出血性进展性卒中的相关临床因素探究

发布时间：2018-06-03 05:33

本文选题：急性出血性进展性卒中 + 亚急性出血性进展性卒中　；参考：《中南大学》2014年博士论文

【摘要】：目的：出血性脑卒中,又称脑出血,是一种严重的卒中亚型,具有较高的死亡率和致残率。出血性进展性卒中比非进展性出血性卒中预后更差,故对其病因、发病机制、预测方法和治疗手段的研究具有更加重要的临床意义。出血性进展性卒中按其发生时间可分为三类,即：急性出血性进展性卒中、亚急性出血性进展性卒中和慢性出血性进展性卒中。急性出血性进展性卒中的主要临床表现是早期神经系统症状恶化,而主要原因是早期血肿扩大；亚急性进展性卒中的主要临床表现是亚急性期神经系统症状恶化,而最主要原因是血肿周围脑水肿。本实验拟对急性出血性进展性卒中和亚急性出血性进展性卒中分别进行前瞻性临床观察性研究和回顾性病例对照研究,探索急性和亚急性出血性进展性卒中的主要相关临床因素和可能预测方法。对于急性进展性出血性卒中,我们主要研究了与早期血肿扩大相关的临床因素,重点研究了糖化血红蛋白、血脂水平、血肿密度不匀征与早期血肿扩大的关系,以及利用临床和影像学特征对早期血肿扩大进行预测的方法；对于亚急性出血性进展性卒中,主要通过识别亚急性进展的病例,分析了发生亚急性进展病例的临床特点和亚急性进展的可能原因,并初步探索了亚急性进展的可能预测因素。方法：本实验分为两个部分进行。1.前瞻性临床观察性研究：收集2013年10月1日至2014年4月1日间由CT诊断为急性自发性脑出血于湘雅二医院住院的病例,依据纳入和排除标准选择病例,分别对病例进行急诊评估、入院评估、24-72小时评估和治疗方案评估,记录病例一般情况、入院生命体征、病史、个人史、初始和复查CT影像学征象、治疗方案以及是否发生早期血肿扩大或早期神经系统症状加重,资料进行统计学分析。2.回顾性病例对照研究：通过中南大学湘雅二医院缩微病历系统,查询中南大学湘雅二医院神经内科2007年12月至2010年12月以“脑出血”入院的病例,依据纳入和排除标准选择病例,从病历记录中提取病例各项临床数据如一般情况、生命体征、病史、个人史、部分初始和复查CT影像学征象、病程中有无加重及治疗方案；选择所有发生亚急性进展的病例作为病例组,按1：2比例选择对照组,资料进行统计学分析。结果：1.前瞻性临床观察性研究：本实验共收集病例40例,10例发生早期神经系统症状加重,发生率为25%。有9例进展原因为早期血肿扩大,1例进展原因为肺部感染。40例中,有11例发生早期血肿扩大,发生率为27.5%。早期血肿扩大组发病-首次CT时间显著低于无早期血肿扩大组(p=0.007)。早期血肿扩大组PT、INR、APTT值显著低于无早期血肿扩大组(PT:11.7±0.7sVS12.7±0.9, p=0.002; INR:0.9±0.1VS1±0.1, p=0.002; APTT:33.7±3.1s VS38±5.8s,p=0.033)。早期血肿扩大组平均HDL-C显著高于无早期血肿扩大组(1.17±0.33mmol/L VS0.82±0.29mmol/L, P=0.003)。筛选出发病-首次CT时间、年龄、PT、APTT、INR、HDL和APTT与PT交互作用共7个变量进入多因素Logistic回归分析,最后得出年龄55.5岁、高密度脂蛋白胆固醇≥1.005mmo1/L、APTT37.1s且PT12.05s可能是早期血肿扩大的预测因素。2.回顾性病例对照研究：经过仔细查看病例,共纳入发生亚急性进展性脑出血的病例21例。在无亚急性进展发生的余下病例中,按照1：2比例随机选择42例病例作为对照组。21例中,9例进展可能原因为脑水肿；5例可能进展原因为肺部感染；1例可能进展原因为脑水肿合并肺部感染；1例可能进展原因为脑室内出血增多；1例可能进展原因为桥脑、脑桥再出血；4例可能进展原因不详。所有发生亚急性进展的21名病例中共死亡5例。亚急性期进展组入院后空腹血糖值(8.98±3.8VS6.45±3.29,p=0.030)和中性粒细胞计数水平(82.3%±8.43%VS77.3%±8.33%,p=0.037)显著高于无亚急性期进展组,而淋巴细胞计数水平显著低于无亚急性期进展组(10.88%±5.99%VS14.99%±5.98%,p=0.014)。中性粒细胞百分比≥74.6%者发生亚急性进展的风险是中性粒细胞百分比74.6%者的4.93倍,淋巴细胞百分比6.75%者发生亚急性进展的风险是淋巴细胞百分比≥6.75%者的24.62倍。结论：1.前瞻性临床观察性研究：糖化血红蛋白水平可能不是早期血肿扩大的预测指标；血肿密度不匀是否为早期血肿扩大的预测指标还需进一步研究；高密度脂蛋白胆固醇水平高可能和早期血肿扩大有关；早期脱水药物应用和止血药物应用对早期血肿扩大可能没有明显影响；血压控制在收缩压140mmHg可能显著减少早期血肿扩大发生；年龄55.5岁、高密度脂蛋白胆固醇≥1.005mmol/L、APTT37.1s且PT12.05s可能是早期血肿扩大的预测因素。2.回顾性病例对照研究：导致亚急性进展性出血性卒中的主要原因是脑水肿加重以及肺部感染,以及脑出血增大或再发脑出血；空腹血糖高、中性粒细胞计数高和淋巴细胞计数低可能对亚急性进展发生有提示作用；中性粒细胞百分比≥74.6%和淋巴细胞百分比6.75%的病例亚急性进展的发生率可能高。
[Abstract]:Objective: hemorrhagic stroke, also known as cerebral hemorrhage, is a serious subtype of stroke, with high mortality and disability. Hemorrhagic progressive stroke has a worse prognosis than non progressive hemorrhagic stroke, so it has more important clinical significance for its etiology, pathogenesis, prediction methods and treatment methods. It can be divided into three categories according to their occurrence time: acute hemorrhagic progressive stroke, subacute hemorrhagic progressive stroke and chronic hemorrhagic progressive stroke. The