早期梗死模式与急性大脑中动脉梗死临床转归相关性及其机制研究

发布时间：2018-02-16 02:43

本文关键词：脑卒中颞前动脉磁共振成像梗死模式大脑中动脉闭塞侧支循环功能预后卒中预后神经影像磁共振成像梗死模式早期神经功能恶化急性脑梗死大脑中动脉静脉溶栓磁共振成像梗死模式功能预后　出处：《南京大学》2016年博士论文　论文类型：学位论文

【摘要】：第一部分急性动脉粥样硬化性大脑中动脉M1段闭塞患者颞前动脉与磁共振弥散加权成像梗死模式及预后的相关性分析背景与目的：本研究初步探讨急性动脉粥样硬化性大脑中动脉M1段闭塞患者颞前动脉的存在对早期磁共振加权成像脑梗死模式及与早期功能预后的影响。方法：连续纳入2007年1月至2012年12月于南京卒中注册系统登记的急性动脉粥样硬化性大脑中动脉M1段闭塞的患者。所有患者于入院期间均完成头颅磁共振成像及血管学检查。采用改良Rankin戥(mRS)评估患者90天功能预后,将mRS≤2定义为预后良好。单因素分析颞前动脉存在与颞前动脉缺失两组患者组间基线资料、ASPECTS评分、梗死模式及早期功能预后的差异,同时多因素logistic回归分析颞前动脉和梗死模式与90天功能预后的相关性。结果：研究共纳入符合入组和排除标准的患者98例。血管成像检查示44例(44.9%)患者存在颞前动脉,54例(55.1%)患者颞前动脉缺失。同颢前动脉缺失组患者相比,颞前动脉存在组患者穿通支动脉区域小梗死比率(22.7%vs 5.6%,P=0.013)及DWI-ASPECTS≥7分的比率(65.9%vs 44.4%,P=0.034)显著升高,而高血压病比率(52.3%vs 72.2%,P=0.042)、NIHSS平分(7.0 vs 8.5,P=0.043)及大脑中动脉M1段远端闭塞比率(56.8%vs 11.4%,P0.042)显著降低,而两组患者侧支循环情况并没有明显差异。Spearman相关分析结果示颞前动脉存在和DWI-ASPECTS评分(R=0.223,P=0.027)及大脑中动脉M1段远端闭塞(R=0.376,P0.001)显著正相关。共有50例(51.0%)患者90天功能预后良好,预后不良48例(49%)。同预后不良组患者相比,预后良好组患者颞前动脉存在比率(62.0%vs 27.1%,P=0.001)、DWI-ASPECTS≥ 7分比率(78.0%vs29.2%,P0.001)及分水岭梗死比率较高(20.0%vs 4.8%,P=0.099),而入院基线NIHSS评分较低(中位数5 vs 11.5,P0.001)。经多因素logistic回归分析校正潜在混杂因素(单因素分析中P0.1)后示：颞前动脉存在是急性动脉粥样硬化性大脑中动脉M1段闭塞患者90天功能预后良好的独立预测因素[优势比(odds ratio, OR)4.45,95%可信区间(confidence interval, CI)1.52-13.03：P=0.007]。结论：急性动脉粥样硬化性大脑中动脉M1段闭塞颞前动脉存在患者穿通支动脉区域小梗死比率较高,梗死体积较低。颞前动脉存在是90天功能预后良好的独立预测因素。第二部分磁共振成像对急性大脑中动脉轻型卒中早期神经功能恶化的预测价值背景与目的：早期神经功能恶化是脑卒中不良预后的重要危险因素,而磁共振成像检查有助于更好的明确缺血性脑卒中的梗死模式,对卒中机制亦有较高的诊断价值。因此,本研究初步探讨早期磁共振成像对大脑中动脉区域轻型卒中神经功能恶化的预测作用。方法：前瞻性纳入起病24小时内住院,且经影像学检查证实为大脑中动脉区域轻型卒中患者。所有患者均于入院24小时内完成磁共振检查。EDN定义72小时内任意一次NIHSS评分较基线NIHSS评分增加2分或2分以上。采用单因素分析组间人口学特征、临床资料、梗死模式及治疗方法的差异,同时多因素logistic回归分析早期磁共振结果和END的相关性。结果：研究共纳入2010年1月至2013年12月于南京军区南京总医院神经内科住院的大脑中动脉区域轻型卒中患者211例。END组患者共65例(30.8%),非END患者146例(69.2%)。同非END组患者相比,END患者内分水岭梗死比率较高(35.4%vs 12.3%,P0.001)。同其他类型梗死模式患者相比,内分水岭梗死患者高脂血症比率(19.5%vs 7.6%,P=0.023)、皮质支梗死比率(24.4%vs11.2%,P=0.027)、皮质分水岭梗死比率(31.7%vs 15.9%：P=0.020)及同侧脑大动脉狭窄比率(70.7%vs 45.3%-P=0.003)较高,而穿通动脉梗死比率(22.0%vs 80.6%,P0.001)较低。经多因素logistic回归分析校正混杂因素后示：内分水岭梗死是大脑中动脉区域轻型卒中END的独立危险因素[优势比(odds ratiO,OR)2.50-95%可信区间(confidence interval,CI)1.09-5.74；P=0.031].结论：内分水岭梗死是大脑中动脉区域轻型卒中END的独立危险因素。第三部分磁共振弥散加权成像梗死模式对大脑中动脉区域梗死患者静脉溶栓预后的预测价值背景与目的：从磁共振弥散加权成像(diffusion weighted imaging, DWI)角度,探讨梗死模式对大脑中动脉区域(middle cerebral artery, MCA)脑梗死患者静脉溶栓预后的影响。方法：回顾性分析经影像学检查证实的大脑中动脉区域急性脑梗死患者172例,所有患者均于溶栓前行磁共振检查。根据DWI结果将梗死模式分为区域性梗死,其他皮质梗死,其他深部梗死,内分水岭梗死,浅表小梗死和深部小梗死。根据改良Rankin量表评分,将90天评分为0-2分的患者定义为预后良好。采用单因素分析比较组间差异,同时多因素logistic回归分析梗死模式和大脑中动脉区域梗死患者静脉溶栓预后不良的相关性。结果：研究共纳入172大脑中动脉区域脑梗死患者,其中区域性梗死或其他深部梗死患者共75例(43.6%),同其他类型梗死模式患者相比,区域性梗死或其他深部梗死患者基线NIHSS评分(P0.001)、脑大动脉闭塞比率(P0.001)和梗死体积均显著升高(P0.001)。89例(51.7%)患者90天功能预后良好,同预后不良组相比,预后良好组患者年龄(61.8士15.4 vs 72.5±15.7,P0.001)NIHSS评分[9.0(4.0-15.5)vs 16.0(11.0-20.0),P0.001)、大脑动脉闭塞比率(30.3%vs 51.8%,P=0.004)、梗死体积[17.1(5.0-46.2)vs 35.3(8.3-73.2),P=0.029]及区域梗死或其他深部梗死模式比率(29.2%vs 59.0%,P0.001)明显降低。经多因素logistic回归分析校正潜在混杂因素后示：特殊梗死模式(区域梗死或其他深部梗死模式)是大脑中动脉区域脑梗静脉溶栓早期预后不良的独立危险因素(OR,0.40；95%CI,0.16-0.99；P=0.047)结论：区域梗死或其他深部脑梗死模式是大脑中动脉区域脑梗死静脉溶栓患者早期预后不良的独立预测因素。
[Abstract]:The first part of acute atherosclerotic middle cerebral artery occlusion of the M1 segment in patients with anterior temporal artery infarction and diffusion-weighted magnetic resonance imaging pattern and prognosis analysis of the correlation between background and purpose: This study was to explore the influence of early magnetic resonance imaging and cerebral infarction patterns and prognosis of early functional arterial occlusion of the M1 segment in patients with acute anterior temporal artery atherosclerosis the brain. Methods: arterial occlusion of the M1 segment were included in January 2007 to December 2012 in Nanjing stroke registration system registration of acute atherosclerotic brain. All patients were completed during cranial magnetic resonance imaging and vascular pathology. Using modified Rankin and (mRS) the 90 day evaluation function