【作者】 王欣；

【导师】 辛世萌；

【作者基本信息】 大连医科大学 ， 神经病学（专业学位）， 2019， 硕士

【摘要】 目的:对比研究前后循环轻型脑梗死患者临床特点和预后的差异性,明确不同梗死部位(前循环梗死和后循环梗死)是否为预后不良的独立危险因素,从而为早期个体化治疗和长期二级预防提供依据。方法:本研究采用回顾性研究方法,共纳入2017年9月-2018年8月在大连医科大学附属第二医院神经内科住院的NIHSS(National Institute of Health stroke scale)评分≤5分的轻型脑梗死患者402例。(1)根据磁共振弥散加权成像(magnetic resonance imaging-diffusion weighted imaging,MRI-DWI)上显示的梗死部位,分为前循环梗死(anterior circulation infarct,ACI)组和后循环梗死(posterior circulation infarct,PCI)组。记录患者的一般资料,包括基线资料(年龄、性别、吸烟史、饮酒史、卒中史、高血压病、糖尿病、冠心病、心房颤动、TOAST[Trial of Org 10 172in acute stroke treatment]病因分型、入院时NIHSS评分、就诊时间、静脉溶栓治疗和双联抗血小板治疗情况)、影像学资料(根据MRI结果计算的梗死体积、颅内外大血管狭窄情况、大血管病变数量)、发病后首次化验的理化指标(包括空腹血糖、糖化血红蛋白、纤维蛋白原、总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、载脂蛋白A1和载脂蛋白B)及主要的临床症状和体征(肢体无力、中枢性面神经麻痹、构音障碍、偏身感觉障碍、认知障碍、视觉障碍、眼球震颤、头晕和眩晕、恶心呕吐、呛咳和吞咽困难、共济失调)。采用单因素分析比较轻型脑梗死ACI组和PCI组之间上述因素的差异性。(2)采用mRS(modified Rankin Scale,改良Rankin量表)评分评估预后,根据患者发病后3个月的预后情况,进一步将轻型脑梗死患者分为预后良好组(mRS≤2分)和预后不良组(mRS>2分),采用单因素分析和多因素Logistic回归分析,找出预后不良的独立危险因素,明确梗死部位(PCI与ACI)是否为发病后3个月时预后不良的独立危险因素。结果:1.本研究纳入符合研究标准的轻型脑梗死患者共402例,其中ACI患者共249例(61.94%),平均年龄65.32±10.84岁,男性151例(60.64%);PCI患者共153例(38.06%),平均年龄63.69±9.76岁,男性101例(66.01%)。随访结果显示有63例(15.67%)出现预后不良结局,ACI组有32例(12.85%)预后不良,PCI组有31例(20.26%)预后不良。2.前后循环轻型脑梗死的对比:