脑微出血与认知功能障碍相关性的前瞻性研究

发布时间：2018-06-15 03:01

本文选题：脑微出血 + 腔隙性脑梗死　；参考：《山东大学》2015年博士论文

【摘要】：背景随着医疗技术水平的不断提高,人们的寿命也在逐渐延长。伴随而来的是认知功能下降的人群也有逐渐增加的趋势,这将严重影响患者本人及其家属的生活质量,给家庭和社会增加非常大的负担。目前核磁共振技术已经非常成熟,人们借助MRI对脑小血管病(small vessel disease, SVD)有了更深的认识。近年来提出了SVD的概念,研究发现其对认知功能障碍(cognitive impairment, CI)有着促进的作用,这引起了人们的格外重视。众所周知,患者一旦发展至痴呆状态,即使精心护理也只能减缓病情的发展,而病程却是不可逆的。SVD多指腔隙性脑梗死(lacunar infarction, LI)、脑微出血 (cerebral microbleeds, CMBs)以及脑白质疏松(leukoaraiosis, LA)。其中,CMBs是如何使得认知功能减退的呢?有没有提前防治的措施?具体的发病机制又是怎样?以往文献绝大部分都是横断面的研究,至于其发展如何研究的较少。本研究应用前瞻性研究方法对此进行分析了CMBs对认知功能的影响。目的通过对患者分组进行多点评估比较,研究CMBs对认知功能的影响,查找CMBs的危险因素,对一些可控的危险因素提前干预,从而尽可能减少认知障碍的发生,旨在为临床工作提供理论参考。方法病例组选取2013.1-2013.12月一年内在神经内科门诊及病房、体检中心就诊的患者。根据入选及排除的条件,最后进入CMBs组参四次评估者为68人,作为A组,根据CMBs分布位置A组再分为下列三个亚组：A1组：病灶在脑叶区及脑叶下的白质区；A2组：病灶在基底节区、丘脑、胼胝体区的白质、内囊、外囊、脑干或小脑等深部脑区；A3组：病灶在脑叶区及深部脑区均有分布。116名脑MRI检查无病灶者作为对照组B组。入组时,所有患者进行一般资料登记,然后分别在入组时、3个月、6个月、12个月时采集血压、血常规、血糖、血脂、同型半胱氨酸等数据信息,其中,血脂包括甘油三酯、总胆固醇、低密度脂蛋白胆固醇。同时,登记颈部血管B超、心电图、头部CT、颅脑MRI+磁敏感加权成像(susceptibility-weighted imaging, SWI)等数据,采用简易精神状态评价量表(mini mental state examination, MMSE)、巴氏指数表和格拉斯哥昏迷评分表进行评分并记录。数据采集完成后,应用统计软件SPSS17.0对结果进行统计学分析。其中,以单因素方差分析、重复测量方差分析、非参数检验处理计量资料,以卡方检验处理计数资料,并运用Pearson线性相关、Spearman线性相关、Logistic回归做相关回归分析,设P0.05有统计学意义。结果1. MMSE低分组文化程度平均水平低于MMSE正常组,年龄平均水平高于后者,高血压病、脑卒中史的患病率高于MMSE正常组,MMSE低分组中脑MRI合并有WMH、CMBs的比率高于MMSE正常组(P0.05)。2.A组平均年龄、男性所占比例高于B组(P0.05)；伴有高血压、糖尿病、脑卒中病史和抗血栓药物史的患者比例也高于B组(P0.05)；A组中合并LI、严重WMH的比例高于B组(P0.05)。3.通过对两组患者进行四次组间比较,发现A组中的A2、A3亚组MMSE总分及单项分中的注意力、计算力得分平均水平四次均低于B组(P0.05)；A3组的画图能力与B组四次比较均有显著差异(P0.05)；A1组在6个月时语言能力得分低于B组,12个月时评估A1的MMSE总分、注意力及计算力、语言能力、图案构画能力均低于B组(P0.05)。4.组内比较：6个月时,A2组、A3组的MMSE总分和计算力、注意力得分,以及A2组中的延迟回忆得分均低于入组时水平(P0.05)；12个月时比较A组的三个亚组及B组的MMSE,总分、注意力和计算力得分、延迟回忆得分均较入组时有显著减退,A组三个亚组的画图能力得分也显著下降(P0.05)。5. Logistic回归分析结果显示年龄、性别、高血压病史、脑卒中史为发生CMBs的危险因素。6. CMBs的数目与MMSE总分存在负相关(P0.001)；CMBs的分布部位与MMSE,总分相关(P0.05)；由脑叶区CMBs组至深部脑区CMBs组再至弥散分布CMBs组的顺序,使得MMSE,总分的平均水平呈下降趋势。结论1.存在CMBs的患者,尤其是深部脑区CMBs患者和弥散分布CMBs患者认知功能受损明显,其中,注意力、计算能力、延迟记忆力以及动手画图能力下降明显,脑叶区的CMBs患者语言表达及执行力受损明显。2.患者的认知功能随着时间推移而逐渐减退,最早体现在注意力、计算力和延迟回忆的减退,其次为画图能力减退。CMBs可对认知功能可以造成损害。其中位于深部脑区的CMBs,以及脑叶区和深部脑区均有分布的CMBs,对认知功能的损害速度要快于单纯脑叶区的CMBs。3.患者年龄越大,发生CMBs的风险越大；有高血压病史、脑卒中史的患者发生CMBs的风险较没有者风险更大；男性发生CMBs的风险高。4. CMBs的病灶越多,认知功能减退的程度越严重；CMBs分布弥散的患者认知损害最重,其次为深部CMBs组,再次为脑叶CMBs。
[Abstract]:Background as the level of medical technology continues to improve, people's life is also increasing, with a gradual increase in cognitive decline, which will seriously affect the quality of life of the patients themselves and their families, and add a great burden to the family and society. Now MRI technology is very mature, People have a deeper understanding of small vessel disease (SVD) with the help of MRI. In recent years, the concept of SVD has been proposed. Research has found that it has a promoting effect on cognitive dysfunction (cognitive impairment, CI), which has aroused great attention. It is well known that once the patient develops to dementia, even careful nursing is also known. It can only slow down the development of the disease, but the course is irreversible.SVD lacunar infarction (LI), cerebral microbleeds, CMBs, and leukoaraiosis (leukoaraiosis, LA). How do CMBs make cognitive function decrease? Are there any measures to prevent and cure early? The specific pathogenesis is What? Most of the previous literature is a cross-sectional study and less research on how it is developed. This study uses a prospective study method to analyze the effect of CMBs on cognitive function. Objective to study the effect of CMBs on the recognition function by multiple evaluation and comparison of the patients, and to find the risk factors of CMBs. Some controlled risk factors were intervened in advance so as to minimize the occurrence of cognitive impairment and to provide a theoretical reference for clinical work. Method case group selected patients in the Department of neurology outpatient and ward in 2013.1-2013.12 month, and the patients in the medical center. According to the conditions of admission and exclusion, the final four assessors of group CMBs were 68. People, as group A, were divided into three subgroups according to the CMBs distribution position A group: group A1: the focus was in the lobar region and the white matter under the lobe of the brain; group A2: the focus was in the basal ganglia, the thalamus, the corpus callosum white matter, the inner capsule, the outer capsule, the brain stem or the cerebellum, and the A3 group: the lesion was distributed in the brain and deep brain regions with.116 name MRI examination. The patients without focus were used as the control group