and prognosis of patients, the definition of mRS = 2 for the good prognosis. The single factor analysis of anterior temporal artery and anterior temporal artery deletion of two groups of patients between groups at baseline, ASPE The CTS score, different infarction patterns and early functional outcomes at the same time, logistic regression analysis and correlation of anterior temporal artery infarction model and functional outcome 90 days. Results: the study included 98 patients met the inclusion and exclusion criteria. Angiography showed that 44 cases (44.9%) patients had anterior temporal artery, 54 cases (55.1%) patients with anterior temporal artery deletion. Compared with Hao artery deletion group patients, anterior temporal artery of patients perforating artery region small infarction ratio (22.7%vs 5.6%, P=0.013) and the ratio of DWI-ASPECTS is more than or equal to 7 points (65.9%vs 44.4%, P=0.034) was significantly increased, and the ratio of hypertension (52.3%vs 72.2%, P=0.042 NIHSS (7), split vs 8.5, P=0.043) and M1 segment of middle cerebral artery occlusion distal ratio (56.8%vs 11.4%, P0.042) decreased significantly, while the two group patients with collateral circulation was no significant difference in the results of.Spearman correlation analysis showed anterior temporal artery. In the score and DWI-ASPECTS (R=0.223, P=0.027) and M1 segment of middle cerebral artery occlusion distal (R=0.376, P0.001) were significantly correlated. There were 50 cases (51%) 90 days function prognosis of patients with good prognosis in 48 cases (49%). Compared with the poor prognosis of patients, patients with good prognosis in patients with temporal artery ratio (62.0%vs 27.1%, P=0.001), DWI-ASPECTS = 7 (78.0%vs29.2%, P0.001) and the ratio of watershed infarction ratio is higher (20.0%vs 4.8%, P=0.099), and the admission baseline NIHSS score was lower (median 5 vs 11.5, P0.001). Multivariate logistic regression analysis adjusted for potential confounding factors (univariate analysis showed P0.1) there is a temporal artery in acute atherosclerotic middle cerebral artery occlusion of the M1 segment of the advantages of independent predictors of patients [90 days a good functional outcome than (odds ratio, OR (confidence) 4.45,95% CI interval, CI) 1.52-13.03:P=0.007]. conclusion Acute atherosclerotic middle cerebral artery occlusion of the M1 segment of anterior temporal artery in the patients with perforating artery infarction area ratio is higher, the infarct volume was lower. Anterior temporal artery are independent predictors of 90 day prognosis is good. In the second part, functional magnetic resonance imaging of acute middle cerebral artery stroke light early neurological deterioration prediction value background and objective: early neurological deterioration is an important risk adverse prognostic factors for stroke, and magnetic resonance imaging examination is helpful to better understand the ischemic stroke infarction model, also has high diagnostic value for stroke mechanism. Therefore, this study was to explore the predictive effect on arterial regions of the brain in light of stroke early magnetic resonance imaging deterioration. Methods: We prospectively enrolled within 24 hours of hospitalization, and confirmed by imaging of arterial regions of the brain in the light Stroke patients. All patients completed the MRI in.EDN within 24 hours after admission within 72 hours of the definition of any NIHSS score compared to the baseline NIHSS score increased 2 points or 2 points or more. The single factor analysis between group differences in demographic characteristics, clinical data, infarction patterns and treatment methods, and multivariate logistic regression correlation analysis early magnetic resonance imaging results and END. Results: the study included from January 2010 to December 2013 in the Nanjing