main clinical manifestation of acute hemorrhagic stroke is the deterioration of early nervous system symptoms, mainly due to the enlargement of early hematoma and the major subacute progressive stroke. The clinical manifestation is the deterioration of the symptoms of the nervous system in the subacute phase, and the most important reason is the brain edema around the hematoma. This experiment is intended to conduct prospective clinical observational studies and retrospective case control studies on acute hemorrhagic progressive stroke and subacute hemorrhagic progressive stroke to explore acute and subacute hemorrhagic progressive stroke. Major clinical factors and possible prediction methods. For acute progressive hemorrhagic stroke, we mainly studied the clinical factors associated with early hematoma enlargement, focusing on glycosylated hemoglobin, blood lipid levels, hematoma density irregularity and early hematoma enlargement, and the use of clinical and imaging features for early blood. The method of predicting the enlargement of the swelling; for subacute and hemorrhagic progressive stroke, mainly through the cases of subacute progress, the clinical characteristics and possible causes of subacute progress in subacute progress were analyzed, and possible predictors of subacute progress were preliminarily explored.
Methods: this experiment was divided into two parts of the.1. prospective clinical observational study: a case of acute spontaneous intracerebral hemorrhage diagnosed by CT in Xiangya No.2 Hospital from October 1, 2013 to April 2014 was collected. According to the inclusion and exclusion criteria, the cases were selected for emergency evaluation, admission assessment and 24-72 hour assessment respectively. And the treatment program assessment, record case general situation, admission to life signs, medical history, personal history, initial and reexamination of CT imaging signs, treatment plans, and whether early hematoma enlargement or early nervous system symptom aggravation, statistical analysis.2. retrospective study of venereal diseases: through Xiangya No.2 Hospital of Central South University The medical record system, inquiring the cases of "cerebral hemorrhage" in the Department of Neurology of Xiangya No.2 Hospital of Central South University from December 2007 to December 2010, and selecting cases according to the inclusion and exclusion criteria and extracting the clinical data from the record of the medical records, such as general conditions, vital signs, history and personal history, and the course of initial and review of the CT image, the course of disease, and the course of disease. All patients with subacute progression were selected as case group, and the control group was selected according to 1:2 ratio, and the data were analyzed statistically.
