自发性脑出血患者急性期高血糖与预后的关系

发布时间：2018-01-01 01:27

本文关键词：自发性脑出血患者急性期高血糖与预后的关系　出处：《南京医科大学》2017年博士论文　论文类型：学位论文

【摘要】：卒中已逐渐成为全球主要死亡原因,具有高发病率、高致死率、高致残率。自发性脑出血(spontaneous intracerebral hemorrhage,sICH)是卒中第二大类型,发病率仅次于缺血性脑卒中,在西方国家占所有卒中患者的10%～15%。与西方国家相比,我国出血性卒中发病率明显升高,达18.8%～47.6%。按照发病原因,脑出血常分为原发性和继发性脑出血。脑出血发病凶险,病情变化快,超过70%的患者发生早期血肿扩大或累及脑室,3个月内的死亡率为20%～30%,且有相当数量的存活者预后不良,导致沉重的经济社会负担,2003年我国统计显示脑出血的直接医疗费用为137.2亿元/年。脑出血临床症状突发,多在活动中起病,常表现为头痛、恶心、呕吐、不同程度的意识障碍及肢体瘫痪等。早期血肿扩大是导致脑出血患者预后不良的首要因素,早期血肿扩大与年龄、性别、血压、血糖、冠心病、烟酒史、凝血异常、昏迷评分及使用甘露醇的关系报道不一。高血糖可分为糖尿病和糖尿病前期两大类。糖尿病已成为目前最常见的慢性非传染病之一,在我国人群中患病人数和患病率呈明显上升趋势。我国成人糖尿病患病率高达11.6%,糖尿病患者人数居全球首位。我国以2型糖尿病为主,占90%以上。糖尿病可增加心血管疾病及某些种类肿瘤的发病风险和死亡风险,其影响机制包括高糖血症、高凝状态、高胰岛素血症、胰岛素抵抗和氧化应激等。糖尿病前期指空腹血浆葡萄糖和(或)口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)的2h血浆葡萄糖(2hPG)升高但未达到糖尿病的诊断标准,包括空腹血糖受损(impaired fasting glucose,IFG)和糖耐量受损(impaired glucose tolerance,IGT),即存在IFG或IGT或两者兼具(IFG+IGT)。糖尿病前期被认为是一种标志或分水岭,如出现则标志着将来发生心脑血管疾病、糖尿病、微血管病以及肿瘤和痴呆等的危险性增高。高血糖与急性卒中关系密切。早在1976年,人们就发现既往没有糖尿病史的急性卒中患者也会出现高血糖。目前已有大量研究证实,急性期高血糖是缺血性卒中和蛛网膜下腔出血预后不良的独立危险因素,高血糖也与缺血性卒中出血转化、溶栓治疗的出血转化有关。脑出血后血糖升高可能与急性期的应激反应、自身激素变化和代谢变化相关,高血糖与急性自发性脑出血预后的关系尚无定论。有临床观察性研究表明,伴有高血糖的脑出血患者急性期病死率增高且预后不良。也有研究认为,血糖升高只是脑出血急性期的一种应激反应,不能作为预后不良的预测因素。本研究采用前瞻性队列研究的方法,连续纳入2006年3月～2010年5月入住南京市第一医院神经内科的自发性脑出血患者,测定入院随机血糖及第二日空腹血糖,分别根据血糖水平分为高血糖组及正常血糖组,完成标准卒中入院登记表,行神经功能缺损评分,发病90d时用改良Rankin量表(modified Rankin Scale,mRS)评价预后,观察脑出血急性期不同的血糖水平与疾病严重程度以及90d预后的相关性,探讨自发性脑出血患者早期高血糖与疾病严重程度及90d预后的关系以及影响预后的相关因素。第一部分自发性脑出血患者入院随机血糖与疾病严重程度及90d预后的关系目的:研究自发性脑出血患者入院随机血糖与疾病严重程度及90d预后的关系。方法:连续纳入发病24小时内诊断明确的自发性脑出血患者,以入院随机血糖≥20mmol/L者作为高血糖组,其余作为正常血糖组。用美国国立卫生院卒中量表(National Institute of Health Stroke Scale,NIHSS)进行神经功能缺损评分,90d时采用改良Rankin量表(mRS)评价预后,分为预后良好组(mRS≤2分)和预后不良组(mRS≥3分,包括死亡或重残)。比较两组的疾病严重程度及90d预后。结果:共纳入228例脑出血患者,其中高血糖组30例(13.2%),血糖正常组198例(86.8%)。共有糖尿病患者26例,高血糖组的糖尿病比例为46.7%,显著高于血糖正常组的6.06%,差异有统计学意义(P0.001)。90d预后不良患者96例,占总数的45.3%,糖尿病和非糖尿病患者之间没有明显差异。Spearman相关性分析表明,入院随机血糖与入院NIHSS评分呈显著正相关(r=0.183,P=0.009),与90d预后不良无明显相关性(r=0.108,P=0.146)。Logistic回归分析显示,年龄(OR:1.053;95%CI:1.015-1.092)、入院时 NIHSS 评分(OR:1.251;95%CI:1.141-1.371)是自发性脑出血患者90d预后不良的独立危险因素(P0.05)。结论:糖尿病患者在脑出血急性期更易出现血糖升高。入院随机血糖水平与自发性脑出血严重程度相关,与90d预后不良无明显相关性。影响90d预后的独立危险因素是患者年龄和入院NIHSS评分。第二部分自发性脑出血患者空腹血糖与疾病严重程度及90d预后的关系目的:研究自发性脑出血患者空腹血糖与疾病严重程度及90d预后的关系。方法:连续纳入发病24小时内诊断明确的自发性脑出血患者,行NIHSS评分,根据入院第2天空腹血糖水平进行分组,以空腹血糖≥7mmol/L者作为高血糖组,其余作为正常血糖组。90d时采用mRS评分评价预后,分为预后良好组(mRS≤2分)和预后不良组(mRS≥3分,包括死亡或重残)。比较两组的疾病严重程度及90d预后。结果:共纳入228例脑出血患者,其中高血糖组59例(25.9%),血糖正常组169例(74.1%)。共有糖尿病患者26例,高血糖组的糖尿病比例为27.1%,明显高于正常血糖组的5.9%,差异有统计学意义(P0.001)。90d预后不良患者96例,占总数的45.3%。Spearman相关性分析表明,空腹血糖与入院NIHSS评分呈显著正相关(r=0.133,P=0.045),与90d预后不良无明显相关性(r=0.116,P=0.098)。Logistic 回归分析显示,年龄(OR:1.070;95%CI:1.033～1.107)、入院时NIHSS评分(OR:1.165;95%CI:1.083～1.253)是自发性脑出血患者90d预后不良的独立危险因素(P0.05)。结论:糖尿病患者在脑出血急性期更易出现血糖升高。空腹血糖水平与自发性脑出血严重程度相关,与90d预后不良无明显相关性。影响90d预后的独立危险因素是患者年龄和入院NIHSS评分。综上所述,本研究的主要创新之处在于:1.观察自发性脑出血急性期随机血糖水平与疾病严重程度的关系和对脑出血患者90d预后的影响按入院随机血糖水平进行分组,观察入院随机血糖水平与入院NIHSS评分及90d预后的关系,探讨随机血糖对自发性脑出血严重程度的影响及脑出血90d预后不良的影响因素。2.观察自发性脑出血急性期空腹血糖水平与疾病严重程度的关系和对90d预后的影响按空腹血糖水平进行分组,观察不同的空腹血糖与入院NIHSS评分及90d预后的关系,探讨空腹血糖水平对自发性脑出血严重程度的影响及脑出血90d预后不良的影响因素。
