerebral infarction admitted to our hospital for intravenous thrombolysis with alteplase from January 2022 to February 2023 were selected. According to the evaluation results of the postoperative MoCA scale, the patients with MoCA score <26 were included in the poor recovery group (18 cases), and those with MoCA score ≥26 were included in the good recovery group (110 cases). The poor recovery group was randomly divided into a training set and a verification set. The change trend and clinical characteristics of Lp-PLA2 before and after treatment were compared between the two groups, and the relationship between the variables and outcome events (adverse recovery of cognitive function) was determined by multivariate Logistic regression analysis, and the prediction line graph and evaluation were drawn based on the risk factors. Then the model was stratified according to the risk score of the column graph by X-tile software, and the clinical application value of the model was further discussed. Results: The Lp-PLA2 levels in both groups were decreased after intravenous thrombolytic therapy with alteplase, but the decrease in the good recovery group (223.45±102.35 μg/L) was higher than that in the poor recovery group (289.36±110.23 μg/L), and the difference between the two groups was statistically significant (P<0.05). Age ≥65 years old, infarct site (frontal lobe), pre-thrombolysis hyperglycemia, fibrinogen, white blood cell count, Lp-PLA2, metabolic syndrome, APTT, and thrombolysis time in poor recovery group were all higher than those in good recovery group, while NIHSS score and MESSS score after treatment were lower than those in good recovery group (P<0.05). Infarct site (frontal cortex), pre-thrombolysis hyperglycemia, fibrinogen ≥2.89g/L, white blood cell count ≥8.00×10⁹/L, Lp-PLA2≥291.36ng/mL, metabolic syndrome, APTT≥31.50s, thrombolysis time ≥4.50s, NIHSS score ≥15.00, and MESSS score ≥12.00 were the risk factor for poor cognitive recovery after intravenous thrombolysis of alteplase (P<0.05). The results of risk prediction model line graph evaluation showed that the C-index of training set and verification set were 0.862 and 0.826, respectively. The calibration curves of the two sets fit well with the ideal curves. The area under ROC curve (AUC) of the training and validation sets were 0.864 (95%CI: 0.789~0.898, P<0.001) and 0.834 (95%CI: 0.774~0.877, P<0.001), respectively. The decision curve showed that when the threshold probability was 0.01 ~ 0.91, the net benefit rate was > 0, which had a high net benefit value, safe and reliable, with strong practicability. The incidence of poor recovery in high risk group was significantly higher than that in medium risk group and low risk group (χ²=6.266, P=0.013). Conclusion: Based on this ideal and practical predictive model, we can identify and actively intervene early in patients with acute cerebral infarction after intravenous thrombolysis to improve their prognosis.

Key words： Acute cerebral infarction Alteplase Intravenous thrombolysis Lipoprotein-associated phospholipase A2 Cognitive function

基金资助:四川省卫生健康委员会科研课题,(编号:20PJ195)

引用本文:

周莉, 郭兰, 邹雪梅, 张轩, 郑辉, 陈星宇. 急性脑梗死患者阿替普酶静脉溶栓后脂蛋白相关磷脂酶A2变化特点及对认知功能恢复的影响[J]. 河北医学, 2023, 29(9): 1494-1501.
ZHOU Li, GUO Lan, ZOU Xuemei, et al. Correlation Analysis between Preoperative Endoscopic Score and Poor Prognosis of Patients with Esophageal Cancer after Endoscopic Submucosal Dissection. HeBei Med, 2023, 29(9): 1494-1501.

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http://www.hbyxzzs.cn/CN/10.3969/j.issn.1006-6233.2023.09.016 或 http://www.hbyxzzs.cn/CN/Y2023/V29/I9/1494

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