急性进展性卒中的影像学特征及其机制研究

发布时间：2018-05-01 14:40

本文选题：脑梗死 + CISS分型　；参考：《河南科技大学》2013年硕士论文

【摘要】：目的：基于CISS分型（chinese ischemic stroke subclassification，CISS）对急性脑梗死(Acute cerebral infarction，ACI)患者进行中国缺血性卒中亚型分析，统计进展性脑梗死与非进展性脑梗死患者各亚型的构成比、病灶分布、影像学特点、病因及发病机制的差别，并探讨进展性脑梗死的危险因素。方法：连续性登记2011年10月1日至2012年10月31日入住河南科技大学第一附属医院神经内科的ACI患者，，入院后立即接受神经科常规查体，并行血糖、血常规、血凝、肝功能、肾功能、同型半胱氨酸和血甘油三酯、胆固醇、低密度脂蛋白、高密度脂蛋白等实验室检查；同时记录患者的个人史(性别、年龄)、卒中的危险因素(高血压史、糖尿病史、既往卒中史、冠心病史、高脂血症史及吸烟史)。所有病人均于入院当时即做头颅CT检查，排除了出血性卒中。结合其MRI/DWI/CT、颈动脉彩超、CTA/MRA等检查结果，依据中国缺血性卒中亚型标准对其进行分型，包括对LAA(large artery therosclerosis)亚型发病机制的分析。统计进展性脑梗死与非进展性脑梗死患者各亚型的构成比、病灶分布、影像学特点、病因及发病机制的差别，并探讨进展性脑梗死的危险因素。结果：328例ACI患者，根据病情变化分为进展组（发病6小时后至一周内经过治疗或未治疗其病情仍然进展，NIHSS评分增加2分或以上者）与非进展组（发病6小时后至一周内未经过治疗或经治疗后病情平稳，未再进展，NIHSS评分减少、不变或增加小于2分者），其中进展组51例，非进展组277例。进展组51例中39例属大动脉粥样硬化(LAA)，占76%，4例属心源性卒中(CS)，占8%，5例属穿支动脉疾病(PAD)，占10%，2例属病因不确定(UE)，占4%，1例属其它病因（OE），占2%，39例大动脉粥样硬化的发病机制分型为：动脉到动脉栓塞11例（28%），载体动脉（斑块或血栓）阻塞穿支动脉3例（8%），低灌注/栓子清除下降17例（43%），混合型8例（21%）。非进展组277例中205例属大动脉粥样硬化(LAA)，占74%，21例属心源性卒中(CS)，占8%，26例属穿支动脉疾病(PAD)，占9%，20例属病因不确定(UE)，占7%，5例属其它病因（OE），占2%。205例大动脉粥样硬化的发病机制分型为：动脉到动脉栓塞96例（47%），载体动脉（斑块或血栓）阻塞穿支动脉17例（8%），低灌注/栓子清除下降21例（10%），混合型71例（35%）。进展组占总数的17%左右，进展组人群糖尿病发生率显著高于非进展组(P0．001，P0．05)，发病年龄、高血压发生率均高于非进展组，但差异无统计学意义；两组之间比较在性别、高胆固醇血症、吸烟史差异无统计学意义。影像学检查结果（头部MRI+DWI+MRA）显示进展组额、颞、顶叶梗死7例；基底节区3例，脑干梗死3例，小脑梗死1例；分水岭梗死37例。采用Bogouss-lavsky神经影像学分类法，按照脑血管分布影像模板，分水岭脑梗死分为皮质前型7例，皮质下型14例，皮质后型6例，混合型10例。非进展组额、颞、顶叶梗死32例，基底节区192例；脑干梗死13例，小脑、枕叶梗死12例；分水岭梗死28例，采用Bogouss-lavsky神经影像学分类法，按照脑血管分布影像模板，分水岭脑梗死分为皮质前型12例，皮质下型8例，皮质后型6例，混合型2例。与非进展组比较，进展组分水岭梗死发生率较高，两组之间有显著性差异(P0．001)。根据血管狭窄标准，51例进展组中32例存在大动脉中重度狭窄或闭塞(占62.7%)，其中颈内动脉颅内段狭窄9例，大脑中动脉狭窄或闭塞18例，椎基底动脉狭窄5例；而277例非进展组，75例存在大动脉中重度狭窄或闭塞(占27%)，颈内动脉颅内段狭窄24例，大脑中动脉狭窄39例，椎基底动脉狭窄者为12例。进展组大动脉中重度狭窄或闭塞发生率显著高于非进展组(P0．001)，且病变血管主要发生在颈内动脉系统。 328例急性脑梗死患者中，男性192例(58.53％)，女性136例(41.47％)，血浆同型半胱氨酸(Hcy)22.54±13.57mol／L。进展组Hcy是24.70±14.47mol／L；非进展组Hcy是19.89±10.67mol／L，两组之间差异有统计学意义(P0．05). 结论：ACI患者的病灶分布及影像学特点与CISS亚型相关。CISS分型病因以大动脉粥样硬化比例最高，机制以动脉到动脉栓塞和低灌注/栓子清除下降最为常见；从影像上看分水岭区梗死进展率较高，尤其皮质下型和混合型预示可能发生进展；糖尿病、颅内外血管狭窄或闭塞、高同型半胱氨酸血症也与急性缺血性脑卒中早期神经功能恶化有关。
[Abstract]:Objective: to analyze the ischemic stroke subtype of acute cerebral infarction (Acute cerebral infarction, ACI) in patients with acute cerebral infarction (Acute cerebral infarction, ACI) based on the Chinese ischemic stroke subclassification (CISS), and to determine the constituent ratio of the subtypes of the progressive cerebral infarction and the non progressive cerebral infarction, the distribution of the focus, the imaging features, the etiology and the pathogenesis of the CISS stroke subclassification. Difference, and explore the risk factors of progressive cerebral infarction.
Methods: ACI patients were enrolled in the Department of Neurology, the First Affiliated Hospital of Henan University of Science and Technology from October 1, 2011 to October 31, 2012, and received routine neurology examination after admission. Blood glucose, blood routine, hemagglutination, liver function, renal function, homocysteine and triglyceride, cholesterol, low density lipoprotein, high density fat were also accepted immediately after admission. Laboratory tests, such as protein, and the individual history of patients (sex, age), risk factors for stroke (hypertension, diabetes, past stroke, coronary heart disease, hyperlipidemia, and smoking history). All patients were performed head CT at the time of admission, excluding hemorrhagic stroke, combined with MRI/DWI/CT, carotid color Doppler ultrasound, CTA/MRA The results were classified according to the Chinese ischemic stroke Central Asian type standard, including the analysis of the pathogenesis of LAA (large artery therosclerosis) subtype. The constituent ratio of the subtypes of the progressive cerebral infarction and the non progressive cerebral infarction, the distribution of the focus, the imaging characteristics, the difference of the etiology and pathogenesis were analyzed, and the progress was discussed. The risk factors of cerebral infarction.