[Abstract]:Stroke has gradually become the main cause of death in the world, with high morbidity, high mortality, high disability rate. Spontaneous intracerebral hemorrhage (spontaneous intracerebral hemorrhage, sICH) are the second major types of stroke, after the incidence of ischemic stroke in the western countries, accounting for all stroke patients 10% ~ 15%. compared with western countries, China's bleeding the stroke incidence rate increased significantly, up to 18.8% ~ 47.6%. according to the cause of disease, often divided into primary and secondary cerebral hemorrhage cerebral hemorrhage. The incidence of dangerous cerebral hemorrhage, the condition changes quickly, there are more than 70% patients with early hematoma enlargement or involving the ventricle, mortality within 3 months was 20% ~ 30%, and the survivors a considerable number of adverse prognosis, resulting in heavy economic and social burden, in 2003 China's statistics show that the direct medical cost of cerebral hemorrhage was 13 billion 720 million yuan / year. The clinical symptoms of sudden cerebral hemorrhage, at the onset of the illness, often The performance of headache, nausea, vomiting, different levels of consciousness and limb paralysis. Early hematoma enlargement is a leading cause of cerebral hemorrhage in patients with poor prognosis, early hematoma enlargement and age, gender, blood pressure, blood glucose, coronary heart disease, smoking and alcohol use, coagulopathy, report coma score and mannitol or not. High blood sugar can be divided into two major categories of diabetes and pre diabetes. Diabetes has become one of the most common chronic non infectious diseases, in Chinese population prevalence and prevalence showed a rising trend. China's adult diabetes disease rate is as high as 11.6%, ranking first in the world. The number of patients with diabetes type 2 in China diabetes, accounting for more than 90%. Diabetes can increase the risk of cardiovascular disease and some types of cancer risk and the risk of death, the influence mechanism including hyperglycemia, hypercoagulable state, high blood insulin, insulin resistance Pre diabetes and oxidative stress. The fasting plasma glucose and (or) oral glucose tolerance test (oral glucose tolerance test, OGTT) 2H plasma glucose (2hPG) increased but did not reach the diagnostic standard of diabetes, impaired fasting glucose (impaired fasting, glucose, IFG) and impaired glucose tolerance (impaired glucose tolerance IGT, namely IFG or IGT), or both (IFG+IGT). Pre diabetes is considered to be a sign or watershed, such as marks of occurrence of cardiovascular disease, the future risk of diabetes, microvascular disease, cancer and dementia increased. High blood glucose and acute stroke are closely related. As early as 1976 and it was found that acute stroke patients had no history of diabetes also had high blood sugar. There are a number of studies have demonstrated that acute hyperglycemia is lower in ischemic stroke and subarachnoid hemorrhage prognosis The independent risk factors, high blood sugar and hemorrhagic transformation of ischemic stroke, thrombolytic therapy of hemorrhagic transformation after cerebral hemorrhage. The stress hyperglycemia may be associated with acute period, related changes in their hormones and metabolism, relationship between prognosis of hyperglycemia and acute cerebral hemorrhage is inconclusive. Clinical observational studies show that with high blood glucose in patients with cerebral hemorrhage in acute stage of higher mortality and poor prognosis. Some