急性缺血性腦中風病人接受再灌流治療後神經功能與心理壓力、害怕中風復發及中風後疲倦之相關性

背景：缺血性腦中風的治療改善了存活率，然而被忽略的腦中風後神經功能及心理壓力、害怕腦中風復發及腦中風後疲倦成為影響生活品質及預後的重要問題，可能影響病人對於治療的遵從性及增加照顧負荷。目的：本研究目的為比較急性缺血性腦中風病人接受兩種再灌流治療，包含血栓溶解劑rt-PA治療(Intravenous Thrombolysis, IVT)組和動脈內取栓術(Endovascular Thrombectomy, EVT)組（接受Intra-Arterial (IA) Thrombectomy或t-PA及IA thrombectomy治療）後神經功能、心理壓力、害怕腦中風復發的差異，並探討腦中風後疲倦之影響因子。方法：研究設計為前瞻性、縱貫性研究，資料收集時間為自2022年3月至2023年1月，收案個數為60位，以立意取樣方式選取臺灣北部某醫學中心腦中風加護病房急性缺血性腦中風病人為研究對象，透過病歷收集及臨床評估神經功能外，採用問卷收集資料，包括「基本資料表」、「知覺壓力量表（Perceived Stress Scale, PSS）」、「害怕中風復發量表（Fear of Stroke Recurrence Questionnaire, FoSRQ）」、「疲倦嚴重程度量表（Fatigue Severity Scale, FSS）」。同意參與研究之受訪者，依照研究設計，於腦中風加護病房接受腦中風再灌流治療前及治療後第3小時、第24小時、第7天、第30天、第90天，藉由病歷查閱、臨床評估收集神經功能變化相關資料；第7天、第30天、第90天受訪者轉至普通病房、復健科病房或出院後，以電話追蹤或門診回診時間收集問卷資料。所得資料以SPSS for Windows 26.0統計套裝軟體進行資料分析，以皮爾森積差相關分析、廣義估計方程式、及羅吉斯迴歸探討急性缺血性腦中風病人接受再灌流治療前及治療後第3小時、第24小時、第7天、第30天、第90天神經功能變化，以及第7天、第30天、第90天的心理壓力、害怕腦中風復發的變化和腦中風後疲倦之影響因子。結果：（一）接受再灌流治療後兩組神經功能皆有顯著改善，EVT組改善程度較多；（二）接受再灌流治療後兩組心理壓力自治療第七天起逐漸升高，且IVT組高於EVT組；（三）接受再灌流治療後兩組害怕腦中風復發在治療後第7天至90天得分顯著降低，表示害怕中風復發程度隨時間改善（四）腦中風後疲倦嚴重程度第7天、第30天、第90天得分間互有顯著正相關，疲倦嚴重程度與神經功能、身體功能、害怕中風復發有顯著相關。以腦中風後第90天疲倦得分18分作為有無疲倦之切點，多變量羅吉斯迴歸分析結果顯示，「第7天NIHSS」得分（OR = 1.45，p = .031）、及「第7天害怕中風復發」得分（OR = 1.13，p = .046）為腦中風後第90天發生疲倦之顯著影響因素，共可解釋24.7%之變異量。結論與臨床應用：接受再灌流治療後個案的神經功能、日常生活功能皆有顯著改善，建議在不同時間窗口及病人情況考量下，若符合條件應優先採用IVT或(及)EVT治療，而非傳統保守治療，同時腦中風後的心理壓力、害怕腦中風復發、腦中風後疲倦應及早辨認並列入管理。關鍵詞：缺血性腦中風、再灌流治療、神經功能、心理壓力、害怕腦中風復發、腦中風後疲倦

