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急性缺血性卒中的血壓管理悖論丨醫脈雙語· 第 11期

導讀


醫脈雙語群是一個神奇的大家庭,聚集了眾多愛英語的神內醫生。每日大家會在群裡分享一篇英文資訊/病例+醫脈雙語之懂你一句+最後分享一首英文歌。大家可以開心的翻譯、交流、學習,每個人都有其獨特的翻譯風格,每個人都在積極的參與著。今後的日子我們將不忘初心、砥礪前行。
本期內容分享的是Melanie Penn的單曲《Ordinary Day》,唱腔溫柔,如微風拂面。大家可以伴隨著輕鬆的音樂節奏,了解一下神經領域最近的研究進展。最後來一碗「雞湯」,開心快樂地學習~

一、雙語資訊

今日分享兩個小研究~


1、急性缺血性卒中血壓悖論

[1] The Blood Pressure Paradox in Acute Ischemic Stroke

? 急性缺血性卒中血壓悖論

[2] There is no consensus on the optimal target forbaseline blood pressure (BP) in acute ischemic stroke patients. Studies of theassociation between acute BP and clinical outcomes are contradictory. Positive,negative, or U-shaped correlations between BP and outcomes have all beendescribed

? 急性缺血性卒中患者最佳基線血壓水準存在爭議。關於急性期血壓與臨床預後關係的研究結論不一,正相關、負相關、U型相關均有報導

[3] In patients with acute ischemic stroke,especially those with large vessel occlusion or a proximal stenosis, higher BPmay help sustain collateral perfusion, which may minimize final infarction.However, high BP may also increase the risk of complications, such as brainedema and hemorrhagic transformation

? 對於急性缺血性卒中患者,特別是大血管閉塞或近端狹窄患者,較高的血壓有益於維持側枝灌注,可以使最終梗死最小化。然而,高血壓也增加併發症風險,如腦水腫和出血轉化。

[4] Consecutive acute ischemic stroke patientspresenting within 12 hours of symptom onset from 7 medical centers globallybetween 2011 and 2017 were prospectively recruited for the International StrokePerfusion Imaging Registry. Patients identified with large vesselocclusion/stenosis with baseline multimodal computed tomography, follow[1]upimaging, and complete clinical profifiles were included. A 90-day modifiedRankin Scale of 0-1 was defined as an excellent functional outcome. Cerebralcollateral flow was quantified by the volume ratio of tissue within the delaytime >3 seconds perfusion lesion with severely delayed contrast transit(delay time >3 seconds/delay time >6 seconds).

? Hong等進行了國際卒中灌注成像登記研究(INSPIRE),納入2011-2017年間全球7家醫學中心連續的發病12小時內的急性缺血性卒中患者。基線多模式CT證實大血管閉塞/狹窄、隨訪影像及臨床資料完整者被納入分析。90天mRS 0-1定義為預後良好,腦側枝血流通過低灌注區(延遲時間>3s)與嚴重低灌注區(延遲時間>3s)體積之比來定量。

[5] Results: There were 306 patients included in thisstudy. With every increase of 10 mmHg in baseline systolic blood pressure, theodds of achieving an excellent functional outcome decreased by 12% inmultivariate analysis (odds ratio = 0.88, p = 0.048). Conversely, increasedbaseline blood pressure was associated with better collateral flow. In thesubgroup analysis according to reperfusion status, higher BP was correlatedwith increased infarct growth in patients without reperfusion but decreasedinfarct volume growth in patients with reperfusion. Higher BP was associatedwith decreased odds of an excellent functional outcome only in patients withoutreperfusion. For every 10 mmHg increase in SBP, the odds of an excellentfunctional outcome were reduced by 16% (multivariate-adjusted OR = 0.84, 95% CI= 0.72–0.99,p = 0.03). However, for patients withreperfusion, every 10 mmHg increase in DBP was associated with 78% increasedodds of an excellent functional outcome (multivariate-adjusted OR = 1.78, 95%CI = 1.004–3.15, p = 0.048).

? 結果:共納入306例患者。多因素分析顯示,基線收縮壓每增加10 mmHg,良好功能預後的可能性下降12% (OR =0.88, p = 0.048)。相反,基線血壓高與較好的側支血流相關。根據再灌注狀態的亞組分析顯示,對於大血管未再通的患者,較高的血壓增加梗死體積,而對於大血管再通的患者,較高的血壓減小梗死體積。較高的血壓降低預後良好可能性僅見於大血管未再通的患者,收縮壓每增加10 mmHg,良好功能預後的可能性下降16%(multivariate-adjusted OR = 0.84, 95% CI = 0.72–0.99,p = 0.03)。而對於大血管再通的患者,舒張壓每增加10 mmHg,良好功能預後的可能性增加78%(multivariate-adjustedOR = 1.78, 95% CI = 1.004-3.15, p = 0.048)

[6] Interpretation: Higher baseline blood pressure inacute ischemic stroke patients with large vessel occlusion/stenosis wasassociated with better collateral flow. However, for patients withoutreperfusion, higher baseline blood pressure was associated with increasedinfarct growth, leading to an unfavorable clinical outcome. The relationshipbetween blood pressure and outcomes is highly dependent on reperfusion, andactive blood pressure–lowering treatment may be inappropriate in acute ischemicstroke patients prior to reperfusion treatment.