studies suggested that hyperglycemia is a stress reaction of cerebral hemorrhage in the acute phase can not be used as a predictor of poor prognosis. This study adopts the method of prospective cohort study, consecutive patients with spontaneous brain from March 2006 to May 2010 in the First Hospital of Nanjing City Department of Neurology bleeding, determination of admission glucose and two days of fasting blood glucose, respectively according to the blood glucose level is divided into the high blood glucose group and normal blood glucose group, complete Standard stroke admission registration form for the neurological deficit score, incidence of 90d when using the modified Rankin scale (modified Rankin Scale, mRS) to evaluate the prognosis, blood glucose level and the severity of acute disease of different correlation of 90d and prognosis observation of cerebral hemorrhage, to explore the relationship between early hyperglycemia and disease severity and prognosis in patients with spontaneous intracerebral 90d hemorrhage and prognostic factors. The first part admission random blood glucose levels and disease severity and prognosis of 90d spontaneous intracerebral hemorrhage Objective: admission random blood sugar and disease severity and prognosis of spontaneous cerebral hemorrhage of 90d. Methods: consecutive patients within 24 hours of onset of spontaneous cerebral hemorrhage patients with clear diagnosis. The admission glucose was larger than 20mmol/L as high blood glucose group, the other as the normal blood glucose group. With the National Institutes of Health Stroke Scale (National Institu Te of Health Stroke Scale, NIHSS) neurological function was evaluated, the modified Rankin scale using 90d (mRS) to evaluate the prognosis, divided into good prognosis group (mRS = 2) and poor prognosis group (mRS = 3, including death or severe disability). Disease severity and prognosis of 90d were compared between the two groups. Results: a total of 228 cases of cerebral hemorrhage patients, the high glucose group 30 cases (13.2%), 198 cases of normal blood sugar (86.8%). A total of 26 cases of diabetic patients, the proportion of diabetic hyperglycemia group was 46.7%, significantly higher than the normal blood glucose group 6.06%, there were statistically significant differences in the prognosis of.90d (P0.001) patients with 96 cases, accounting for 45.3% of the total, no significant difference of.Spearman analysis show that the correlation between patients with and without diabetes mellitus, admission glucose and admission NIHSS score was positively correlated (r=0.183, P=0.009), and no significant correlation between the prognosis of 90d (r=0.108, P=0.146).Logistic regression Analysis showed that age (OR:1.053; 95%CI:1.015-1.092), admission NIHSS score (OR:1.251; 95%CI:1.141-1.371) is an independent risk factor of poor prognosis of 90d patients with spontaneous intracerebral hemorrhage (P0.05). Conclusion: diabetic patients in acute stage of cerebral hemorrhage is more prone to hyperglycemia. Admission random blood glucose levels and the severity of spontaneous intracerebral hemorrhage, and the poor prognosis of 90d. There was no significant correlation between independent risk factors for the prognosis of 90d patients are age and admission NIHSS score. The purpose of the relationship between