English
SVN中文解读:血压变异对急性脑梗死临床结局影响的决定因素:来自神经影像参数的分层分析

Determinants of the impact of blood pressure variability on neurological outcome after acute ischaemic stroke

Adam de Havenon, Alicia Bennett, Gregory J Stoddard, Gordon Smith,Lee Chung, Steve O'Donnell, J Scott McNally, David Tirschwell, Jennifer JMajersik

DOI: 10.1136/svn-2016-000057 Published 27 January 2017

【作者简介】



Dr. Adam de Havenon is an Assistant Professor of Neurology atthe University of Utah, School of Medicine. After receiving his B.A. from YaleUniversity (New Haven, CT) in 2001, he received his medical degree from BrownUniversity School of Medicine in 2009 (Providence, RI) and completed internshipand neurology residency at the University of Utah in 2013. He finished a vascularneurology fellowship at University of Washington (Seattle, WA) in 2014, underthe mentorship of Dr. David Tirschwell, where he also pursued additionaltraining and certification in carotid and transcranial Doppler (TCD)ultrasound.

In July of 2014, Dr. Adam de Havenon returnedto Salt Lake City to establish his vascular neurology practice within theStroke Center at the University of Utah. His clinical practice includesevaluating and treating acute strokes in the hospital and emergency department andproviding outpatient consultation in the stroke clinic, including urgentreferrals. He has a particular clinical interest in stroke in the young,intracranial atherosclerosis, optimizing secondary stroke risk factorreduction, vascular malformations such as aneurysms, and evaluating patientsfor interventional procedures such as carotid endarterectomy or stenting. Healso provides emergency consultation to stroke patients at community hospitalsvia the University of Utah telestroke network.

Dr. Adam de Havenon's independent research isfocused on studying the application of advanced imaging modalities to betterunderstand the physiology of large vessel atherosclerosis and pathways ofcollateral blood flow in stroke patients. He is conducting a prospectiveclinical trial to evaluate the utility of MRI in choosing stroke patients thatmay benefit from experimental treatment to maintain blood flow to the area ofstroke. He has published on a number of topics related to neuroimaging and isexcited to be back at the University of Utah, which boasts one of the finestneuroradiology departments in the country and a fleet of state-of-the-artSiemens MRI scanners.

http://healthcare.utah.edu/fad/mddetail.php?physicianID=u0666658#tab1


【中文解读】

 如何优化脑梗死急性期血压管理、改善临床预后,仍是存在较多争议的卒中领域热点课题。近年来,越来越多的研究显示:脑梗死急性期血压变异性增加,是独立于血压水平之外,与不良预后相关的独立危险因素。神经影像学检查可以直观显示并量化梗死病灶和半暗带的容积,评估梗死灶近端血管闭塞、侧支循环代偿情况等,这些影像参数直接影响患者临床预后。因此,将神经影像学参数纳入到血压变异性的相关研究中,可以提供更直接的证据,探讨脑梗死急性期血压变异和梗死病灶的关系,为脑梗死急性期血压管理开启新的思路。

本文作者回顾性分析了2007-2014年间犹他大学神经科卒中中心住院治疗的急性脑梗死患者,记录入院后120小时内的血压变异情况,以测量间血压(中位数:57/人)计算血压变异参数,包括标准差、变异系数和连续变异等。随访卒中后3-12个月患者的mRS评分,并以此为因变量进行有序logistic回归分析。为进一步分析梗死病灶和相关影像学特征对上述回归分析结果的影响,以患者入院后CT灌注和血管成像的结果对患者进行影像学指标分层,包括梗死核心、低灌注和半暗带容积以及灌注-弥散不匹配区、梗死近端大血管狭窄和侧支循环情况等。 

研究纳入了110例非腔隙性前循环梗死患者,基线NIHSS12分,其中53%存在近端血管闭塞,多数患者接受了静脉溶栓(50%)或/和血管内治疗(40%)。结果显示:收缩压变异与不良预后显著相关,其中ORSD5.54ORCV3.30ORSV2.27。在纳入神经影像学分层指标后,具有较大梗死核心、低灌注和半暗带,以及近端血管闭塞和侧支循环代偿良好等神经影像特点的患者中,血压变异性与不良预后的相关性更强。 

本文存在一定的局限性。首先,纳入患者多数属于中重度卒中患者,多数接受静脉溶栓或血管内治疗,对结果进行解释时应充分考虑病例选择偏倚。其次,未对患者急性期是否使用血压活性药物进行分析;第三,研究的性质决定了该结果不能对研究变量间的因果关系做出推论。尽管如此,本文的结论为脑梗死急性期血压管理补充了新的内容:血流动力学的稳定与脑梗死病灶的良性转归相关,并可能是改善临床预后的潜在重要举措。


【解读专家】

石铸,博士,主任医师,硕士研究生导师,东莞市人民医院神经内科副主任。2014年在加州大学旧金山分校(USCF)进行访问学者研究。承担国家自然科学基金等各类基金项目7项,第一著者发表学术论文30余篇。主要研究方向为地区脑血管疾病的流行病学和临床诊治研究。



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