【作者】 曹海燕；

【导师】 薛蓉； 王景华； 张立群；

【作者基本信息】 天津医科大学 ， 神经病学， 2009， 硕士

【摘要】 目的通过对卒中单元急性脑卒中住院病人进行有关卒中流行病学、危险因素、卒中机制、卒中亚型和卒中结局等有用信息的登记及相关因素分析,更好的掌握脑卒中的临床特征、危险因素、病因和发病机制分型,最终达到规范和提高急性脑血管病的整体诊治水平,降低致死、致残率,提高患者及家属的生存质量之目的。方法本研究共连续收集了卒中单元748例发病在14天以内的脑卒中患者。这是一个基于住院病例的登记研究,并且利用了电脑数据库系统,对所有患者采用计算机统一编码。所有患者的诊断均经头颅CT和MRI证实。这一研究始于2007年12月止于2009年2月。主要分析了患者的基本信息、危险因素、发病至到院的时间间隔、卒中分型、住院时间、住院期间各种并发症发生率、病死率、药物治疗、出院时情况、按性别分别将患者分成两组比较两组脑卒中患者的特点、并分析糖尿病合并脑梗死患者的临床特点。结果卒中单元748例卒中患者中脑梗死585例(78.21%),出血性卒中98例(13.10%),短暂性脑缺血发作(TIA)65例(8.69%)。男性患者457例(61.10%),女性患者291例(38.90%)。年龄为65.95±11.90岁,住院天数为16.37±9.57天。52.81%的患者在发病24小时内到医院就诊,只有4.01%的患者在发病2小时内到达医院就诊。在卒中的危险因素中,发生率最高的为高血压占71.39%,其次为吸烟、饮酒、糖尿病,比例依次分别为:47.73%、39.30%、35.70%。23.93%的患者同时合并高血压、吸烟和饮酒三种危险因素。入院前用于一级预防的抗高血压药、抗血小板药、他汀类药物比例均比较低。脑梗死的OCSP分型中,腔隙性梗死(LACI)为最常见的类型,所占比例为30.94%,其次为部分前循环梗死(PACI)(30.60%)。脑梗死的TOAST分型中,大动脉粥样硬化性梗死(LAA)为最常见的类型,占43.59%,其次为小动脉闭塞(SAO)(30.94%)。TACI型与PACI型最常见的病因均为大动脉粥样硬化性梗死(LAA),LACI型最常见于小动脉闭塞(SAO)。脑梗死最常见的部位为基底节(42.23%)。脑实质出血最常见的部位为基底节丘脑区(66.67%)。本研究中头颅MRA的检查率最高,为15.51%,其次为颈部血管超声(8.08%)。DSA的检查率仅为4.01%。颈动脉狭窄或闭塞的患者临床表现复杂多样,与个体血管解剖变异、侧支循环代偿及梗死的发病机制有关。住院期间并发症发生率最高的为泌尿系感染,发生率为36.50%。抑郁发生率为36.10%。脑心综合症的发生率为65.47%。卒中单元急性期的治疗比较规范。患者出院时神经功能缺损程度较入院时减轻,出院时59.36%的患者mRS评分≤2。住院期间病死率为3.74%。死亡患者中,71.43%的患者死亡与卒中有直接关系,28.57%的患者死亡与卒中有间接关系。出院带药各药比例均较入院前用药的比例高。三个月随访病死率为4.31%,三个月随访患者综合生活能力较出院时明显提高。三个月随访口服各药比例均较出院带药比例降低。死亡患者中,66.67%的患者死亡与卒中有直接关系。33.33%的患者死亡与卒中有间接关系。男女患者比较:女性患者较男性患者年龄大、文化程度低、发病至到院的时间间隔长。住院期间女性患者所做检查项目较男性少,如血管检查、经胸超声心动图检查等。女性患者较男性患者入院时神经功能缺损严重,住院期间好转率低,并发症发生率高,预后差。糖尿病脑梗死患者较非糖尿病患者合并的危险因素多、多发梗死和大面积脑梗死发生率较非糖尿病患者高,神经功能缺损严重、抑郁发生率高,出院时神经功能好转率低、预后差、病死率高。结论研究人口统计学特征基本与世界其他地区报道的卒中登记研究结果相一致。本研究中,缺血性卒中较出血性卒中常见,二者所占比例分别为86.9%和13.10%。缺血性卒中和出血性卒中最常见的病变部位均为基底节丘脑区。公众对脑卒中的识别能力低、急救意识差,院前急救系统不完善,院前延误十分严重。在卒中的危险因素中,发生率最高的为高血压。有相当一部分患者同时合并两种或三种及以上危险因素,卒中的多重危险因素促进了卒中的发病。脑梗死的OCSP分型中,最常见的为腔隙性梗死。TOAST分型中,大动脉粥样硬化性梗死(LAA)最常见。急性期的OCSP分型能部分提示病因,对指导临床治疗有益。在本研究阶段中血管检查率低,临床医生对血管检查的重要性认识不足,对缺血性卒中的病因和发病机制分型诊断尚不完善。卒中单元急性期的治疗规范有效。患者死亡原因分析,死亡原因与卒中直接相关的占大多数,其余患者死亡原因与卒中间接相关,因此关注中枢性呼吸循环衰竭、脑疝及严重的肺感染、消化道出血等并发症,降低病死率。卒中的一级预防和二级预防体系不够完善。女性卒中患者较男性在发病、救治、临床诊治及预后等方面有其独特性。糖尿病脑梗死患者较非糖尿病患者合并的危险因素多、神经功能缺损严重、抑郁发生率高,出院时神经功能好转率低、预后差、病死率高。更多还原

