重症监护病房儿童脑卒中临床特征和功能结局分析

周吉华; 明美秀; 陈伟明; 陆国平

doi:10.16766/j.cnki.issn.1674-4152.002840

重症监护病房儿童脑卒中临床特征和功能结局分析

doi: 10.16766/j.cnki.issn.1674-4152.002840

复旦大学附属儿科医院重症医学科，上海 201102

基金项目:

国家重点研发计划项目 2021YFC2701800

国家重点研发计划项目 2021YFC2701805

详细信息

通讯作者:
陆国平，E-mail：lgp@fudan.edu.cn

中图分类号: R743.3
计量
- 文章访问数: 133
- HTML全文浏览量: 42
- PDF下载量: 9
- 被引次数: 0
出版历程
- 收稿日期: 2022-12-09
- 网络出版日期: 2023-04-20

Characteristics and functional outcome of childhood stroke in a pediatric intensive care unit

Department of Critical Care Medicine, Children ' s Hospital of Fudan University, Shanghai 201102, China

摘要

摘要: 目的探讨儿童重症监护病房(PICU)脑卒中临床特征和分析功能结局的危险因素。方法选取2018年7月—2022年6月复旦大学附属儿科医院PICU收住的脑卒中连续病例163例，以出院时脑功能分类量表评分(范围1~6分)≥4分为功能结局预后差。采集临床特征，通过多因素logistic回归分析，评估功能结局预后差及院内死亡的危险因素。结果 163例脑卒中患儿中男88例(54.0%)，起病年龄为4.5(1.2, 9.3)岁；缺血性脑卒中(IS)84例，出血性脑卒中(HS)79例，急性期总体出院病死率为16.6%，IS和HS病死率分别为8.3%(7/84)和25.3%(20/79)；55例(33.7%)出院时功能结局预后差；136例出院存活患儿中，95例(69.9%)遗留残疾；收入PICU时的改良格拉斯哥昏迷评分(GCS)低(OR=0.658，95% CI：0.582~0.743，P＜0.001)与出院时功能结局预后差显著相关；HS(OR=3.071，95% CI：1.121~8.417，P=0.029)和改良GCS低(OR=0.738，95% CI：0.648~0.840，P＜0.001)与院内死亡显著相关。结论 PICU脑卒中患儿中，IS和HS约各占一半，1/3的患儿出院时功能结局预后差，出院存活患儿中超过2/3遗留残疾。收入PICU时的改良GCS低为出院时功能结局预后差的危险因素，HS和改良GCS低为院内死亡的危险因素。
- 脑卒中 /
- 缺血性脑卒中 /
- 出血性脑卒中 /
- 功能预后 /
- 儿童
Abstract: Objective To explore the clinical characteristics of children with stroke in a pediatric intensive care unit (PICU) and analyze the risk factors of its functional outcome. Methods A total of 163 consecutive childhood stroke patients admitted in PICU of the Affiliated Pediatric Hospital of Fudan University from July 2018 to June 2022 were included. The score of the brain function classification scale at hospital discharge (ranging from 1 to 6 points) ≥ 4 points was regarded as poor functional outcome. Patients characteristics were collected, and multivariate logistic regression analyses were performed to screen risk factors of poor functional outcome at hospital discharge and in-hospital mortality. Results Among 163 patients, 88 cases were male patients (54.0%), with an onset age of 4.5 (1.2, 9.3) years. There were 84 cases of ischemic stroke (IS) and 79 cases of hemorrhagic stroke (HS). The overall case-fatality was 16.6% at hospital discharge, and the mortality rates of IS and HS were 8.3% (7/84) and 25.3% (20/79) respectively. There were 55 patients (33.7%) with poor functional outcomes at hospital discharge. Among 136 cases surviving to hospital discharge, 95 cases (69.9%) had residual disability. Lower modified Glasgow Coma Scale (GCS) score on PICU admission was significantly associated with poor functional outcome at hospital discharge (OR=0.658, 95% CI: 0.582-0.743, P < 0.001). HS (OR=3.071, 95% CI: 1.121-8.417, P=0.029) and lower modified GCS score on PICU admission (OR=0.738, 95% CI: 0.648-0.840, P < 0.001) were significantly associated with in-hospital mortality. Conclusion Among patients with childhood stroke hospitalized in PICU, IS and HS account for about half of childhood stroke each. One-third cases have poor functional outcome at hospital discharge, however, of those survivors, over two-thirds cases have residual disability. Lower modified GCS on PICU admission is a risk factor of poor functional outcome at hospital discharge and it could be used as a clinical early warning parameter for risk probability prediction. HS and lower modified GCS on PICU admission are risk factors of in-hospital mortality.
- Stroke /
- Ischemic stroke /
- Hemorrhagic stroke /
- Functional outcome /
- Children

