缺血性中风亚急性期脑灌注特点与中医证候规律的相关性研究

发布时间：2018-04-29 14:25

本文选题：CT脑灌注 + 脑梗死　；参考：《北京中医药大学》2017年硕士论文

【摘要】：目的:通过观察缺血性中风病亚急性期CT脑灌注成像(perfusion computed tomography,CTP)和中医演变规律,探索梗死后脑灌注特点和中医证候演变规律之间的关系,为诊断提供依据,为中医治疗寻找更好切入点。方法:纳入发病72h内的急性脑梗死患者30例,入院完善常规CT平扫、MRI,发病3-5天完成CT脑灌注检查,一站式获取全脑灌注成像、全脑血管成像(CT angiography,CTA),测量梗死部位及健侧镜像区的主要灌注参数,包括对比剂平均通过时间(mean transt time,MTT)、脑血流量(cerebral blood flow,CBF)、脑血容量(cerebral blood volume,CBV)。选取入院第1、3、5、7、14天作为观察时点,依据《缺血性中风证候要素诊断量表》采集中医证候信息,同时根据NIHSS量表评价神经功能。综合各项数据与临床信息,进行统计学分析。结果:1.CTP成像分析纳入的30例患者中,28例存在梗死部位灌注异常。梗死部位灌注异常存在三种情况:①MTT延长,CBF下降,CBV下降;②MTT延长,CBF下降,CBV正常或上升;③MTT延长,CBF正常或上升,CBV下降。将MTT延长,CBF下降,CBV正常或上升视为梗死部位再灌注,纳入患者再灌注率为42.7%。梗死部位与健侧的MTT、CBF、CBV差异均有统计学意义(P0.05)。2.再灌注与各时点神经功能的相关性将前循环梗死的患者按有、无再灌注分为两组,再灌注组NIHSS评分低于无再灌注组,在入院第5、7、14天差异有统计学意义(P0.05)。3.影响脑灌注情况的相关因素①梗死部位:30例患者中,位于基底节、脑干的梗死再灌注发生率为10.0%,位于放射冠、皮层、小脑的梗死再灌注发生率为80.0%,且基底节、脑干的相对脑血容量(relative cerebral blood volume,rCBV)显著低于放射冠、皮层、小脑(P0.05)。②一级侧支循环和CTA最大密度投影(maximal intensity projections,MIP)成像血流情况:按病变侧的交通动脉是否开放分为两组,两组间各灌注参数无显著差异。TIMI分级0-1级和2-3级两组间比较,各灌注参数、再灌注发生率差异无统计学意义。③其他因素:再灌注组与无再灌注组之间在年龄,高血压、糖尿病、冠心病病史,收缩压以及舒张压方面差异均无统计学意义。4.中风证候要素演变规律①证候比例变化:入院第1天证候以内风证为主导,占比内风证痰湿证血瘀证内火证;入院第3、第5和第7天以血瘀证痰湿证内火证为主;气虚、阴虚证在观察时段中始终占比较低。②单证候演变趋势:内风证入院第1天至第3天迅速下降,此后保持较低水平。痰湿证发病初期比例较高,第3天为分值最高峰,随后逐步下降。血瘀证呈现缓慢上升趋势,在第7天为分值最高峰。内火证、气虚证呈现逐步下降的趋势。阴虚证基本保持平稳。5.证候演变与脑灌注情况相关性经非参数检验,第1天气虚组患者健侧CBF参数低于无气虚组,第5天、第7天气虚组患者的rCBV低于无气虚组,差异有统计学意义(P0.05),经Spearman双变量相关分析,第5天气虚证分值与rCBV呈负相关(相关系数rs=-0.397,P=0.030),第1天气虚证分值与健侧CBF参数、第7天气虚证分值与rCBV的相关性未发现统计学意义。各时点内风证、内火证、痰湿证、血瘀证、阴虚证组间比较梗死区CBF、健侧CBF、梗死区CBV、健侧CBV、rCBV差异无统计学意义。结论:1.CT灌注成像可以定性、定量显示脑梗死亚急性期脑灌注情况。部分患者梗死部位出现自发性再灌注,对患者早期症状改善有积极影响。再灌注发生率与梗死部位有关,皮层、放射冠、小脑的再灌注率高于基底节和脑干;再灌注发生率与一级侧枝循环开放情况、CTA-MIP像血流情况、年龄、高血压、冠心病、高血脂、糖尿病、收缩压、舒张压未发现相关性。2.缺血性中风病证候演变存在一定特征规律。证候表现及严重程度与脑灌注情况之间存在一定相关性,气虚证患者可能比无气虚证患者脑灌注水平更低,发生自发性再灌注的几率也更低。
[Abstract]:Objective: To explore the relationship between the characteristics of cerebral perfusion after cerebral infarction (perfusion computed tomography (CTP) and the evolution of traditional Chinese medicine (TCM) in the subacute phase of ischemic apoplexy, to explore the relationship between the characteristics of cerebral perfusion after infarction and the law of the evolution of TCM syndrome, to provide a basis for diagnosis and to find a better entry point for the treatment of traditional Chinese medicine. Method: to include the acute cerebral infarction in the pathogenesis of 72h. 30 patients were admitted to the hospital to complete the routine CT scan, MRI, to complete the CT cerebral perfusion examination on the 3-5 day of onset, and one station to obtain the whole brain perfusion imaging, the whole brain angiography (CT angiography, CTA), to measure the main perfusion parameters of the infarct site and the healthy side mirror area, including the average pass time of the contrast agent (mean transt time, MTT), and the cerebral blood flow (cerebral blood). CBF), cerebral blood volume (cerebral blood volume, CBV). Select the admission day 1,3,5,7,14 as the observation time point, collect the TCM syndrome information according to the diagnostic scale of ischemic stroke syndrome factor, and evaluate the nerve function according to the NIHSS scale. The comprehensive data and clinical information, carry on statistical analysis. Results: 1.CTP imaging analysis included 30 Among the patients, 28 cases had abnormal perfusion of infarct site. There were three cases of infarction site perfusion abnormality: (1) MTT prolonged, CBF decreased, CBV decreased; MTT prolonged, CBF decreased, CBV was normal or ascending; MTT prolonged, CBF normal or ascending, CBV decreased. MTT extended, CBF decreased, CBV normal or rise was reperfused as infarction site, included reperfusion in patients. The difference of MTT, CBF, CBV in 42.7%. infarct site and the healthy side was statistically significant (P0.05) the correlation between.2. reperfusion and nerve function at each time point, the patients with anterior circulation infarction were divided into two groups without reperfusion, and the NIHSS score in the reperfusion group was lower than that in the non reperfusion group, and