B. When the group was enrolled, all the patients were registered with general data, then the blood pressure, blood routine, blood sugar, blood lipid, homocysteine and other data were collected for 3 months, 6 months and 12 months, respectively, and the blood lipid included glycerol three ester, total cholesterol, low density lipoprotein cholesterol. Blood vessel B-ultrasound, electrocardiogram, head CT, brain MRI+ magnetic sensitivity weighted imaging (susceptibility-weighted imaging, SWI) and other data, using a simple mental state assessment scale (mini mental state examination, MMSE), the pasteurized index table and the Glasgow coma scale. After the data collection was completed, the statistical software SPSS17.0 was applied. The results were analyzed statistically. Among them, a single factor analysis of variance, repeated measurement of variance analysis, non parameter test processing measurement data, chi square test processing counting data, and using Pearson linear correlation, Spearman linear correlation, Logistic regression analysis, P0.05 have statistical significance. Results 1. MMSE low group culture The average level was lower than the normal MMSE group, the age average level was higher than that of the latter, the incidence of hypertension and stroke history was higher than that of the normal MMSE group, and the ratio of MRI in the middle MMSE group was higher than that of the MMSE normal group (P0.05).2.A group (P0.05), and the proportion of men was higher than the B group (P0.05), with hypertension, diabetes, and stroke history. The proportion of patients with antithrombotic drugs was also higher than that in group B (P0.05); group A was combined with LI, and the proportion of severe WMH was higher than that of group B (P0.05).3. through four groups of two groups, A2 in the A group, A3 sub group and the attention of the single score. The average level of calculating power score was four times lower than that of the group. There were significant differences in the four times compared with the group B (P0.05); in group A1, the score of language ability was lower than that of group B at 6 months, and the total score of MMSE in A1 was evaluated at 12 months, and the ability of attention and calculation, language ability and pattern construction were lower than that in group.4. (P0.05) in group B: 6 months, A2 group, A3 group, total MMSE total and computational power, attention score, and group of attention. The score of delayed recollection was lower than that of the entry group (P0.05). At 12 months, the scores of MMSE, total, attention and computing power in three subgroups and B groups in group A were significantly lower than those in the group, and the score of drawing ability in three subgroups of group A decreased significantly (P0.05).5. Logistic regression analysis showed age and sex, The history of hypertension, the history of cerebral apoplexy was a risk factor for the occurrence of CMBs, the number of.6. CMBs was negatively correlated with the total MMSE score (P0.001); the distribution of CMBs was related to MMSE, the total score was related (P0.05), and the average level of the total score decreased from the CMBs group to the CMBs group in the deep brain region to the CMBs group in the diffuse distribution. Conclusion 1. existed. The cognitive impairment of patients with CMBs, especially in patients with CMBs in deep brain and diffuse distribution of CMBs, was significantly impaired, in which attention, computational ability, delayed memory, and hands-on drawing ability decreased significantly. The cognitive function of patients with.2. in the patients with CMBs in the lobar area decreased gradually, and the earliest decline in cognitive function of the patients with.2. was the earliest. The impairment of attention, computational power and delayed recall, followed by the impairment of drawing ability.CMBs, can cause damage to cognitive function. The CMBs in the deep brain region, and the CMBs in the brain and deep brain regions, are faster than the CMBs.3. patients in the single lobar area, and the greater the age of CMBs. The greater the risk for the patients with a history of hypertension and stroke history, the risk of CMBs was greater than that of those who did not; the more the risk of CMBs was higher in men, the more the focus of.4. CMBs, the more the degree of cognitive impairment was, the most severe cognitive impairment in the scattered patients with CMBs, followed by the deep CMBs group, and again the CMBs. of the brain lobe CMBs..
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R749.13

【共引文献】