關鍵字

缺血性腦中風；再灌流治療；神經功能；心理壓力；害怕腦中風復發；腦中風後疲倦

並列摘要

Background: Treatment of ischemic stroke improves survival rates. However, neglected neurological outcomes and mental stress after stroke, fear of stroke recurrence, and post-stroke fatigue affect patients’ quality of life and prognosis, as well as patient compliance and consequently increase the care load. Aim: In this study, we compared neurological outcomes, mental stress, fear of stroke recurrence, and fatigue between patients with acute ischemic stroke who underwent recanalization therapies using intravenous thrombolysis (IVT) with the recombinant-type tissue plasminogen activator (rt-PA) as the thrombolytic agent and endovascular thrombectomy (EVT) (including intra-arterial [IA] thrombectomy or a combination of rt-PA and IA thrombectomy). We also investigated associated and predicting factors with post-stroke fatigue. Method: This prospective longitudinal study performed between March 2022 and January 2023 included 60 patients selected from patients with acute ischemic stroke admitted to the neurointensive care unit of a medical center in Northern Taiwan. Data were obtained through medical record review, clinical assessments of neurological outcomes, and questionnaires including the Perceived Stress Scale, Fear of Stroke Recurrence Questionnaire, and the Fatigue Severity Scale. Patients who consented to participate in the study were evaluated before and 3 hours, 24 hours, 7 days, 30 days, and 90 days after recanalization therapies administered in the neurointensive care unit. Questionnaire data were obtained at the time patients were transferred to general wards, rehabilitation units, or during outpatient follow-up visits using telephone interviews or clinic appointments. Data were analyzed using the SPSS software for Windows, version 26.0. We used Pearson’s correlation analysis and generalized estimating equations to determine changes in neurological outcomes before and 3 hours, 24 hours, 7 days, 30 days, and 90 days after recanalization therapies. Furthermore, we investigated changes in mental stress and fear of stroke recurrence 7, 30, and 90 days post stroke and their correlations with post-stroke fatigue. Logistic regression was used to investigate the predicting factors for fatigue 90 days post stroke. Results: (1) Both groups showed significant improvement in neurological outcomes after recanalization therapies; however, greater improvement was observed in the EVT group. (2) Mental stress increased gradually from the seventh day after recanalization therapies; stress levels were higher in the IVT than in the EVT group. (3) Fear of stroke recurrence significantly decreased in both groups from 7 to 90 days after recanalization therapies, which indicated a decrease over time. (4) Post-stroke fatigue scores were significantly positively correlated between days 7, 30, and 90; fatigue levels were significantly correlated with neurological outcomes, physical function, and fear of stroke recurrence. Taking the fatigue score of 18 on the 90th day after stroke as the cut-off point, the results of multivariate logistic regression analysis showed that "day 7 NIHSS" (OR = 1.45, p = .031) "day 7 fear of stroke recurrence " (OR = 1.13, p = .046) were significant predictors, and a total of 24.7% variance was accounted for by these two variables. Conclusion and Clinical Application: Neurological outcomes and daily life functioning improved significantly in patients who were treated with recanalization therapies. IVT or EVT treatment should be prioritized over conventional conservative treatment based on different time windows and patient conditions. Furthermore, early diagnosis and prompt management of post stroke mental stress, fear of stroke recurrence, and post stroke fatigue are important. Keywords: Ischemic stroke, recanalization therapies, neurological outcomes, mental stress, fear of stroke recurrence, post stroke fatigue.

並列關鍵字

ischemic stroke ； recanalization therapies ； neurological outcomes ； mental stress ； fear of stroke recurrence ； post stroke fatigue

參考文獻

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385-396. https://doi.org/10.2307/2136404

Laures-Gore, J. S., & Defife, L. C. (2013). Perceived stress and depression in left and right hemisphere post-stroke patients. Neuropsychological Rehabilitation, 23(6), 783–797. https://doi.org/10.1080/09602011.2013.811087

李依宸、侯重光（2019）．急性大血管阻塞缺血性腦中風經動脈血管內取栓術治療的介入時間與預後之近期發展．臨床醫學月刊，82（2），490-494。http://doi.org/10.6666/ClinMed.201808_82(2).0089