頭頸部癌症病人接受放射線治療後產生缺血性中風之特徵及預後因子

Abstract

摘要 背景:頭頸部癌症的病人接受過放射治療後，會有較高的風險產生缺血性中風，這是目前已經被證實的事情。先前的研究主要在闡述中風風險提高的比例，以及先行的頸部血管狹窄之變化，並沒有對中風本身的特色做出明確的整理。因此，本篇研究主要希望探討頭頸部癌症的病人經放射治療後發生缺血性中風的各項臨床表現，特別是找出中風預後的預測因子。 方法:我們透過台大醫院的中風登錄找出2010年一月到2016年六月間連續發生的缺血性腦中風，且之前有因為頭頸部癌症做過放射線治療的病人。我們以回溯性研究的方式分析這些病人的資料。其中，不好的中風預後定義為中風後一個月modified Rankin Scale (mRS) > 2的病人。先進放射線治療定義為強度調控放射治療加上體積弧形調控放射治療。 結果：在收案的期間內，有60位病人符合收案條件 (平均年齡：61.9±11.3歲，90.0%為男性)。這些病人當中，27.8%的人是後循環中風 (n=15)。放射線治療到中風發生的時間間距範圍為0.5 - 40年，百分之五十的個案發生中風的時間 (50 % survival time) 為8年。在所有的病人當中，大多數的人存在有傳統的中風危險因子，包括有高血壓 (65.0%)，糖尿病 (20.0%)，高膽固醇 (15.0%)，高三酸甘油脂 (18.3%)，抽菸 (48.3%)，過去中風病史 (16.7%) 和心房顫動 (6.7%)。這群病人的中風嚴重程度以美國國衛院腦中風評估表(NIHSS)來評估之下中位數是5 (IQR:3-15)。五十位病人 (83.3%) 有中風後一個月的modified Rankin Scale的紀錄，其中22位病患 (44.0%)有不好的預後。關於預後方面，單變項分析顯示預後不好的人有顯著較高比例的到院時嚴重中風 (47.1% vs. 4.2%, p=0.002)；另外還有較低的比例罹患高血壓 (50.0% vs. 75.0%, p=0.07) 以及較少的比例使用先進放射線治療 (40.0% vs. 70.0%, p=0.08) 的趨勢。多變項分析顯示，嚴重的NIHSS (OR:26.1, 95% CI: 1.15-596 p=0.041)和先進放射線治療 (OR: 0.05, 95% CI: 0.004-0.71, p=0.027) 仍然是獨立的不好預後的預測因子。 結論：有接受過放射線治療的病患發生中風，後循環的中風並不罕見。總體來看，先進放射線治療方式可能是這群病人中風的預後保護因子

Background: Patients with head and neck cancer receiving radiation therapy have increased risk of stroke. Previous studies were focused on the epidemiology and stroke risk factor analyses. Our study aims to demonstrate the clinical characteristics of acute stroke in patients with head and neck cancer, especially to investigate stroke outcome indicators. Methods: We retrospectively reviewed patients who had previous radiotherapy due to head and neck cancer and suffered from acute ischemic stroke during January, 2010- June, 2016 at a single medical center. Unfavorable outcome was defined as modified Rankin Scale (mRS) > 2 at 1 month after stroke. Advanced radiotherapy was defined as application of intensity modulation radiation therapy or volumetric arc therapy. Results: During the study period, 60 patients fulfilled the inclusion criteria (mean age 61.9±11.3 years, 90.0% male) and 27.8% of them (n=15) had stroke in posterior circulation. Range of interval between radiotherapy and stroke onset was 0.5 to 40 years. Fifty percent survival time was 8 years. Coexisting conventional stroke risk factors were common, such as hypertension (65.0%), diabetes mellitus (20.0%), High cholesterol (15.0%), High triglyceride (18.3%), smoking (48.3%), previous stroke (16.7%) and atrial fibrillation (6.7%). The median National Institute of Health Stroke Scale (NIHSS) at admission was 5 (IQR:3-15). Fifty patients (83.3%) had record of modified Rankin Scale at 1 month after stroke and twenty-two of them (44.0%) had unfavorable outcome. In univariate analysis, the patients had unfavorable outcome had higher percentage of severe NIHSS (47.1% vs.4.2%, p=0.002). Besides, patients with unfavorable outcome had trend of lower percentage of hypertension (50.0% vs. 75.0%, p=0.07) and lower percentage of advanced radiotherapy (40.0% vs. 70.0%, p=0.08). In multivariate analysis, severe NIHSS (OR:26.1, 95% CI: 1.15-596 p=0.041) and advanced radiotherapy (OR: 0.05, 95% CI: 0.004-0.71, p=0.027) still remained independent indicators of unfavorable outcome. Conclusion: Acute ischemic stroke in posterior circulation is common in head and neck cancer patients receiving radiation therapy. Advanced radiotherapy is a protective indicator of unfavorable outcome.