大脑左右半球大动脉粥样硬化性缺血性卒中发病机制的差异性

发布时间：2018-05-30 20:50

本文选题：大动脉粥样硬化性缺血性卒中 + 中国缺血性卒中分型　；参考：《中国人民解放军医学院》2017年硕士论文

【摘要】：背景与目的:颅内外大动脉粥样硬化是导致缺血性卒中最常见的原因,其中以颈动脉(carotid artery,CA)、大脑中动脉(middle cerebral artery,MCA)病变为主。当前公认的较全面且简便的卒中解剖梗死模式包括:弥散小梗死、区域性梗死、穿支动脉梗死、分水岭梗死。相对应的导致卒中发生的机制包括:(1)动脉到动脉的栓塞;(2)载体动脉斑块覆盖穿支动脉开口;(3)低灌注/栓子清除下降;(4)混合机制。按常理推测,左、右两侧大动脉狭窄导致卒中发生的机制应无差别。然而有研究报道大动脉粥样硬化性(large-artery atherosclerosis, LAA)卒中更多发生在左侧。本研究通过对比左右两侧前循环大动脉狭窄导致脑梗死的患者在狭窄血管分布、影像梗死模式是否存在两侧的不一致性,进而推断左右两侧前循环大动脉狭窄在导致卒中发生的机制中是否存在差异。方法:收集2008年1月-2016年5月就诊于中国人民解放军总医院神经内科,发病后2周内行颅脑磁共振(magnetic resonance imaging, MRI)检查,弥散加权成像(diffusion-weighted imaging, DWI))显示在前循环供血区域存在单侧半球梗死,且完善血管影像证实有责任血管狭窄的患者。根据梗死灶部位,将患者分为左侧半球梗死组(left hemisphere stroke, LHS)和右侧半球梗死组(right hemisphere stroke, RHS)。比较上述分组间患者的一般资料、血管病危险因素、责任血管狭窄部位、中国缺血性卒中分型(ChinaIschemic Stroke Subclassification,CISS)各亚型分布,并分析不同部位血管狭窄与卒中发病机制的相关性。结果:(1)研究纳入339例LHS患者,332例RHS患者。年龄、性别、体重指数、血管病危险因素、血管狭窄部位在左右两侧前循环大动脉粥样硬化性脑梗死患者中无统计学差异。(2)左侧大脑半球前循环梗死患者CISS分型为:动脉到动脉栓塞的208例(61.36%),载体动脉斑块或血栓堵塞穿支动脉开口 58例(17.11%),低灌注/栓子清除下降156例(46.02%)。右侧大脑半球前循环梗死患者CISS分型为:动脉到动脉栓塞的174例(52.41%),载体动脉斑块或血栓堵塞穿支动脉开口 50例(15.06%),低灌注/栓子清除下降者203例(61.14%)。前循环大动脉粥样硬化性脑梗死患者CISS分型各亚型在左右两侧大脑半球的分布有显著统计学差异。动脉到动脉的栓塞更多分布在左侧脑梗死患者(p=0.019),低灌注/栓子清除下降在右侧脑梗死患者中更多见(p=0.000)。(3) 156例左侧分水岭梗死患者中,前分水岭梗死者49例(31.41%),内分水岭梗死者126例(80.77%),后分水岭梗死者92例(58.97%)。在203例表现为右侧大脑半球分水岭梗死的患者中,前分水岭梗死者85例(41.87%),内分水岭梗死者176例(86.70%),后分水岭梗死者123例(60.59%)。前分水岭梗死在右侧大脑半球更多见(p=0.042),而内分水岭、后分水岭梗死在左右侧大脑半球中的分布无统计学差异。(4)分水岭梗死患者中,单独CA病变120例,其中前分水岭梗死者62例(51.67%),内分水岭梗死者94例(78.33%),后分水岭梗死者55例(45.83%);单独MCA病变113例,其中前分水岭梗死者29例(25.66%),内分水岭梗死者86例(76.11%),后分水岭梗死者61例(53.98%)。前分水岭梗死的发生率CA病变组较MCA病变组高(p=0.000),内分水岭梗死的发生率与后分水岭梗死的发生率在CA病变组与MCA病变组之间无显著统计学差异。结论:通过研究,发现对于左侧半球梗死的患者而言,动脉到动脉栓塞机制比低灌注/栓子清除障碍所起的作用显得更加重要;而对于右侧半球梗死患者来说,低灌注/栓子清除障碍机制的作用可能更为主要。深入分析左右侧半球梗死患者的侧枝循环及脑血流灌注改变是否存在差异性,有助于为个体化治疗方案的制定提供理论借鉴。
[Abstract]:Background and objective: large intracranial and external atherosclerosis is the most common cause of ischemic stroke, including the carotid artery (CA) and the middle cerebral artery (middle cerebral artery, MCA). The generally accepted and simple pattern of apoplexy of stroke includes: diffuse small infarction, regional infarction, perforator artery infarction Death, watershed infarct. The corresponding mechanisms that lead to stroke include: (1) artery to artery embolism; (2) the carrier artery plaque covers the perforating artery opening; (3) low perfusion / embolic reduction; (4) the mechanism of mixing. Large-artery atherosclerosis (LAA) stroke is more likely to occur on the left side. In this study, the distribution of narrow vessels in patients with cerebral infarction in the left and right anterior circulatory artery stenosis was compared, and the inconsistency between the two sides of the infarct pattern was found, and the left and right anterior circulatory artery stenosis was pushed to lead to stroke. Methods: there was a difference in the mechanism. Methods: January 2008 -2016 May was collected in the General Hospital of PLA neurology department. 