HTML全文

表 1 脑卒中患儿基本信息和临床特征

Table 1. Basic information and clinical features of children with stroke

特征	脑卒中全队列 (n=163)	缺血性脑卒中 (n=84)	出血性脑卒中 (n=79)
性别[例(%)]
男性	88(54.0)	48(57.1)	40(50.6)
女性	75(46.0)	36(42.9)	39(49.4)
年龄[M(P₂₅, P₇₅), 岁]	4.5(1.2, 9.3)	2.5(0.7, 7.4)	6.6(3.4, 10.7)
年龄段[例(%)]
29 d~＜1岁	36(22.1)	27(32.1)	9(11.4)
1岁~＜3岁	28(17.2)	20(23.8)	8(10.1)
3岁~＜6岁	30(18.4)	12(14.3)	18(22.8)
6岁~＜9岁	25(15.3)	9(10.7)	16(20.3)
9岁~＜12岁	27(16.6)	12(14.3)	15(19.0)
12岁~＜15岁	16(9.8)	4(4.8)	12(15.2)
15岁~＜18岁	1(0.6)	0	1(1.3)
临床表现包含局灶性神经功能缺陷[例(%)]	88(54.0)	56(66.7)	32(40.5)
临床表现包含全身性非特异性症状[例(%)]	150(92.0)	72(85.7)	78(98.7)
临床表现同时包含局灶性神经功能缺陷和全身性非特异性症状[例(%)]	77(47.2)	46(54.8)	31(39.2)
收入PICU时的改良GCS[M(P₂₅, P₇₅), 分]	11(7, 14)	12(8, 15)	11(6, 14)
3~8分[例(%)]	57(35.0)	24(28.6)	33(41.8)
9~12分[例(%)]	39(23.9)	24(28.6)	15(19.0)
13~15分[例(%)]	67(41.1)	36(42.9)	31(39.2)
机械通气支持[例(%)]	58(35.6)	31(36.9)	27(34.2)
入住PICU时间[M(P₂₅, P₇₅), d]	8.0(4.0, 13.5)	6.0(4.0, 13.8)	8.5(3.3, 13.0)
住院总时间[M(P₂₅, P₇₅), d]	14.0(8.0, 22.0)	15.5(8.0, 24.0)	14.0(8.0, 20.0)
出院时PCPC[例(%)]
1分(正常)	41(25.2)	6(7.1)	35(44.3)
2分(轻度残疾)	39(23.9)	32(38.1)	7(8.9)
3分(中度残疾)	28(17.2)	23(27.4)	5(6.3)
4分(严重残疾)	9(5.5)	4(4.8)	5(6.3)
5分(昏迷/植物状态)	19(11.7)	12(14.3)	7(8.9)
6分(脑死亡/死亡)	27(16.6)	7(8.3)	20(25.3)

下载: 导出CSV

表 2 缺血性脑卒中儿童的病因危险因素(n=84)

Table 2. Etiological risk factors in children with ischemic stroke (n=84)

病因危险因素	例(%)
颅脑动脉病变	29(34.5)
局灶性脑动脉病变	15(17.9)
烟雾病	13(15.5)
高血压脑病	1(1.2)
心脏病变	16(19.0)
先天性心脏病	10(11.9)
感染性心内膜炎伴赘生物	4(4.8)
心肌炎	2(2.4)
颅内感染性疾病	12(14.3)
化脓性脑膜炎	8(9.5)
病毒性脑炎	4(4.8)
系统性疾病	9(10.7)
脓毒症	7(8.3)
遗传代谢病	2(2.4)
颅内肿瘤	7(8.3)
起病前1周内轻微头部外伤	4(4.8)
病因不明确	7(8.3)

下载: 导出CSV

表 3 出血性脑卒中儿童的病因危险因素(n=79)

Table 3. Etiological risk factors of hemorrhagic stroke in children (n=79)