? 解讀:對於急性大血管閉塞/狹窄性缺血性卒中患者,基線較高的血壓與較好的側支血流相關。但是,對於大血管未再通的患者,基線較高的血壓增大梗死體積,與預後不良相關。血壓與預後的關係高度依賴血管再通狀態,再灌注治療前積極降壓可能並不合適。

信源:Lan Hong, Xin Cheng, Longting Lin,et al.The Blood Pressure Paradox in Acute Ischemic Stroke.ANN NEUROL 2019;85:331-339.

——譯者:宿遷市第一人民醫院神經內科陳孝東


2、腦出血後再發主要腦缺血及出血事件的風險

[1] Five-Year Risk of Major Ischemic andHemorrhagic Events After Intracerebral Hemorrhage

? 腦出血後主要出血和缺血性事件的5年風險

? 腦出血後5年內再發主要腦缺血及出血事件風險

[2] Background and Purpose—We aimed todetermine incidences and predictors of major vascular events in intracerebral hemorrhage(ICH) survivors.

? 背景和目的:確定腦出血倖存者中主要血管事件的發生率和預測因子。

? 背景和目的:我們的目的是明確顱內出血倖存者的主要血管事件發生及預測因素。

[3] Methods—We did a prospective observationalcohort study in patients with spontaneous ICH from the Prognosis of IntracerebralHemorrhage cohort in Lille, France. We studied incidences and predictors oflong-term vascular events (cerebral and extracerebral, ischemic andhemorrhagic) in patients alive at 30 days with a prespecified subgroup analysisaccording to ICH location. We performed multivariable analyses (competing riskanalyses, with death during follow-up as a competing event).

? 方法:我們選擇法國裡爾市自發性腦出血患者從預後方面進行了前瞻性觀察隊列研究。主要研究了30天記憶體活患者的長期血管事件(包括顱內外腦缺血和出血事件)的發生率和預測因子,並根據腦出血的位置分組進行亞組分析。我們進行了多變數分析(對抗性風險因素分析及可致死亡的一個對抗事件)。

[4] Results—From the 560 patients withspontaneous ICH enrolled between November 2004 and March 2009, we included 310 patients(median age, 70 years). Eighty-two patients presented at least 1 major vascularevent leading to an incidence rate of 20.0% (95% CI, 15.7–24.7) at 5 yearsafter ICH.

? 結果:2004年11月至2009年3月之間共登記了560例自發性腦出血患者,其中310例(平均年齡70歲)納入研究。82例患者在腦出血後5年中至少出現1次主要血管事件,發生率為20.0%(95%CI,15.7-24.7)。

[5] Inthe overall cohort, ischemic events were more frequent than hemorrhagic events.However, the incidence strikingly differed according to ICH location: deep ICHwas associated with future ischemic events (subhazard ratio, 1.85; 95% CI,1.01–3.40), whereas lobar ICH was with hemorrhagic events(subhazard ratio,2.38; 95% CI, 1.17–4.86).

? 在整個隊列中,缺血事件的發生率比出血事件更高。然而,根據ICH位置,發病率明顯不同:深部ICH與缺血事件相關(亞危險比,1.85; 95%CI,1.01-3.40),而腦葉ICH與出血事件相關(亞危險比,2.38; 95%CI ,1.17-4.86)。

[6] In deep ICH, the incidence of ischemicevents at 5 years was 6× higher than the incidence of hemorrhagic events.

? 在深部ICH中,5年缺血事件的發生率比出血事件的發生率高6倍。

[7] Conclusions—ICH survivors are at high riskof both cerebral and extracerebral vascular events. The ischemic or hemorrhagicrisk profile varies according to the index ICH location with a strongerischemic risk in deep ICH.

? 結論:腦出血存活者同時面臨腦內和腦外血管事件的高風險。缺血性或出血風險因腦出血部位的不同而不同,深部腦出血的缺血風險較高。

[8] Secondary prevention,tailored on ICHlocation, should target not only cerebral recurrences but also extracerebralvascular events.

? 對於針對腦出血部位的二級預防,不該隻把目標放在顱內複發上,還要關注顱外血管事件。

? 根據腦出血部位制定的二級預防不僅要針對腦血管病複發,而且要針對腦血管外事件複發。

信源:Five-Year Risk of Major Ischemic and Hemorrhagic Events After Intracerebral Hemorrhage.Stroke. 2019 50(5):1100-1107. doi: 10.1161/STROKEAHA.118.024449.

——譯者:趙偉、杭師大附院王小川、大坪醫院黎炳護、哈醫大神內陳星、廊坊市人民醫院袁淑珍等

二、醫脈雙語之懂你一句

今日雞湯一碗:He who has overcome his fears will truly be free.

你一言我一語???

? 勝於自我恐懼 收之真正自由

? 克服恐懼,超越自我

? 無懼無畏,自由放飛

? 勇者無懼

? 自勝者強

? 克服了恐懼的人才是真正的自由

? 成大事者無懼

? 戰勝恐懼,終獲自由

? 克服恐懼才能獲得自由的靈魂

? 有敬畏而無恐懼之心才是真正自由

? 能改成是感覺好些

? 強者自救,聖者渡人

——譯者:哈醫大神內陳星、姚、曉昀、amy、順德均安醫院何深文、扶溝縣醫院神內梁丙寅、宇森、廊坊市人民醫院神內科袁淑珍、南堡開發區醫院神內何臻善、遼健集團鐵煤總醫院神內陳建國、杭師大附院王小川等


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