Analysis Of Influencing Factors Related To Hemorrhagic Transformation And Prognosis In Patients With Acute Ischemic Stroke After Intravenous Thrombolysis

Background and ObjectiveWith the development of society,the improvement of people’s living standards and the change of living habits,the incidence of stroke in China has increased significantly in recent years.Ischemic stroke is the most common type of stroke,accounting for about 77.8%of all strokes.About 3%of patients with acute ischemic stroke(AIS)become disabled and die within 1 month after onset,which greatly increases the burden on families and society.In natural course of AIS,some patients will undergo hemorrhage transformation(HT),which often leads to poor prognosis.Patients and physicians are particularly cautious about thrombolysis because of concerns about the risk of bleeding after thrombolysis.Existing studies have found that only 1.6%of AIS patients in China receive thrombolytic therapy.At present,there are relatively few studies on the risk factors of hemorrhage conversion after thrombolysis in patients with AIS,and there is still no definite conclusion whether some of the factors are risk factors of hemorrhage conversion.Previous studies have shown that Serum free Triiodothyronine(FT3)level,alanine aminotransferase,aspartate aminotransferase and the ratio of alanine aminotransferase to aspartate aminotransferase were closely related to the severity and prognosis of acute ischemic stroke,while there were few studies on the relationship between low level of FT3,alanine aminotransferase(ALT),aspartate aminotransferase(AST)and the ratio of alanine aminotransferase to aspartate aminotransferase(AAR)and hemorrhage conversion and prognosis after thrombolysis in AIS.Therefore,in this study,we collected patients with AIS who received thrombolytic therapy in our hospital,and statistically analyzed the related examination and test indexes to find out the influence factors of HT after thrombolysis and that affecting the prognosis of patients,and analyzed the relationship between low level of FT3,AST,ALT and AAR to aspartate aminotransferase and HT and prognosis after thrombolysis,in order to provide the basis for clinical treatment and reduce the occurrence of HT after thrombolysis.Materials and Methods1 Research objectsA retrospective collection of 370 AIS patients who received rt-PA intravenous thrombolytic therapy in the Department of Neurology of the First Affiliated Hospital of Zhengzhou University from June 2017 to June 2020.350 cases met the inclusion criteria and 27 cases were excluded due to the exclusion criteria,and finally included 323 cases into the study,including the general clinical data and biochemical indicators.According to the imaging examination and clinical symptoms of patients after thrombolysis,we judged whether HT occurred after thrombolysis and divided the patients into hemorrhagic transformation group and non-HT group.The patients were followed up by telephone after 90 days of thrombolytic therap.The follow-up patients were scored by mRS.Patients with mRS scores of 0-2 points were classified into the group with good prognosis,and patients with mRS scores of 3-6 points were classified into the group with poor prognosis(The patients who died were classified as poor prognosis group,with a score of 6).2 Statistical treatmentSPSS 20.0 software was used to analyze the data included in this study.The variables of measurement data that conformed to the normal distribution were expressed as Mean ±standard deviation(x±5)and using T-test to analyze.The measurement data that did not conform to the normal distribution were tested as MannWhitney U rank sum test The categorical variables were expressed as example(n)and rate(%)and the indicators related to hemorrhagic transformation and prognosis after thrombolysis were screened out by using the Chi-square test or Fisher test.The ROC curve was used to calculate the optimal cut-off value for the continuous variables.According to the cut-off value,the continuous variables were converted into binary variables and assigned values(≥cut-off value=1,<cut-off value=0).The variables that were significant for univariate analysis were included in the multivariate Logistic regression model to screen out the influencing factors of hemorrhagic transformation and short-term prognosis of patients with acute ischemic stroke after thrombolysis.The differences were statistically significant(P<0.05).Results1 Clinical FeaturesAmong the 323 patients included in this study,227 were male(70.3%),96 were female(29.7%),46 cases(14.2%)experienced HT,277 cases(85.8%)experienced no HT,224 patients(69.3%)had a good prognosis,and 30.7%had a poor prognosis,the patients who had a poor prognosis includ 11 patients(3.4%)who died,35 patients(10.8%)with coronary heart disease,62 patients(19.2%)with atrial fibrillation,180 patients(55.7%)with hypertension,116 patients(35.9%)with diabetes,43 patients(13.3%)with a history of alcohol consumption,58 patients(18.0%)with a history of smoking,74 patients(22.9%)with a history of antiplatelet