作者：王晶晶 ，李斗 ，肖书丽

单位：

1.101300北京市顺义区医院院前急救科　2.101300北京市，北京急救中心

Units：

1.Department of Pre-hospital Emergency, Beijing Shunyi Hospital, Beijing 101300, China 2.Beijing Emergency Medical Center, Beijing 101300, China

关键词：

缺血性卒中；大血管闭塞性急性缺血性脑卒中；远隔缺血适应；机械取栓；治疗结果

Keywords：

Ischemic stroke; Acute ischemic stroke with large vessel occlusion; Distant ischemic adaptation; Mechanical thrombectomy; Treatment outcome

CLC：

R 743.3

DOI：

10.12114/j.issn.1008-5971.2023.00.284

Funds：

首都卫生发展科研专项项目（首发2022-2-3032）

摘要：

目的　分析院前远隔缺血适应（RIC）联合院内机械取栓治疗大血管闭塞性急性缺血性脑卒中（AIS LVO）的效果。方法　收集2020年1月至2023年1月北京市顺义区医院、首都医科大学宣武医院及首都医科大学附属北 京世纪坛医院收治的AIS-LVO患者146例为研究对象。采用随机数字表法将患者分为RIC联合机械取栓组与机械取栓 组，各73例。RIC联合机械取栓组接受院前RIC联合院内机械取栓治疗，机械取栓组接受院内机械取栓治疗。比较两组 治疗前和治疗后1、7、90 d美国国立卫生研究院卒中量表（NIHSS）评分，治疗前和治疗后14 d炎症指标〔C反应蛋白 （CRP）、白介素6（IL-6）〕、氧化应激指标〔超氧化物歧化酶（SOD）、丙二醛（MDA）〕水平及脑梗死体积，治 疗前和治疗后90 d 36项健康调查简表（SF-36）评分、Barthel指数，临床疗效，治疗后90 d神经功能预后良好率，治 疗期间并发症发生率。结果　治疗方法与时间在NIHSS评分上存在交互作用（P＜0.05）；治疗方法、时间在NIHSS评 分上主效应显著（P＜0.05）。治疗后1、7、90 d，RIC联合机械取栓组NIHSS评分低于机械取栓组（P＜0.05）。治疗 后1、7、90 d，机械取栓组、RIC联合机械取栓组NIHSS评分分别低于本组治疗前（P＜0.05）；治疗后7、90 d，机械 取栓组、RIC联合机械取栓组NIHSS评分分别低于本组治疗后1 d（P＜0.05）；治疗后90 d，机械取栓组、RIC联合机 械取栓组NIHSS评分分别低于本组治疗后7 d（P＜0.05）。治疗后14 d，RIC联合机械取栓组CRP、IL-6、MDA水平低 于机械取栓组，SOD水平高于机械取栓组（P＜0.05）；治疗后14 d，机械取栓组、RIC联合机械取栓组CRP、IL-6、 MDA水平分别低于本组治疗前，SOD水平分别高于本组治疗前（P＜0.05）。治疗后14 d，RIC联合机械取栓组脑梗死 体积小于机械取栓组（P＜0.05）；治疗后14 d，机械取栓组、RIC联合机械取栓组脑梗死体积分别小于本组治疗前 （P＜0.05）。治疗后90 d，RIC联合机械取栓组SF-36评分、Barthel指数高于机械取栓组（P＜0.05）；治疗后90 d，机 械取栓组、RIC联合机械取栓组SF-36评分、Barthel指数分别高于本组治疗前（P＜0.05）。RIC联合机械取栓组临床疗 效优于机械取栓组（P＜0.05）。治疗后90 d，RIC联合机械取栓组神经功能预后良好率高于机械取栓组（P＜0.05）。 两组治疗期间症状性颅内出血、脑血管痉挛、新发栓塞、动脉夹层发生率比较，差异无统计学意义（P＞0.05）。结论 院前RIC联合院内机械取栓可有效减轻AIS-LVO患者神经功能缺损程度，其机制可能与减轻炎症反应和氧化应激有 关；院前RIC联合院内机械取栓还可缩小AIS-LVO患者脑梗死体积，提高生活质量、日常生活活动能力、临床疗效， 改善预后，且安全性好。