病因危险因素	例(%)
颅脑血管畸形	39(49.4)
动静脉畸形	25(31.6)
海绵状畸形	11(13.9)
动脉瘤	2(2.5)
烟雾病	1(1.3)
出凝血功能障碍疾病	20(25.3)
特发性维生素K缺乏	9(11.4)
白血病	4(5.1)
重症肝病	3(3.8)
血友病	2(2.5)
再生障碍性贫血	1(1.3)
血小板减少性紫癜	1(1.3)
系统性疾病	4(5.1)
脓毒症	4(5.1)
颅内肿瘤	4(5.1)
颅内感染性疾病	3(3.8)
化脓性脑膜炎	2(2.5)
病毒性脑炎	1(1.3)
高血压脑病	2(2.5)
病因不明确	7(8.9)

下载: 导出CSV

表 4 变量的赋值方法

Table 4. Assignment methods for variables

变量	赋值方法
自变量
性别	男=0，女=1
年龄	以实际值赋值
脑卒中两大类别	IS=0，HS=1
收入PICU时的改良GCS	以实际值赋值
因变量
出院时功能结局	预后佳=0，预后差=1
院内死亡	出院时存活=0，院内死亡=1

下载: 导出CSV

表 5 脑卒中患儿出院时功能结局的多因素logistic回归分析

Table 5. Multivariate logistic regression analysis of functional outcome at discharge in children with stroke

变量	B	SE	Wald χ²	P值	OR值	95% CI
性别	0.076	0.432	0.031	0.860	1.079	0.463~2.517
年龄	-0.002	0.004	0.318	0.573	0.998	0.989~1.006
脑卒中两大类别	0.307	0.431	0.509	0.476	1.360	0.584~3.166
收入PICU时的改良GCS	0.419	0.062	45.360	＜0.001	0.658	0.582~0.743

下载: 导出CSV

表 6 脑卒中患儿院内死亡的多因素logistic回归分析

Table 6. Multivariate logistic regression analysis of in-hospital death in children with stroke

变量	B	SE	Wald χ²	P值	OR值	95% CI
性别	-0.349	0.494	0.498	0.480	0.706	0.268~1.859
年龄	0.004	0.005	0.842	0.359	1.004	0.995~1.014
脑卒中两大类别	1.122	0.514	4.759	0.029	3.071	1.121~8.417
收入PICU时的改良GCS	-0.304	0.066	20.923	＜0.001	0.738	0.648~0.840

下载: 导出CSV

参考文献(20)

