【摘要】 背景:脑卒中后常常会出现明显的神经心理学改变,除认知功能受损外,抑郁、焦虑等症状亦十分突出。目的:运用神经心理学方法探讨与脑卒中后相关的神经心理学变化特点。设计:病例-对照实验。单位:大庆市第三医院心理科,哈尔滨医科大学附属第二医院神经内科。对象:选择2001-10/2002-06哈尔滨医科大学附属第二医院神经科住院治疗的脑卒中患者60例。男33例,女27例,年龄42～75岁,平均年龄(59.3±8.8)岁。脑梗死49例,脑出血11例。病灶为单灶31例,多灶(含个病灶以上)29例。左半球病变20例,右半球病变21例,双侧病变19例。病变部位在颞叶6例、枕叶2例、额顶颞联合病变15例、内囊4例、基底核19例、侧脑室旁4例、丘脑4例、小脑1例、多部位5例。病灶大小<15mm的患者33例,≥15mm27例。同期选择来自哈尔滨市社区和市郊居民60例为对照组,男33例,女27例,年龄42～75岁,平均年龄(58.77.9)岁,无脑器质性病变、无精神障碍及重大躯体疾病,无精神病家族史。方法:病情处于稳定恢复期患者使用症状自评量表(90个项目,9个症状因子,分为5级评分(从0～4级,0=从无,1=轻度,2=中度,3=相当重,4=严重),汉密顿抑郁量表(共24项。其中11个躯体症状按0～2级评分,13个精神症状按0～4级评分。总分超过>24分严重抑郁、17～24分中等抑郁、～16分轻度抑郁、<7分没有抑郁),抑郁自评量表(共20项,按症状出现频度评定,分为4个等级。正向评分题,则依次评为1,2,3,4分;反向评分题,则评为4,3,2,1分。总分最高80分。抑郁严重程度=受试者各条目累积分/80×100,抑郁指数范围为25～100,规定指数在0.5以下为无抑郁,.5～0.59为轻度抑郁,0.6～0.69为中度抑郁,0.7以上为重度抑郁),焦虑自评量表(含有20个项目,分为4级评分,主要评定项目所定义的症状出现的频度。正向计分评为1,2,3,4分;反向计分评为4,3,2,1分。总分乘以.25取整数,即得标准分,分值越小越好,分界值为50。焦虑总分低于50分者为正常;50～60分为轻度焦虑,61～70分是中度焦虑,70以上者是重度焦虑)评定脑卒中后患者的精神状态。中度以上抑郁患者针对不同的病情特点给予适当的心理治疗及精神科药物治疗,共4周,1个疗程。主要观察指标:①两组对象4个量表总分比较。②脑卒中患者不同病变性质、病灶部位以及病灶大小时4个量表总分比较。③伴发抑郁患者治疗前后症状自评量表因子分比较。结果:60例脑卒中患者和60例对照组均进入结果分析。①脑卒中组和对照组症状自评量表、汉密顿抑郁量表、抑郁自评量表、焦虑自评量表总分比较:脑卒中组均高于对照组(131.45±18.89),(94.25±9.08)分;(18.73±6.54),(8.60±2.39)分;(56.49±11.85),(41.63±9.91)分;(40.086.55),(28.72±1.84)分,t=7.45～13.75,P<0.05。②脑卒中组病变性质、病灶部位以及病灶大小不同的患者4个量表总分比较:在脑卒中组,左半球病变、皮质病变、多发病灶、大病灶(≥15mm)4个量表总分高于右半球病变、皮质下病变、单发病灶、小病灶(5～14mm),(t=1.92～4.31,<0.05);而脑梗死患者与脑出血患者评分基本一致(P>0.05)。③伴发抑郁患者治疗前后症状自评量表因子分比较:21例患者有中等程度以上的抑郁症状。症状自评量表、汉密顿抑郁量表、抑郁自评量表、焦虑自评量表总分明显高于对照组(t=7.45～13.75,9.83～21.20,P<0.01)。结论:脑卒中后的神经心理学改变比较明显,这种改变与脑卒中病变部位、病灶大小和病灶部位有关,与病变性质关系不密切。有明显抑郁症状患者经心理干预后抑郁情绪明显改善,说明脑卒中后患者需要心理干预。更多还原

【Abstract】 BACKGROUND: There are obvious neuropsychological changes after stroke besides the damage of cognitive function, and the symptoms of depression and anxiety which are also very conspicuous.OBJECTIVE: To investigate the related characteristics of neuropsychological changes after stroke by means of neuropsychological methods.DESIGN: A case-control study.SETTING: Department of Psychology, the Third Hospital of Daqing; Department of Neurology, the Second Affiliated Hospital of Harbin Medical University.PARTICIPANTS: Sixty stroke inpatients (33 males and 27 female) aged from 42 to 75 years old with an average of (59.3±8.8) years old were selected from the Department of Neurology, the Second Affiliated Hospital of Harbin Medical University between October 2001 and June 2002. Totally 49 cases had cerebral infarction and 11 cases had cerebral hemorrhage; 31 cases had single focus and 29 cases had multiple focuses (including 2 focuses or more); 20 cases had lesion in left hemisphere, 21 cases had lesion in right hemisphere and 19 cases had bilateral lesions. The lesion was at temporal lobe in 6 cases, at occipital lobe in 2 cases, at frontoparietal temporal lobe in 15 cases, at internal capsule in 4 cases, at basal nuclei in 19 cases, at lateral ventricle in 4 cases, at thalamus in 4 cases, at cerebellum in 1 case and at multiple sites in 5 cases. The focal size was < 15 mm in 33 cases and ≥ 15 mm in 27 cases. Sixty residents (33 males and 27 females) aged 42 to 75 years with an average of (58.7±7.9) years old were selected simultaneously from the communities and suburbs of Harbin city as the controls and they all had no cerebral and organic lesion, mental disorder, severe somatic diseases and family history of mental disease.INTERVENTIONS: The poststroke mental status of the patients at stable recovery period was assessed with symptom checklist-90 (SCL-90, consisted of 90 items and 9 symptoms, scored by 5 grades of 0 to 4, including 0 as never, 1 as mild, 2 as moderate, 3 as a little severe and 4 as severe; Hamilton