摘要目的:分析前循环急性缺血性脑卒中(AIS)患者机械取栓术后发生出血转化(HT)的危险因素，探讨床旁超声测量视神经鞘直径(ONSD)预测患者术后发生HT的临床应用价值。方法:前瞻性收集河南省人民医院神经外科自2017年4月至2019年10月应用机械取栓术治疗的268例AIS患者的临床资料。使用床旁超声测量患者术后7 d内视神经鞘直径(ONSD)，根据患者术后7 d内头颅CT/MRI等复查结果将患者分为HT组(57例)、非出血转化(NHT)组(211例)，按照欧洲急性卒中协作研究(ECASS)分型对HT组患者进行分型。比较HT组和NHT组患者的临床资料，采用多因素Logistic回归分析确定AIS患者机械取栓术后发生HT的独立危险因素。采用受试者工作特征(ROC)曲线分析ONSD值对AIS患者术后发生HT的预测价值。比较不同分型HT患者临床资料的差异。结果:与NHT组比较，HT组患者的穿刺至血管再通时间较长，取栓大于3次者所占比例较高、基线侧支循环评分为0分者所占比例较高，基线Alberta卒中项目早期CT评分(ASPECTS)较低，术后7 d内ONSD增加，差异均有统计学意义( P<0.05)。多因素Logistic回归分析显示穿刺至血管再通时间(OR=1.012，95%CI：1.001~1.023， P=0.037)、取栓大于3次(OR=2.467，95%CI：1.107~5.501， P=0.027)、基线侧支循环评分(OR=0.578，95%CI：0.338~0.989， P=0.045)以及术后7 d内ONSD(OR=1.405，95%CI：1.008~1.082， P=0.019)是AIS患者机械取栓术后发生HT的独立危险因素( P<0.05)。ROC曲线分析显示ONSD预测AIS患者术后发生HT的最佳临界值为5.035 mm，曲线下面积(AUC)为0.777(95%CI：0.704~0.849)。脑实质出血(PH)-1型HT患者术后7 d内ONSD及ONSD≥5.035 mm者所占比例大于出血性脑梗死(HI)-2型，PH-2型HT患者术后7 d内ONSD及ONSD≥5.035 mm者所占比例大于PH-1型，差异均有统计学意义( P<0.05)。 结论:AIS患者机械取栓术后7 d内ONSD是HT发生的独立危险因素，患者ONSD≥5.035 mm时易发生HT，其与HT的严重程度有关。床旁超声测量ONSD有助于早期评估前循环AIS患者机械取栓术后HT的发生。

abstractsObjective:To analyze the risk factors for hemorrhagic transformation (HT) in patients with acute ischemic stroke (AIS) after mechanical thrombectomy, and explore the clinical value of bedside ultrasound measurement of optic nerve sheath diameter (ONSD) in predicting postoperative HT.Methods:Clinical data of 268 patients with AIS, accepted mechanical thrombectomy in our hospital from April 2017 to October 2019, were collected. Bedside ultrasound measurement of ONSD was performed in all patients. According to dynamic cerebral imaging 7 d after surgery, patients were divided into HT group ( n=57) and non-HT group ( n=211). Patients from HT group were classified according to the European Acute Stroke Collaborative Study (ECASS) classification. Clinical data of patients from the two groups were compared, and multivariate Logistic regression analysis was used to analyze the influencing factors for HT in patients with AIS after mechanical thrombectomy. The predictive value of ONSD in incidence of postoperative HT in AIS patients was analyzed by receiver operating characteristic (ROC) curve. The clinical data of HT patients with different classification subtypes were compared. Results:HT patients had significantly longer time from puncture to recanalization, significantly higher percentage of patients having more than three times of thrombectomy, significantly higher percentage of patients having baseline collateral circulation scale score of 0, statistically lower baseline Alberta stroke program early CT scale (ASPECTS), and significantly increased ONSD within 7 d of surgery as compared with the NHT patients ( P<0.05). Multivariate Logistic regression analysis indicated that time from puncture to recanalization (OR=1.012, 95%CI: 1.001-1.023, P=0.037), percentage of patients having more than three times of thrombectomy(OR=2.467, 95%CI:1.107-5.501, P=0.027), baseline collateral circulation scale scores (OR=0.578, 95%CI: 0.338-0.989, P=0.045), and ONSD within 7 d of surgery (OR=1.405, 95%CI: 1.008-1.082, P=0.019) were independent influencing factors for HT in patients with AIS after mechanical thrombectomy. The optimal cut-off value of ONSD for diagnosis of HT was 5.035 mm, area under curve (AUC) was 0.777 (95% confidence interval: 0.704-0.849). In HT patients, parenchyma hemorrhage (PH)-1 type patients had significantly higher ONSD and proportion of patients with ONSD≥5.035 mm within 7 d of surgery as compared with hemorrhagic infarction (HI)-2 type patients, and PH-2 type patients had significantly higher ONSD and proportion of patients with ONSD≥5.035 mm within 7 d of surgery as compared with PH-1 type patients ( P<0.05). Conclusions:ONSD within 7 d of mechanical thrombectomy is an independent risk factor for HT in AIS patients; when ONSD≥5.035 mm, patients are prone to have HT, which is related to the severity of HT. Bedside ultrasound measurement of ONSD is helpful for early evaluation of HT after mechanical thrombectomy in anterior circulation AIS patients.