fasting blood glucose and disease severity and prognosis in patients with 90d second part of spontaneous intracerebral hemorrhage: relationship between fasting blood glucose and the disease severity and prognosis of 90d patients with spontaneous cerebral hemorrhage. Methods: the study included 24 consecutive patients hours of diagnosis of spontaneous intracerebral hemorrhage were clear, the scores of NIHSS were grouped according to the admission of second daysfasting glucose levels in fasting blood glucose More than 7mmol/L as high blood glucose group, the other as the normal blood glucose group.90d mRS score was used to evaluate the prognosis, divided into good prognosis group (mRS = 2) and poor prognosis group (mRS = 3, including death or severe disability). Disease severity and prognosis of 90d were compared between the two groups. Results: Na in 228 cases of cerebral hemorrhage patients, the high glucose group 59 cases (25.9%), 169 cases of normal blood sugar (74.1%). A total of 26 cases of diabetic patients, the proportion of diabetic hyperglycemia group was 27.1%, significantly higher than the normal blood glucose group 5.9%, the difference was statistically significant (P0.001.90d) a poor prognosis in 96 patients of the total, accounted for 45.3%.Spearman correlation analysis showed that fasting blood glucose and NIHSS scores on admission showed a significant positive correlation (r=0.133, P=0.045), and the poor prognosis of 90d had no significant correlation (r=0.116, P=0.098).Logistic regression analysis showed that age (OR:1.070 CI:1.033; 95% ~ 1.107), admission NIHSS score (OR:1.165 95%CI:1.083; - 1.253) was an independent risk factor of poor prognosis of 90d patients with spontaneous intracerebral hemorrhage (P0.05). Conclusion: diabetic patients prone to hyperglycemia in patients with acute cerebral hemorrhage. The fasting blood glucose level and the severity of spontaneous cerebral hemorrhage associated with poor prognosis of 90d. There was no significant correlation between the independent risk factors for the prognosis of 90d is age and admission scores in patients with NIHSS. To sum up, the main innovation of this study lies in: 1. to observe the relationship between the random blood glucose level and disease severity of spontaneous intracerebral hemorrhage and the prognosis of 90d in patients with cerebral hemorrhage were divided into two groups according to the admission random blood glucose levels, to observe the relationship between admission glucose level and NIHSS scores on admission and prognosis of 90d to investigate the effect of random blood glucose, the severity of spontaneous cerebral hemorrhage and cerebral hemorrhage and 90d factor of poor prognosis of.2. observation of acute spontaneous intracerebral hemorrhage Effect of fasting glucose level and the severity of the disease and the prognosis of 90d were grouped according to the level of fasting blood glucose, fasting blood glucose and observe the relationship between NIHSS scores on admission and prognosis of different 90d, to investigate the effects of fasting blood glucose on the severity of spontaneous cerebral hemorrhage and cerebral blood factors which affect the prognosis of 90d.

【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R743.34;R587.2

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