前循环大血管闭塞对轻度缺血性卒中患者远期认知功能的影响

发布时间：2018-05-25 19:18

本文选题：闭塞性脑血管病变 + 缺血性卒中　；参考：《第三军医大学》2017年硕士论文

【摘要】：背景脑血管病已成为我国居民的“第一杀手”,每年新发急性脑血管病(即脑卒中)患者高达250万人,而每年死于脑卒中的患者则超过150万人,脑卒中死亡率、发病率以及国家对其医疗开支每年呈稳定递增的趋势[1]。加之大多数卒中存活患者遗留不同程度的残疾,给家庭带来严重的经济和人力负担。闭塞性脑血管病变(cerebrovascular total occlusive disease,COD)指脑血管100%或接近100%的狭窄,是血管狭窄或非狭窄时的终末状态。它是脑血管病的重要亚型[2],可能是我国国民高卒中发病率的重要因素之一[3],也是脑卒中预防和治疗的重点目标[4],尤其是颅内大血管的闭塞性病变。COD在人群中的发病率至今仍不清楚。Horie等[5]对1053例缺血性卒中患者进行磁共振脑血管成像(magnetic resonance angiography,MRA)检查,结果发现:7.88%(83/1053)的患者存在脑血管大动脉的急性和非急性闭塞(包括心源性以及粥样硬化性)。COD引起的临床症状多种多样,侧支循环形成迅速而良好者可无任何临床症状,而形成差者可表现为严重的肢体瘫痪,甚至死亡[6]。颈内动脉(internal carotid artery,ICA)闭塞时,一些患者可以无任何症状,或仅表现头晕、头痛等相对较轻的临床症状,多数患者表现的卒中或短暂性脑缺血发作(transient ischemic attack,TIA)症状和其他非闭塞病变导致的神经功能缺失症状相似,如一过性或永久性的肢体偏瘫、偏麻、偏盲或言语障碍等,其中一过性黑朦(即短暂性偏盲)是眼动脉分支近端闭塞的象征性症状[6]。ICA闭塞性病变以及大脑中动脉(middle cerebral artery,MCA)的M1段闭塞是卒中症状恶化的独立预测因子[7]。我国大型颅内动脉粥样硬化研究(Chinese Intracranial Atherosclerosis Study,CICAS)表明脑血管闭塞的患者,一年内再发卒中的风险高达7.27%,高于存在中重度颈部或颅内血管狭窄患者的卒中再发率[3]。即使丰富的侧支代偿使血管闭塞时患者无任何症状,但代偿的血管长期处于负荷状态,最终会出现失代偿而导致相应的神经功能缺失症状。缺血性卒中超急性期时间窗内,重组组织型纤溶酶原激活物(recombinant tissue plasminogen activator,rt-PA)静脉溶栓和动脉血管内治疗(endovascular therapy,EVT)是使超急性期闭塞血管再通的有效方法,但这些方法治疗的时间窗过窄,限于4.5~8小时内,致使许多卒中症状超过时间窗的病人得不到及时治疗,并且时间窗内静脉溶栓和动脉EVT治疗的血管再通率极低(就全国而言平均水平不足20%),大多数患者经过治疗后临床症状缓解但仍然存在头颈部相应血管的闭塞,后续的治疗则主要以二级预防为主。这些长期存在的闭塞性血管病变对患者以后认知功能是否产生影响目前不得而知。全脑数字减影血管造影术(digital angiography,DSA)是目前诊断脑血管病变的“金标准”。对于缺血性脑血管病,DSA不但能清楚地显示脑血管图像,还可清楚地显示动脉管腔狭窄、闭塞、侧支循环建立情况等。不仅如此,经DSA诊断明确后,操作者可直接对血管病变进行血管内治疗,并观察手术效果,这种将检查与治疗同时进行的优势,目前其他检查方法还无法实现。自2005年第1例慢性ICA闭塞病变被成功再通后,随着EVT器械的不断改进,介入工作者对闭塞病变血管内再通术掀起了许多挑战的热情。能否应用血管内介入治疗技术对错过超急性期救治的闭塞血管再通,目前也缺乏充足的证据。目的本研究拟用DSA来筛选存在COD的患者,同时评估相应的认知功能特点,探讨脑血管COD病变对轻度缺血性卒中患者远期认知功能的影响。对存在明显低灌注的闭塞患者行血管内介入再通术,探讨血管再通后认知功能的改变情况,从而为脑血管COD病变患者的血管再通治疗提供依据。方法自2013年5月至2016年7月,从我院卒中患者登记数据库中连续纳入出现神经功能缺损、临床症状在14天以后、90天以内,经DSA证实存在前循环大血管闭塞(large artery occlusion,LAO)的轻度缺血性卒中患者170例(即LAO组),纳入97例造影证实无前循环大血管闭塞的轻度缺血性卒中患者与其配对作为对照组。另外将存在明显低灌注且手术再通的23例患者作为LAO再通组,34例存在明显低灌注但未手术再通的患者作为LAO未再通组,进行观察分析。比较所有纳入患者入组后12个月、24个月认知功能情况,包括简易智能精神状态检查量表(mini-mental state examination,MMSE)、蒙特利尔认知功能评分表(Montreal Cognitive Assessment,Mo CA)。结果随访期间,LAO组与对照组两组患者认知功能存在明显差异:12个月后MMSE[LAO组(25.73±2.26)vs对照组(26.96±1.69),P0.01],Mo CA[LAO组(24.18±3.42)vs对照组(25.70±1.56),P0.01];24个月后MMSE[LAO组(25.47±2.09)vs对照组(26.58±1.63),P0.01)],MoCA[LAO组(24.14±2.57)vs对照组(25.30±1.80),P0.01)]。LAO再通组与LAO未再通组两组患者认知功能也存在明显差异:12个月后MMSE[LAO再通组(27.29±1.31)vs LAO未再通组(26.29±1.36),P0.05],MoCA[LAO再通组(26.29±1.42)vs LAO未再通组(24.91±1.96),P0.05];24个月后MMSE[LAO再通组(27.50±1.10)vs LAO未再通组(25.57±1.67),P0.01)],Mo CA[LAO再通组(26.75±1.18)vs LAO未再通组(24.29±2.22),P0.01)]。结论前循环COD可能导致轻度缺血性卒中患者远期认知功能下降,血管内介入再通术可以明显改善该类患者远期的认知功能。
[Abstract]:Background cerebrovascular disease has become the "first killer" of Chinese residents, with more than 2 million 500 thousand new patients with acute cerebrovascular disease (stroke) each year, while more than 1 million 500 thousand people die of stroke each year, stroke mortality, morbidity, and the national trend of steady increase in medical expenses and the survival of [1]. combined with most of the stroke survival. Patients with different degrees of disability bring serious economic and human burden to the family. Cerebrovascular total occlusive disease (COD) refers to the stenosis of cerebral vascular 100% or close to 100%, which is the terminal state of vascular stenosis or non stenosis. It is an important subtype