Abstract：

Objective To explore the effect of pre hospital remote ischemic conditioning (RIC) combined with intra hospital mechanical thrombectomy in the treatment of acute ischemic stroke with large vessel occlusion (AIS-LVO) . Methods A total of 146 AIS-LVO patients admitted to Beijing Shunyi Hospital, Xuanwu Hospital, Capital Medical University and Beijing Century Temple Hospital Affiliated to Capital Medical University from January 2020 to January 2023 were collected as the study objects. The patients were divided into RIC combined with mechanical thrombectomy group and mechanical thrombectomy group using a random number table method, with 73 patients in each group. The RIC combined with mechanical thrombectomy group received pre hospital RIC combined with intra hospital mechanical thrombectomy treatment, while the mechanical thrombectomy group received intra hospital mechanical thrombectomy treatment. National Institutes of Health Stroke Scale (NIHSS) scores before treatment and at 1, 7, and 90 days after treatment, the levels of inflammatory markers [C-reactive protein (CRP) , interleukin-6 (IL-6) ] and oxidative stress markers [superoxide dismutase (SOD) , malondialdehyde (MDA) ] , the volume of cerebral infarction before treatment and at 14 days after treatment, the scores of Short-Form 36 Health Survey Scale (SF-36) and Barthel index before treatment and at 90 days after treatment, the clinical efficacy, the good prognosis rate of neurological function at 90 days after treatment, and the incidence of complications during the treatment were compared between the two groups. Results There was an interaction between treatment methods and time on the NIHSS score (P < 0.05) ; the main effect of treatment method and time on NIHSS score was significant (P < 0.05) . At 1, 7, and 90 days after treatment, the NIHSS score in the RIC combined with mechanical thrombectomy group was lower than that in the mechanical thrombectomy group (P < 0.05) . At 1, 7, and 90 days after treatment, the NIHSS scores of the mechanical thrombectomy group and the RIC combined with mechanical thrombectomy group were lower than those before treatment respectively (P < 0.05) ; at 7 and 90 days after treatment, the NIHSS scores of the mechanical thrombectomy group and the RIC combined with mechanical thrombectomy group were lower than those at 1 day after treatment respectively (P < 0.05) ; at 90 days after treatment, the NIHSS scores of the mechanical thrombectomy group and the RIC combined with mechanical thrombectomy group were lower than those at 7 days after treatment respectively (P < 0.05) . At 14 days after treatment, the levels of CRP, IL-6, and MDA in the RIC combined with mechanical thrombectomy group were lower than those in the mechanical thrombectomy group, while the levels of SOD were higher than those in the mechanical thrombectomy group (P < 0.05) ; at 14 days after treatment, the levels of CRP, IL-6, and MDA in the mechanical thrombectomy group and the RIC combined with mechanical thrombectomy group were lower than those before treatment, while the levels of SOD were higher than those before treatment, respectively (P < 0.05) . At 14 days after treatment, the volume of cerebral infarction in the RIC combined with mechanical thrombectomy group was smaller than that in the mechanical thrombectomy group (P < 0.05) ; at 14 days after treatment, the volume of cerebral infarction in the mechanical thrombectomy group and the RIC combined with mechanical thrombectomy group was smaller than that before treatment respectively (P < 0.05) . At 90 days after treatment, the SF-36 score and Barthel index in the RIC combined with mechanical thrombectomy group were higher than those in the mechanical thrombectomy group (P < 0.05) ; at 90 days after treatment, the SF-36 score and Barthel index in the mechanical thrombectomy group and RIC combined with mechanical thrombectomy group were higher than those before treatment respectively (P < 0.05) . The clinical efficacy of the RIC combined with mechanical thrombectomy group was better than that of the mechanical thrombectomy group (P < 0.05) . At 90 days after treatment, the good prognosis rate of neurological function of the RIC combined with mechanical thrombectomy group was higher than that of the mechanical thrombectomy group (P < 0.05) . There was no statistically significant difference in the incidence of symptomatic intracranial hemorrhage, cerebral vasospasm, new embolism, and arterial dissection between the two groups during the treatment (P > 0.05) . Conclusion Pre hospital RIC combined with intra hospital mechanical thrombectomy can effectively alleviate the degree of neurological impairment in AIS-LVO patients, and its mechanism may be related to reducing inflammatory response and oxidative stress. Pre hospital RIC combined with intra hospital mechanical thrombectomy can also reduce the volume of cerebral infarction in AIS-LVO patients, improve quality of life, daily living activities, clinical efficacy and prognosis, and have good safety.

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