Results: 328 patients with ACI were divided into a progressive group according to the change of the condition (6 hours after the onset of the disease or a week after treatment or untreated progress, the NIHSS score increased by 2 or more) and the non progression group (6 hours after the onset of the disease was untreated or treated without any further progression, the NIHSS score decreased, unchanged or increased. " There were 51 cases in progress group and 277 cases in non progression group. 39 cases in 51 cases were large atherosclerosis (LAA), 76%, 4 cases of cardiogenic stroke (CS), 8%, 5 cases of perforator artery disease (PAD), 10%, 2 of etiology uncertainty (UE), 4%, 1 cases (OE), accounting for the pathogenesis of large atherosclerosis 11 cases (28%) of arterial to arterial embolism, 3 cases of perforating artery occlusion (8%), 17 cases (43%) and 8 cases (21%) of low perfusion / embolus, 205 cases of large atherosclerosis (LAA), 74%, 21 cases of cardiogenic apoplexy (CS), 17 cases of perforator artery disease (PAD). Because of uncertainty (UE), accounting for 7%, 5 were other causes (OE), accounting for the pathogenesis of major atherosclerosis in 2%.205: artery to arterial embolism (47%), carrier artery (plaque or thrombus) blocking perforating artery in 17 cases (8%), low perfusion / embolic reduction in 21 cases (10%), and mixed type 71 (35%).
The progression group accounted for about 17% of the total, and the incidence of diabetes in the progressive group was significantly higher than that in the non progressing group (P0.001, P0.05). The age of onset and the incidence of hypertension were higher than those in the non progressing group, but the difference was not statistically significant. There was no statistical difference between the two groups in sex, hypercholesterolemia and smoking history.
Imaging examination results (head MRI+DWI+MRA) showed 7 cases of progressive group, temporal and parietal infarction, 3 cases in basal ganglia, 3 cases of brain stem infarction, 1 cases of cerebellar infarction, 37 case of watershed infarction. The Bogouss-lavsky neuroimaging classification method was used to classify the cerebral vessels in 7 cases, 14 cases of subcortical type, and 14 cases of subcortical type. There were 6 cases of post mass, 10 cases in mixed type, 32 cases of temporal, parietal lobe infarction, 192 cases of basal ganglia, 13 cases of brain stem infarction, 12 cases of cerebellum, 12 case of occipital lobe infarction, 28 cases of watershed infarction, using Bogouss-lavsky neuroimaging classification method, according to the imaging template of cerebral vascular distribution, divided into 12 cases of anterior cortical type, 8 cases subcortical type, 8 cases of subcortical type, and cortex subcortical type 8 cases. There were 6 cases of posterior type and 2 cases of mixed type. Compared with the non progressive group, the incidence of watershed infarction was higher in the progressive group, and there was a significant difference between the two groups (P0.001).
According to the standard of vascular stenosis, 32 cases in the 51 progressive group had severe stenosis or occlusion of the large artery (62.7%), including 9 cases of intracranial stenosis in the internal carotid artery, 18 cases of middle cerebral artery stenosis or occlusion, 5 cases of vertebral basilar artery stenosis, 277 cases of non progressive group, 75 cases with severe stenosis or occlusion of the large artery (27%), and intracranial stenosis of the internal carotid artery. Narrowing of 24 cases, middle cerebral artery stenosis in 39 cases, and vertebrobasilar stenosis in 12 cases. The incidence of severe stenosis or occlusion in the advanced artery was significantly higher than that in the non progression group (P0.001), and the lesion vessels mainly occurred in the internal carotid artery system.
Among the 328 patients with acute cerebral infarction, 192 (58.53%), 136 (41.47%) for women, 24.70 + 14.47mol / L in plasma homocysteine (Hcy) 22.54 + 13.57mol / L., and 19.89 + 10.67mol / L in non progression group, and the difference between the two groups was statistically significant (P0.05).
Conclusion: the lesion distribution and imaging features of ACI patients with CISS subtype related.CISS types are most common in the proportion of large atherosclerosis, and the most common mechanism is arterial to arterial embolism and low perfusion / embolic reduction. The incidence of infarct in the watershed is high, especially in the subcortical and mixed types. Progression, diabetes, intracranial or extracranial artery stenosis or occlusion, hyperhomocysteinemia are also associated with early deterioration of neurological function in acute ischemic stroke.

【学位授予单位】：河南科技大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R743.3

【共引文献】