drug use,and 39 patients(12.1%)with a history of stroke.2 Univariate analysis of HTThere were no statistically significant differences in Sex,age,history of alcohol consumption,history of smoking,total cholesterol,triglycerides,high-density lipoprotein,low-density lipoprotein,neutrophil count,lymphocyte count,neutrophil to lymphocyte ratio(NLR),AST,total bilirubin,coronary heart disease,diabetes,antiplatelet drug use,past stroke and fibrinogen level between the HT group and the non-HT group(P≥0.05).There were statistically significant differences in FT3 level,history of atrial fibrillation,history of hypertension,cerebral infarct size,white blood cell count,pre-thrombolysis NIHSS score,ALT,AAR,albumin level,uric acid level,blood glucose and C-reactive protein level before thrombolysis(P<0.05).3 Using ROC curve to calculate the best truncation value of continuous variables related to HTThe optimal cutoff value of NIHSS score before thrombolysis is 13 points,the optimal cutoff value of white blood cell is 9.45×109/L,the optimal cutoff value of blood sugar before thrombolysis is 12.74 mmol/L,the optimal cutoff value of c-reactive protein is 10.85mg/L,the optimal cutoff value of ALT is 19.50 U/L,the optimal cutoff value of AAR is 1.31,the value of the truncation of uric acid 296.5μmol/L,albumin cutoff value is 41.33 g/L.4 Multivariate analysis of HTWhether HT occurs after thrombolysis is transformed into a dependent variable(HT into=1,not HT into=0).Meaningful variables of Univariate analysis are transformed into independent variables,that including NIHSS score before thrombolysis,white blood cell count,ALT,AAR,blood glucose,uric acid,albumin,FT3 level before thrombolysis,cerebral infarction area,history of hypertension and assign values to the independent variables,(NIHSS score before thrombolysis(≥13=1,<13=0),white blood cell count(≥9.45 ×109/L=1,<9.45 ×109/L=0),ALT(≥19.50U/L=1,<19.50 U/L=0),AAR(≥1.31=1,<1.31=0),Uric acid(≥296.50μmol/L=1,<296.50 pmol/L=0),pre-thrombolytic blood glucose(≥12.74 mmol/L=1,<12.74 mmol/L=0),albumin(≥41.33g/L=1,<41.33 g/L=0),FT3 level(low FT3 level=1,Non-low FT3 level=0),infarct size(massive cerebral infarction=1,non-massive cerebral infarction=0),hypertension(with hypertension=1,without hypertension=0).Through the Logistic regression analysis,the results show that The NIHSS score before thrombolysis>13 points,blood glucose before thrombolysis≥12.74 mmol/L,AAR≥1.31,low FT3 level,massive cerebral infarction and atrial fibrillation were the independent risk factors for HT in patients with AIS after thrombolysis.5 Univariate analysis of prognosisThere was no statistically significant difference(P≥0.05)between Patients with good prognosis and poor prognosis group in sex,age,history of atrial fibrillation,drinking alcohol,smoking,coronary heart disease,hypertension,diabetes,antiplatelet drug use,past stroke,white blood cell count,neutrophil count,lymphocyte count,NLR,blood glucose before thrombolysis,total cholesterol,low density lipoprotein,fibrinogen,ALT,AST,AAR,albumin and C-reactive protein,while there was statistically significant difference(P<0.05)in NIHSS score,HT or not,cerebral infarct size,uric acid,total bilirubin,and FT3 level before thrombolysis.6 Using ROC curve to calculate the optimal truncation value of continuous variables related to prognosisThe cutoff values of the NIHSS score before thrombolysis were 10 points,uric acid were 309.00μmol/L and total bilirubin were 10.47μmol/L.7 Multivariate analysis of prognosisThe prognosis after thrombolysis was taken as the dependent variable(poor prognosis=1,good prognosis=0),and the NIHSS score before thrombolysis,uric acid,total bilirubin,whether HT occurred,cerebral infarct size,and FT3 level were taken as independent variables,and assign values to independent variables(NIHSS score before thrombolysis(≥10 points=1,<10 points=0),uric acid(>309.00μmol/L=1,<309.00μmol/L=0),total bilirubin(≥10.47μmol/L=1,<10.47 μmol/L=0),HT(HT=1,non-HT=0),cerebral infarct area(massive cerebral infarction=1,non-massive cerebral infarction=0),free triiodothyronine level(low FT3 level=1,non-low FT3 level).Through Logistic regression,the results showed that HT,and NIHSS score>10 before thrombolysis were the independent risk factors for poor prognosis in patients with acute cerebral infarction after thrombolysis.Total bilirubin>10.47μmol/L was a protective factor for good prognosis in patients with acute cerebral infarction after thrombolysis.Conclusion1.Low FT3 level,massive cerebral infarction,NIHSS score>13 before thrombolysis,blood glucose>12.74mmol/L and AAR>1.31 were the independent risk factors for HT after thrombolysis in patients with AIS.2.HT,massive and NIHSS score>10 before thrombolysis were the independent risk factors for poor prognosis in patients with acute cerebral infarction after thrombolysis.Total bilirubin≥10.47μmol/L was a protective factor for good prognosis in patients with acute cerebral infarction after thrombolysis.3.FT3 levels and AAR may be good biomarkers for predicting HT after intravenous thrombolysis in acute cerebral infarction.