military region, the middle cerebral artery in the Department of Neurology, Nanjing general hospital in the area of light stroke patients in 211 cases of.END group were 65 cases (30.8%), 146 cases of non END patients (69.2%). Compared with non END patients, END patients. Watershed infarction ratio is higher (35.4%vs 12.3%, P0.001). Compared with other types of patterns in patients with watershed infarction infarction, patients with hyperlipidemia ratio (19.5%vs 7.6%, P=0.023), cortex infarct ratio (24.4%vs11 .2%, P=0.027), cortical watershed infarction ratio (31.7%vs 15.9%:P=0.020) and ipsilateral cerebral artery stenosis ratio (70.7%vs 45.3%-P=0.003) high, and perforating artery infarction ratio (22.0%vs 80.6%, P0.001) is low. Through logistic regression analysis after adjusting for confounding factors showed: watershed infarction is an independent risk factor [odds ratio the middle cerebral artery territory stroke END (odds light ratiO, OR (confidence) 2.50-95% CI interval, CI) 1.09-5.74; P=0.031]. conclusion: watershed infarction is an independent risk factor of middle cerebral artery area light stroke END. In the third part, diffusion weighted magnetic resonance imaging model of middle cerebral artery infarction patients with venous infarction prognosis area background and purpose: the prognostic value of diffusion-weighted magnetic resonance imaging (diffusion weighted, imaging, DWI) to investigate the angle model of middle cerebral artery infarction area (middle cerebral artery, MCA) effect of intravenous thrombolysis in patients with cerebral infarction prognosis. Methods: retrospective analysis of the imaging area of the brain artery examination confirmed 172 cases of acute cerebral infarction patients, all patients before thrombolysis MRI. According to the results of DWI infarction model is divided into regional infarction, other cortical infarction, other deep within the watershed infarction, infarction, superficial small infarction and deep small infarction. According to the modified Rankin scale score, the patients defined 90 days 0-2 score for the prognosis is good. The single factor analysis to the difference between the groups at the same time, the multi factor Logistic model and correlation analysis of infarction of middle cerebral artery venous infarction patients thrombolysis prognosis regression. Results: the study included 172 patients with cerebral infarction of middle cerebral artery area, regional infarction or other deep infarction patients in 75 cases (43.6%), with other types of Compared with the regional pattern of infarction, infarction or other deep infarction in patients with baseline NIHSS score (P0.001), cerebral artery occlusion ratio (P0.001) and infarct volume were significantly increased (P0.001).89 cases (51.7%) of 90 days compared with the functional prognosis of patients with good prognosis group and good prognosis group (61.8 patients with age 15.4 vs 72.5 + 15.7 P0.001), NIHSS [9.0 (4.0-15.5) vs score 16 (11.0-20.0), P0.001), middle cerebral artery occlusion ratio (30.3%vs 51.8%, P=0.004), infarct volume (5.0-46.2) vs 35.3 [17.1 (8.3-73.2), P=0.029] and regional infarction or other deep infarction model ratio (29.2%vs 59%, P0.001) significantly reduced. Through logistic regression analysis after adjusting for potential confounders: special infarction patterns (regional infarction or other deep infarction model) is an independent risk factor of cerebral artery vein thrombolysis in early cerebral infarction area of poor prognosis (OR, 0.40; 95%CI 0.16-0.99, P=0.047) conclusion: regional infarction or other deep cerebral infarction models are independent predictors of poor early prognosis in patients with cerebral infarction in middle cerebral artery area.

【学位授予单位】：南京大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R743.3

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