the difference in the day 5,7,14 day was statistically significant (P0.05).3. influenced the brain. Related factors of perfusion (1): Infarct Sites in the basal ganglia in 30 patients, the incidence of infarct reperfusion in the brain stem was 10%, in the radiological crown, in the cortex and in the cerebellum, the incidence of reperfusion was 80%, and the relative cerebral blood volume (relative cerebral blood volume, rCBV) in the basal ganglia was significantly lower than that in the corona, cortex, and cerebellum (P0.05). The blood flow status of the first grade collateral circulation and CTA maximum density projection (maximal intensity projections, MIP) was divided into two groups according to the opening of the communicating artery on the diseased side. There was no significant difference in the perfusion parameters between the two groups in the two groups of grade 0-1 and 2-3, and there was no statistical difference between the perfusion parameters and the incidence of reperfusion. His factors: there was no significant difference in age, hypertension, diabetes, coronary heart disease history, systolic pressure and diastolic pressure between the reperfusion group and the non reperfusion group, and there was no statistical significance in the evolution of the syndrome factors of.4. stroke syndrome (1) the change of syndrome ratio: the first days of admission to the hospital was guided by the wind syndrome, which accounted for the internal fire syndrome of the phlegm dampness syndrome and blood stasis syndrome, and the admission was third, Fifth and seventh days with blood stasis syndrome of phlegm damp syndrome mainly, Qi deficiency and yin deficiency syndrome was always low in the observation period. (2) the evolution trend of syndrome syndrome: internal wind syndrome declined rapidly from first days to third days, and then maintained a lower level. The proportion of phlegm damp syndrome in the early stage was higher, third days was the highest peak, and then gradually decreased. Blood stasis syndrome showed slowly. The rising trend was the highest peak at seventh days. Internal fire syndrome and Qi deficiency showed a gradual decline. The correlation between.5. syndrome and cerebral perfusion was tested by non parameter test. The CBF parameters of the patients in the first weather asthenia group were lower than that of the non Qi deficiency group, fifth days, and the seventh weather asthenia group were lower than the non Qi deficiency group, the difference has the difference. Statistical significance (P0.05), after Spearman bivariate correlation analysis, the score of fifth weather deficiency syndrome was negatively correlated with rCBV (correlation coefficient rs=-0.397, P=0.030), first weather deficiency syndrome scores and the healthy side CBF parameters, and the correlation between seventh weather deficiency syndrome scores and rCBV was not statistically significant. There was no statistical difference between CBF in infarct area, CBF in the healthy side, CBV in infarct area and CBV in the healthy side. Conclusion: 1.CT perfusion imaging can qualitatively and quantitatively show cerebral perfusion in subacute cerebral infarction. Spontaneous reperfusion has a positive effect on the improvement of early symptoms in some patients. The incidence of reperfusion and the location of infarct area are positive. The rate of reperfusion in the cerebellum is higher than that of the basal ganglia and brain stem. The incidence of reperfusion and the opening of the first grade collateral circulation, CTA-MIP like blood flow, age, hypertension, coronary heart disease, hyperlipidemia, diabetes, systolic pressure, diastolic pressure and diastolic pressure are not found to have certain characteristics in the evolution of the syndrome of.2. ischemic stroke. There is a certain correlation between the severity and the cerebral perfusion, and the patients with Qi deficiency may have lower cerebral perfusion than those without Qi deficiency, and the probability of spontaneous reperfusion is lower.

【学位授予单位】：北京中医药大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R277.7

【参考文献】