Results: 1. prospective clinical observational study: 40 cases were collected in this experiment, 10 cases had early neurological symptom aggravation, the incidence was 25%., 9 cases were caused by early hematoma enlargement, 1 cases were caused by pulmonary infection in.40 cases, 11 cases had early hematoma enlargement, the incidence of early hematoma enlargement group of 27.5%. was the first time. The time of CT was significantly lower than that of no early hematoma enlargement group (p=0.007). The value of PT, INR, APTT in the early hematoma enlargement group was significantly lower than that of no early hematoma enlargement group (PT:11.7 + 0.7sVS12.7 + 0.9, p=0.002; INR:0.9 + 0.1VS1 + 0.1, p=0.002; APTT:33.7 +) was significantly higher than that in the non early hematoma enlargement group (1. 17 + 0.33mmol/L VS0.82 + 0.29mmol/L, P=0.003). Screening out the onset of the first CT time, age, PT, APTT, INR, HDL and APTT and PT interact with 7 variables into multiple factor Logistic regression analysis. Finally, the age of 55.5 years and high density lipoprotein cholesterol (HDL) were predicted to be the cause of early hematoma enlargement. .2. retrospective case control study: after careful examination of cases, 21 cases of subacute progressive cerebral hemorrhage were included. In the remaining cases without subacute progress, 42 cases were randomly selected as.21 cases in the control group according to the proportion of 1:2. The possible cause of the progression was brain edema in 9 cases; the 5 cases may be progressing to the lung. Infection; 1 patients may progress in the cause of brain edema and pulmonary infection; 1 may progress in the cause of increased intraventricular hemorrhage; 1 may progress in the bridge brain, pontine rebleeding; 4 may progress in unknown reasons. All 21 cases of subacute progress in 5 cases. The subacute progression group after admission to the fasting blood glucose value (8.9) The levels of 8 + 3.8VS6.45 + 3.29, p=0.030) and neutrophils count (82.3% + 8.43%VS77.3% + 8.33%, p=0.037) were significantly higher than those in the non subacute stage, but the lymphocyte count level was significantly lower than that in the non subacute stage (10.88% + 5.99%VS14.99% 5.98%, p=0.014). The risk of subacute progress in the percentage of moderate granulocyte percentage more than 74.6% The percentage of neutrophils was 4.93 times more than that of 74.6%. The risk of subacute progress in the percentage of lymphocyte percentage 6.75% was 24.62 times the percentage of lymphocyte percentage more than 6.75%.
Conclusions: 1. prospective clinical observational studies: glycosylated hemoglobin levels may not be a predictor of early hematoma enlargement; whether hematoma density unevenness is a predictor of early hematoma enlargement needs further study; high density lipoprotein cholesterol levels may be associated with the expansion of early hematoma; early dehydrating drugs are used and The use of hemostatic drugs may not significantly affect the expansion of early hematoma; blood pressure control at systolic pressure 140mmHg may significantly reduce early hematoma enlargement; age 55.5, high density lipoprotein cholesterol (HDL) or 1.005mmol/L, APTT37.1s and PT12.05s may be a pretest factor for early hematoma enlargement: a retrospective case control study of.2.: leading to a retrospective case control study The main cause of subacute progressive hemorrhagic stroke is the aggravation of brain edema and pulmonary infection, as well as the increase of cerebral hemorrhage or recurrent cerebral hemorrhage; high fasting blood glucose, high neutrophils count and low lymphocyte count may be suggestive of subacute progress; the percentage of neutrophils is more than 74.6% and the percentage of lymphocyte is 6.75. The incidence of subacute progress in% of cases is likely to be high.
【学位授予单位】：中南大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R743.3

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