【Abstract】 Objective In accordance with data registration and analysis of epidemiology, risk factors,mechanism,subtype and outcomes of stroke patients in hospital stroke unit,to learn clinical characteristics,risk factors,etiology,pathogenesis and types of stroke for standardizing and strengthening diagnosis and treatment of acute cerebrovascular diseases and reducing mortality and disability rate as well as improving quality of life of patients and their families.Methods 748 stroke patients within 14 days course in stroke unit were collected from December 2007 to January 2009 in this study.Based on registration of hospitalization,data of patients were encoded with computer database system.All patients were diagnosed by CT or MRI.Demographic characteristics,risk factors, duration from onset to attendance,stroke types,hospitalization duration,complication incidence and mortality in hospitalization,drug treatment,and discharge condition were analyzed.According to sex,the patients were divided into two groups and compared characteristics of stroke in both groups.Furthermore,clinical characteristics of cerebral infarction patients accompanied by diabetes were discussed.Results Of 748 stroke patients,585 were cerebral infarction patients in stroke unit(78.21%),98 with hemorrhagic stroke(13.10%),65 with transient ischemic attack (8.69%).Male,457 cases(61.10%);female,291 cases(38.90%).The age is 65.95 11.90.Only 4.01%patients attended hospital within 2 hours after onset,the attending delay was very common.Among the risk factors of stroke,the first was hypertension(71.39%).23.93%with hypertension and smoking and drinking.According to cerebral infarction types OCSP in patients,LACI was the major type.Given cerebral infarction types TOAST in patients,LAA was the major type(43.59%).OCSP types for acute stages partially indicate causes.Among patients with cerebral infarction,the frequent predilection site were basal ganglia(42.23%),among patients with intraparenchymal hemorrhage,66.67%lied in basal ganglia and thalamus.Of all the patients,36.36%took conventional vascular examination.Skull MRA test was the major approach for the patients,the rate was up to 15.51%.The highest complication rate was urinary tract infection 36.50%.The treatment of acute stroke was effective in stroke unit.Among the deaths,71.43%directly caused by stroke,28.57%indirectly caused by stroke.Higher administration of drugs for discharged patients than pre-hospitalization was observed.During the first 3 months in follow up,mortality was 4.31%.In the deaths,66.67%had direct relation with stroke,33.33%had indirect relation.There was difference of medical resource application between male and female.Female patients had worse neurologic dysfunction than male.Poorer efficacy for female and higher incidence of complication were observed in hospitalization. Compared with cerebral infarction patients without diabetes,the patients complicated with diabetes,had more risk factors.Severe neurologic dysfunction,multiple lesions and massive cerebral infarction incidence were observed in cerebral infarction patients with diabetes.Conclusion There is consistence of demographic characteristics between our study and present reports in other countries.Compared with hemorrhagic stroke, ischemic stroke was more frequently observed,basal ganglia and thalamus were the common sites for both stroke.The study revealed that the public have poor recognition on identification and medical aid,the imperfect first-aid system.Among the all risk factors,hypertension topped No 1.A majority of patients possessed two or more than risk factors,the multiple risk promote the progression of pathogenesis of stroke.In cerebral infarction patients with OCSP,LACI listed top one of all types.In TOAST,SAO followed LAA.OCSP types for acute stages partially indicate causes and should be beneficial for clinical treatments.The etiology and mechanism as well as Differentiation and diagnosis need further studies.Due to imperfect primary and secondary prevention system,public education should be strengthening.In comparison with male,female patients share distinctive characteristics of onset, medical aid,clinical diagnosis and treatment as well as prognosis.For cerebral infarction patients with diabetes,there were more risk factors.Besides,the incidences of multiple lesion,massive cerebral infarction,depression,neurologic dysfunction and mortality were higher than the patients without diabetes.更多还原