摘要：

目的 探讨肿瘤患者发生缺血性卒中的影响因素、生化指标、病因，以及影像学特点，以提高临床认识。方法 收集 2018 年 4 月至 2019 年 1 月收治的 693 例缺血性卒中患者临床资料，比较缺血性卒中伴活动性癌症组（癌症组，31 例）与传统急性缺血性卒中不伴癌症组（对照组，662 例）入院时社会人口学数据、脑卒中危险因素、入院时美国国立卫生研究院卒中量表（NIHSS）评分，血小板计数、D-二聚体、纤维蛋白原、C-反应蛋白水平，扩散加权成像（DWI）显示的梗死灶特点［急性多发性缺血病变（AMIMCT）］，记录癌症组患者肿瘤类型及组织学分型差异。采用单因素和多因素后退法Logistic回归分析癌症相关缺血性卒中的影响因素。结果 与对照组相比，癌症组患者年龄偏高（χ² = 2.148，P = 0.032），高血压（χ² = 5.425，P = 0.020）和高脂血症（Fisher 确切概率法：P = 0.000）比例低；血清 D-二聚体（Z = 2687.500，P = 0.001）、纤维蛋白原（t = 2.402，P = 0.022）和 C-反应蛋白（Z = 3669.000，P = 0.001）水平升高。两组TOAST分型差异具有统计学意义（Fisher确切概率法：P = 0.000），与对照组相比，癌症组大动脉粥样硬化（LAA）型比例较低（Fisher确切概率法：P = 0.000），不明病因（SUE）型比例较高（χ² = 175.418，P = 0.000）；而 AMIMCT 比例较高（χ² = 22.560，P = 0.000）。多因素后退法 Logistic 回归分析显示，癌症组患者缺乏高脂血症病史（OR = 0.188，95%CI：0.048 ~ 0.730；P= 0.016），而 SUE 型（OR = 29.854，95%CI：10.310 ~ 86.449；P = 0.000）以及高水平的血清 D?二聚体（OR = 1.663，95%CI：1.294 ~ 2.137；P = 0.000）和纤维蛋白原（OR = 1.785，95%CI：1.294 ~ 2.137；P = 0.000）是其危险因素。结论 癌症相关缺血性卒中患者常缺乏大动脉粥样硬化证据，血清 D-二聚体和纤维蛋白原水平升高，以及 SUE 型提示此类患者可能存在高凝状态和栓塞机制。

关键词: 卒中, 脑缺血, 癌, 回归分析

Abstract:

Objective To explore the influencing factors, biomarkers, etiology and imaging features of cancer-associated ischemic stroke. Methods The clinical data of 693 patients with ischemic stroke from April 2018 to January 2019 were retrospectively collected. The patients were divided into ischemic stroke with active cancer (cancer group, N = 31) and traditional ischemic stroke (control group, N = 662). The sociodemographic data, risk factors for stroke, National Institutes of Health Stroke Scale (NIHSS) scores on admission, platelet count, D-dimer, fibrinogen and C-reactive protein (CRP) level, features of infarcts on diffusion-weighted imaging [DWI, which was acute multiple ischemic lesions located in more than one vascular territories (AMIMCT)], and the tumor type and histological classification in cancer group were recorded. Univariate and multivariate backward Logistic regression analysis were used to analyze the influencing factors of cancer-associated ischemic stroke. Results Compared with control group, patients in cancer group had older age (χ² = 2.148, P = 0.032), lower proportion of hypertension (χ² = 5.425, P = 0.020) and hyperlipidemia (Fisher exact probability: P = 0.000), and elevated levels of serum D-dimer (Z = 2687.500, P = 0.001), fibrinogen (t = 2.402, P = 0.022) and CRP (Z = 3669.000, P = 0.001). There was significant difference between 2 groups on TOAST (Fisher exact probability: P = 0.000). Patients in cancer group had lower proportion of large artery atherosclerosis (LAA; Fisher exact probability: P = 0.000), but higher proportion of stroke of undetermined etiology (SUE; χ² = 175.418, P = 0.000) and AMIMCT (χ² = 22.560, P = 0.000). Multivariate backward Logistic regression analysis showed having no history of hyperlipidemia (OR = 0.188, 95%CI: 0.048-0.730; P = 0.016), SUE (OR = 29.854, 95%CI: 10.310-86.449; P = 0.000), elevated levels of D?dimer (OR = 1.663, 95%CI: 1.294-2.137; P = 0.000) and fibrinogen (OR = 1.785, 95% CI: 1.294-2.137; P = 0.000) were risk factors for cancer-associated ischemic stroke. Conclusions It is usually lack of evidence of LAA for cancer-associated ischemic stroke. Elevated D-dimer and fibrinogen, and SUE demonstrated that hypercoagulability and microembolus embolism may be the possible mechanism of cancer-associated ischemic stroke.

Key words: Stroke, Brain ischemia, Carcinoma, Regression analysis