of cerebral vascular disease, [2], and may be the high death of our country. One of the important factors in the incidence of the disease, [3], is also the key target of the prevention and treatment of cerebral apoplexy [4], especially the occlusion of the intracranial large vessels, the incidence of.COD in the population is still not clear about.Horie and other [5] in 1053 patients with ischemic stroke (magnetic resonance angiography, MRA), and the result is the result. Now: 7.88% (83/1053) patients have a variety of acute and non acute occlusion (including cardiogenic and atherosclerotic).COD in the patients with large cerebral artery artery (including cardiogenic and atherosclerotic), and the side branch circulation is rapid and the good person can not have any clinical symptoms, and the poor formation can be characterized by severe paralysis of the limb and even the death of the [6]. internal carotid artery (Intern When Al carotid artery, ICA), some patients can have no symptoms, or only have relatively mild clinical symptoms such as dizziness and headache, and most patients exhibit similar symptoms of stroke or transient ischemic attack (transient ischemic attack, TIA) and other non occlusive lesions, such as one perpetual or permanent symptom. Sexual hemiplegia, hemiplegia, hemianamia, or speech disorder, of which an amamamamus (i.e., transient hemianas) is a symbolic symptom of the occlusion of the proximal occluding artery of the ophthalmic artery, [6].ICA occlusion and the middle cerebral artery, MCA, M1 segment occlusion, an independent predictor of stroke like deterioration, [7]. in China, large intracranial artery porridge Chinese Intracranial Atherosclerosis Study (CICAS) shows that patients with cerebral vascular occlusion have a risk of recurrent stroke within one year as high as 7.27%, higher than the recurrence rate of stroke in patients with moderate or severe cervical or intracranial stenosis, [3]. even if rich collateral compensatory causes blood vessels to obliterate patients without any symptoms, but the compensatory vessels For a long time in the state of load, there will be an eventual loss of compensation and the corresponding symptoms of neural dysfunction. In the hyperacute phase of the ischemic stroke, the recombinant tissue type plasminogen activator (recombinant tissue plasminogen activator, rt-PA) intravenous thrombolysis and arterial intravascular therapy (endovascular therapy, EVT) are the hyperacute phase closure. The effective method of blocking vascular recanalization, but the time window of these methods is too narrow, limited to 4.5~8 hours, resulting in many stroke symptoms beyond the time window for patients without timely treatment, and the time window intravenous thrombolytic and arterial EVT treatment of vascular recanalization rate is extremely low (the average level is less than 20% in the country), the majority of patients are treated. After the treatment, the clinical symptoms are relieved but the corresponding blood vessels of the head and neck are still occluded, and the follow-up treatment is mainly two stage prevention. The long-term existing occluded angiopathy has no effect on the cognitive function of the patients. Digital angiography, DSA is the diagnosis of the brain at present. The "gold standard" of vascular disease. For ischemic cerebrovascular disease, DSA can not only clearly display the cerebral