脑卒中康复患者静脉血栓的发病率及对功能的影响

doi:10.3969/j.issn.1006-9771.2022.01.007

摘要/Abstract

摘要：

目的回顾性分析康复病房中脑卒中恢复期患者静脉血栓疾病的发生率及其对功能预后的影响。方法回顾性分析2015年1月至2020年10月北京博爱医院神经康复病房脑卒中住院患者3 557例。统计人口学特征、卒中特点(类型、部位)、实验室指标(D-二聚体、动脉氧分压)、运动功能(Brunnstrom分期、Fugl-Meyer运动和平衡评分、小腿三头肌改良Ashworth评分、Holden步行功能分级)、日常生活活动能力(Barthel指数),以及抗凝剂/抗血小板治疗数据。结果下肢静脉血栓和肺栓塞的发生率分别为28.5%和1.29%,多数发生在发病30 d后。相比脑出血,缺血性脑卒中患者发生肺栓塞风险更高(χ² = 12.49, P < 0.001),年龄更大(t = 2.501, P < 0.05);大面积脑卒中、严重下肢瘫痪和日常生活活动能力低下的患者更易发生静脉血栓栓塞疾病。并发肺栓塞患者经过康复,功能和日常生活活动能力均比入院时显著改善(|t| > 4.302, P < 0.001)。结论康复病房中脑卒中恢复期患者下肢静脉血栓和肺栓塞的发生率不容忽视。应根据风险因素对患者进行分层,年龄较大、既往有血栓形成史、大面积脑卒中和严重肢体瘫痪的患者风险更大。并发肺栓塞患者,如抗凝治疗有效,可早期开展个体化全面康复,以改善其功能预后和日常生活活动能力。

关键词: 脑卒中, 静脉血栓栓塞, 肺栓塞, 康复, 风险因素

Abstract:

Objective To explore the risk of venous thromboembolism (VTE), especially lower-extremity deep vein thrombosis (DVT) and pulmonary embolism (PE), for stroke patients in rehabilitating, and the functional outcome. Methods A total of 3 557 stroke patients in the neurological rehabilitation center of Beijing Bo'ai Hospital for stroke rehabilitation from January, 2015 to October, 2020 were reviewed through the electronic medical record system. Demographic characteristics, stroke characteristics (type and location), laboratory data (D-dimer polymer and arterial partial pressure of oxygen), motor function (Brunnstrom stage, Fugl-Meyer Assessment of motor and balance, modified Ashworth Scale score of triceps crus, and Holden Walking Ability Classification), activities of daily living (Barthel Index), and anticoagulant/antiplatelet treatment data were collected and analyzed. Results The incidence of DVT and PE was 28.5% and 1.29%, respectively. Most were found 30 days later after onset. The incidence of PE was higher after ischemic stroke (χ² = 12.49, P < 0.001) rather than hemorrhagic stroke. The patients with hemispheric stroke, severe lower-extremity paralysis, and poor activities of daily living were more prone to complications associated with VTE. After rehabilitation, the function of stroke patients with PE could be improved (|t| > 4.302, P < 0.001). Conclusion The risk of DVT and PE in patients during stroke convalescence may not be negligible, and those with older age, previous history of thrombosis, severe stroke, and severe limb paralysis may be stratified in high-risk. Following anticoagulation treatment, early individualized comprehensive rehabilitation can be done for patients with PE to improve their function and activities of daily living.

Key words: stroke, venous thromboembolism, pulmonary embolism, rehabilitation, risk factors

中图分类号:

R743.3

吴晓莉,胡雪艳,张玉阁,叶长青,陈予东,厉含之,杨凌宇,高飞,杨宇琦,山磊,刘丽旭. 脑卒中康复患者静脉血栓的发病率及对功能的影响[J]. 《中国康复理论与实践》, 2022, 28(1): 44-49.

WU Xiaoli,HU Xueyan,ZHANG Yuge,YE Changqing,CHEN Yudong,LI Hanzhi,YANG Lingyu,GAO Fei,YANG Yuqi,SHAN Lei,LIU Lixu. Epidemiology and functional outcome of venous thromboembolism after stroke in rehabilitation wards[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(1): 44-49.

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项目	脑梗死(n = 1 349)	脑出血(n = 2 208)	χ²/t值	P值
并发DVT/n	623	391	333.126	< 0.001
性别(男/女)/n	371/252	266/125	7.397	0.007
年龄/岁	65.6±10.45	58.91±11.36	9.598	< 0.001
瘫痪情况(偏瘫/双瘫)/n	609/14	376/11^a	6.748	0.034
并发DVT和PE/n	26	15	0.070	0.791

项目		脑梗死(n = 1 349)	脑出血(n = 2 208)	χ²/t值	P值
并发PE/n		29	17	12.490	< 0.001
性别(男/女)/n		14/15	13/4	3.514	0.061
年龄/岁		66.76±6.43	59.71±12.73	2.501	0.016
住院时病程/d		51.14±46.91	50.53±61.55	0.038	0.970
既往史/n	高血压	17	17	9.517	0.002
	冠心病	0	1
	房颤	6	0
	恶性肿瘤	1	2
	糖尿病	7	1
	既往卒中病史	9	0
吸烟/n		13	5	1.069	0.301
饮酒/n		10	6	0.003	0.956
病灶部位/n	皮层	3	2	0.600	0.741
	皮层下	9	7
	皮层和皮层下	17	8
瘫痪侧/n	左	16	8	2.778	0.249
	右	10	9
	双侧	3	0
NIHSS评分		11.59±4.562	12.06±4.562	-0.366	0.716
下肢NIHSS评分		2.76±1.527	3.24±1.033	-1.141	0.260
FMA平衡评分		2.76±1.527	1.59±2.785	1.866	0.069
FMA下肢运动评分		8.66±6.909	6.41±5.087	1.164	0.251
下肢Brunnstrom分期		2.48±1.153	2.24±1.30	0.670	0.506
BI评分		25.17±17.702	19.71±16.533	1.035	0.306
Holden步行能力分级		0.34±0.769	0.12±0.485	1.095	0.280
小腿三头肌MAS评分		0.28±0.649	0.12±0.332	0.933	0.356
D-二聚体/mg·L^-1		4.51±4.17	7.23±10.81	-1.213	0.232
动脉血氧分压/mmHg		70.40±8.31	69.31±8.36	0.431	0.669
无症状PE/n		7	6	1.220	0.543
轻症PE/n		9	3
重度PE/n	严重	12	8
重度PE/n	死亡	1	0

项目	入院时 (n = 45)	出院时 (n = 45)	t值	P值
NIHSS评分	11.60±4.78	7.40±4.76	5.753	< 0.001
FMA运动评分	22.04±23.30	27.42±26.20	-4.302	< 0.001
FMA平衡评分	2.64±3.25	4.71±3.85	-4.713	< 0.001
下肢Brunnstrom分期	2.42±1.20	2.84±1.07	-4.855	< 0.001
BI评分	23.44±17.38	36.33±19.67	-7.712	< 0.001
Holden步行能力分级	0.27±0.69	0.82±1.07	-4.748	< 0.001