2 weeks after the onset, the magnetic resonance imaging (MRI) examination, diffusion weighted imaging (diffusion-weighted imaging, DWI) showed that there was a unilateral hemisphere in the anterior circulation blood supply region. Patients who were infarcted and improved vascular imaging confirmed that the patients with responsible vascular stenosis were divided into the left hemisphere infarction group (left hemisphere stroke, LHS) and the right hemisphere infarction group (right hemisphere stroke, RHS) according to the location of the infarct. Compare the general data of the patients with the above groups, the risk factors of vascular disease, the stenosis of the vessels, and the stenosis of the vessels, The distribution of ChinaIschemic Stroke Subclassification (CISS) subtypes in Chinese ischemic stroke (CISS) and the correlation between vascular stenosis in different parts and the pathogenesis of stroke. Results: (1) the study included 339 cases of LHS and 332 cases of RHS. Age, sex, body mass index, risk factors of vascular disease, and the position of vascular stenosis in the left and right sides There were no statistical differences among patients with atherosclerotic cerebral infarction (2) the CISS classification of patients with left cerebral hemisphere anterior circulation infarction was 208 cases (61.36%) of arterial to arterial embolism, 58 cases of carrier artery plaque or thrombus clogging perforating artery opening (17.11%), 156 cases of low perfusion / thrombus reduction (46.02%). Right cerebral hemisphere anterior circulation infarction. The CISS classification of dead patients was: 174 cases (52.41%) of artery to arterial embolism, 50 cases (15.06%) of carrier artery plaque or thrombus blocking perforating artery opening, 203 cases (61.14%) with low perfusion / embolic reduction. The distribution of CISS subtypes in the left and right cerebral hemisphere in patients with anterior circulation large atherosclerotic cerebral infarction was statistically significant difference. Arterial embolism was more distributed in patients with left cerebral infarction (p=0.019), and lower perfusion / emboli decreased in patients with right cerebral infarction (p=0.000). (3) among 156 left watershed infarcts, 49 cases of anterior watershed infarction (31.41%), 126 internal dividing ridge deceased (80.77%), 92 (58.97%) in the posterior watershed infarction (58.97%). 2 Among the 03 patients with the right hemisphere watershed infarction, 85 (41.87%) were anterior watershed infarcts, 176 (86.70%) in the internal watershed infarcts and 123 (60.59%) in the posterior watershed infarct. The anterior watershed infarction was more seen in the right hemisphere (p=0.042), while the internal watershed was distributed in the left and right hemispheres. Statistical differences. (4) among the patients with watershed infarction, 120 cases of CA lesions were isolated, including 62 cases (51.67%) of the anterior watershed infarcts, 94 internal watershed infarcts (78.33%), 55 cases of the posterior watershed infarction (45.83%), 113 of the MCA lesions, 29 (25.66%) of the watershed infarcts, 86 (76.11%) in the internal watershed infarcts, and the posterior watershed infarct. Cases (53.98%). The incidence of anterior watershed infarction in the CA lesion group was higher than that in the MCA lesion group (p=0.000). There was no significant difference between the incidence of the internal watershed infarcts and the incidence of the posterior watershed infarct between the CA lesion group and the MCA lesion group. Conclusion: the arterial to arterial embolization mechanism was found for patients with left hemisphere infarction. The role of low perfusion / embolic disorder appears to be more important; for patients with right hemisphere infarction, the role of low perfusion / embolic barrier mechanism may be more important. The formulation of the case provides a theoretical reference.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

【相似文献】