[1]	FERRIERO D M, FULLERTON H J, BERNARD T J, et al. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association[J]. Stroke, 2019, 50(3): e51-e96.
[2]	GANESAN V, HOGAN A, SHACK N, et al. Outcome after ischaemic stroke in childhood[J]. Dev Med Child Neurol, 2000, 42(7): 455-461. doi: 10.1017/S0012162200000852
[3]	YVON E, LAMOTTE D, TIBERGHIEN A, et al. Long-term motor, functional, and academic outcome following childhood ischemic and hemorrhagic stroke: a large rehabilitation center-based retrospective study[J]. Dev Neurorehabil, 2018, 21(2): 83-90. doi: 10.1080/17518423.2016.1247923
[4]	GOEGGEL SIMONETTI B, CAVELTI A, ARNOLD M, et al. Long-term outcome after arterial ischemic stroke in children and young adults[J]. Neurology, 2015, 84(19): 1941-1947. doi: 10.1212/WNL.0000000000001555
[5]	王荃, 钱素云. 儿童意识水平及脑功能障碍的常用评估方法[J]. 中华实用儿科临床杂志, 2013, 28(18): 1367-1370. doi: 10.3760/cma.j.issn.2095-428X.2013.18.003 WANG Q, QIAN S Y. A common assessment method for the level of consciousness and brain dysfunction in children[J]. Journal of Applied Clinical Pediatrics, 2013, 28(18): 1367-1370. doi: 10.3760/cma.j.issn.2095-428X.2013.18.003
[6]	中华医学会神经外科学分会, 国家卫健委脑卒中筛查与防治工程委员会, 海峡两岸医药卫生交流协会神经外科分会缺血性脑血管病学组. 大面积脑梗死外科治疗指南[J]. 中华医学杂志, 2021, 101(45): 3700-3711. Neurosurgery Branch of Chinese Medical Association of Stroke Screening and Prevention Engineering Committee of National Health Commission, Ischemic cerebrovascular Group of Neurosurgery Branch of Cross-Straits Medical and Health Exchange Association. 大面积脑梗死外科治疗指南[J]. 中华医学杂志, 2021, 101(45): 3700-3711.
[7]	KOTHARI R U, BROTT T, BRODERICK J P, et al. The ABCs of measuring intracerebral hemorrhage volumes[J]. Stroke, 1996, 27(8): 1304-1305. doi: 10.1161/01.STR.27.8.1304
[8]	FISER D H. Assessing the outcome of pediatric intensive care[J]. J Pediatr, 1992, 121(1): 68-74. doi: 10.1016/S0022-3476(05)82544-2
[9]	LEHMAN L L, KHOURY J C, TAYLOR J M, et al. Pediatric stroke rates over 17 years: report from a population-based study[J]. J Child Neurol, 2018, 33(7): 463-467. doi: 10.1177/0883073818767039
[10]	FULLERTON H J, WU Y W, ZHAO S J, et al. Risk of stroke in children: ethnic and gender disparities[J]. Neurology, 2003, 61(2): 189-194. doi: 10.1212/01.WNL.0000078894.79866.95
[11]	MACKAY M T, WIZNITZER M, BENEDICT S L, et al. Arterial ischemic stroke risk factors: the international pediatric stroke study[J]. Ann Neurol, 2011, 69(1): 130-140. doi: 10.1002/ana.22224
[12]	MALLICK A A, GANESAN V, KIRKHAM F J, et al. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study[J]. Lancet Neurol, 2014, 13(1): 35-43. doi: 10.1016/S1474-4422(13)70290-4
[13]	WINTERMARK M, HILLS N K, DEVEBER G A, et al. Arteriopathy diagnosis in childhood arterial ischemic stroke: results of the vascular effects of infection in pediatric stroke study[J]. Stroke, 2014, 45(12): 3597-3605. doi: 10.1161/STROKEAHA.114.007404
[14]	BOULOUIS G, STRICKER S, BENICHI S, et al. Etiology of intracerebral hemorrhage in children: cohort study, systematic review, and meta-analysis[J]. J Neurosurg Pediatr, 2021, 27(3): 357-363. doi: 10.3171/2020.7.PEDS20447
[15]	CHUNG B, WONG V. Pediatric stroke among Hong Kong Chinese subjects[J]. Pediatrics, 2004, 114(2): e206-e212. doi: 10.1542/peds.114.2.e206
[16]	PIASTRA M, DE LUCA D, GENOVESE O, et al. Clinical outcomes and prognostic factors for spontaneous intracerebral hemorrhage in pediatric ICU: a 12-year experience[J]. J Intensive Care Med, 2019, 34(11-12): 1003-1009. PIASTRA M, DE LUCA D, GENOVESE O, et al. Clinical outcomes and prognostic factors for spontaneous intracerebral hemorrhage in pediatric ICU: a 12-year experience[J]. J Intensive Care Med, 2019, 34(11-12): 1003-1009. doi: 10.1177/0885066617726049
[17]	BESLOW L A, LICHT D J, SMITH S E, et al. Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study[J]. Stroke, 2010, 41(2): 313-318. doi: 10.1161/STROKEAHA.109.568071
[18]	BOULOUIS G, STRICKER S, BENICHI S, et al. Mortality and functional outcome after pediatric intracerebral hemorrhage: cohort study and meta-analysis[J]. J Neurosurg Pediatr, 2021, 27(6): 661-667. BOULOUIS G, STRICKER S, BENICHI S, et al. Mortality and functional outcome after pediatric intracerebral hemorrhage: cohort study and meta-analysis[J]. J Neurosurg Pediatr, 2021, 27(6): 661-667. doi: 10.3171/2020.9.PEDS20608
[19]	GORDON A L, GANESAN V, TOWELL A, et al. Functional outcome following stroke in children[J]. J Child Neurol, 2002, 17(6): 429-434. doi: 10.1177/088307380201700606
[20]	赵香梅, 秦历杰, 杨先芝. NT-proBNP水平在急性缺血性脑卒中患者中的应用价值[J]. 中华全科医学, 2020, 18(2): 177-180. doi: 10.16766/j.cnki.issn.1674-4152.001198