depression scale (HAMD, consisted of 24 items, including 11 somatic symptoms scored by 0 to 2 grades and 13 mental symptoms scored by 0 to 4 grades; the total score > 24 points was taken as severe depression, 17 to 24 as moderate depression, 7 to 16 as mild depression, < 7 as no depression), self-rating depressive scale (SDS, consists of 20 items, evaluated according to the occurrence frequency of the symptom, and classified into 4 grades; the score was 1, 2, 3 and 4 points for the forward scored questions, but 4, 3, 2 and 1 point for the backward scored questions; the highest total score was 80 points; the depressive severity=accumulative scores of each item/80×100, the depressive index ranged 25 to 100, the index < 0.5 was taken as no depression, 0.5 to 0.59 as mild depression, 0.6 to 0.69 as moderate depression, > 0.7 as severe depression) and self-rating anxiety scale (SAS, consisted of 20 items, scored by 4 grades, mainly evaluated according to the occurrence frequency of the symptoms. The forward scores were 1, 2, 3 and 4 points, and the backward scores were 4, 3, 2 and 1 point; the total score multiplied by 1.25, and then the integer was taken as the standard score, the lower the better, and the delimitative value was 50. The total score of anxiety < 50 points was taken as normal, 50 to 60 as mild anxiety, 61 to 70 as moderate anxiety, > 70 as severe anxiety). According to the different characters of disease, the patients with moderate depression and above were given suitable psychotherapy and psychiatric drugs for 4 weeks as a course.MAIN OUTCOME MEASURES: 1 Comparison of the total scores of the 4 scales between the two groups; 2 Comparison of the total scores of the 4 scales between stroke patients with different lesion natures, focal sites and focal sizes; 3 Comparison of the factor scores of SCL-90 in the patients accompanied by depression. RESULTS: All the 60 stroke patients and 60 cases in the control group were involved in the analysis of results. 1 Comparison of the total scores of SCL-90, HAMD, SDS and SAS between the stroke group and control group: All the total scores were higher in the stroke group than in the control group [(131.45±18.89), (94.25±9.08) points; (18.73±6.54), (8.60±2.39) points; (56.49±11.85), (41.63±9.91) points: (40.08±6.55), (28.72±1.84) points, t=7.45 to 13.75, P < 0.05]. 2 Comparison of the total scores of the 4 scales between stroke patients with different lesion natures, focal sites and focal sizes: In the stroke group, the total scores were higher in the patients with lesion in left hemisphere, cortical lesion, multiple focuses and large focal size (≥ 15 mm) than in those with lesion in right hemisphere, subcortical lesion, single focus and small focal size (< 15 mm) (t=1.92 to 4.31, P < 0.05), but the scores were almost the same between the patients with cerebral infarction and those with cerebral hemorrhage (P > 0.05). 3 Comparison of the factor score of SCL-90 in the patients accompanied by depression before and after treatment: 21 patients had moderate depressive symptoms and above, and their total scores of SCL-90, HAMD, SDS and SAS were obviously higher than those in the control group (t=7.45 to 13.75, 9.83 to 21.20, P < 0.01). CONCLUSION: The poststroke neuropsychological changes are more obvious, and the changes are associated with the lesion location, focal size and focal site, but have no close correlation with the lesion nature. After psychological interventions, the depressive emotion is markedly ameliorated in the patients with obvious depressive symptoms and it is then indicated that poststroke patients should be given psychological interventions.更多还原