vascular image, but also clearly show the stenosis, occlusion and collateral circulation of the artery. Not only so, after the diagnosis of DSA, the operator can directly treat the vascular disease in blood vessel, and observe the effect of the operation, this kind of effect will be observed. At the same time, the advantages of examination and treatment are not yet realized. Since first cases of chronic ICA occlusion have been successfully re opened in 2005, with the continuous improvement of the EVT instruments, the intervention workers have raised many challenges to the intravascular recanalization of the occlusive lesions. The aim of this study is to screen the patients with COD, and to evaluate the corresponding cognitive function and to explore the effect of COD lesions on the long-term cognitive function of patients with mild ischemic stroke, and to do intravascular intervention for patients with obvious low perfusion of DSA. The change of cognitive function after vascular recanalization was explored to provide a basis for the treatment of vascular recanalization in patients with cerebral vascular COD lesions. Methods from May 2013 to July 2016, neural function defects were continuously included in the registration database of stroke patients in our hospital. The clinical symptoms were 14 days later, within 90 days and confirmed by DSA. 170 patients with mild ischemic stroke (group large artery occlusion, LAO) with mild ischemic stroke (group LAO) were included in 97 cases with mild ischemic stroke without anterior circulation large vascular occlusion and paired as a control group. In addition, 23 patients with obvious low perfusion and surgical recanalization were used as the LAO Re Group, and 34 cases were obvious. The patients with low perfusion but no surgical recanalization were observed and analyzed as the LAO non recanalization group. The cognitive functions were compared for 12 months and 24 months after the patients were enrolled in the group, including the simple intelligent mental state Checklist (Mini-Mental State Examination, MMSE), and the Montreal recognition function score table (Montreal Cognitive Assessment, Mo CA). During the follow-up period, there were significant differences in cognitive function between the LAO group and the control group: MMSE[LAO group (25.73 + 2.26) vs control group (26.96 + 1.69), P0.01], Mo CA[LAO group (24.18 + 3.42) vs control group (25.70 + 1.56), P0.01], and MMSE[LAO group (25.47 + 2.09) vs control group (25.47 + 2.09) vs control group (P0.01) after 24 months. There was also significant difference in cognitive function between group (25.30 + 1.80), P0.01)].LAO recanalization group and two group of LAO without recanalization group: MMSE[LAO recanalization group (27.29 + 1.31) vs LAO non Re Group (26.29 + 1.36), P0.05], MoCA[LAO Re Group (26.29 + 1.42) vs LAO non Re Group (24.91 + 1.96), P0.05], MMSE[LAO re group after 24 months. O (25.57 + 1.67), P0.01), Mo CA[LAO recanalization group (26.75 + 1.18) vs LAO non Re Group (24.29 + 2.22), P0.01). Conclusion the forward circulation COD may lead to the decline of long-term cognitive function in patients with mild ischemic stroke, and intravascular interventional recanalization can obviously improve the long-term cognitive function of this type of patients.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

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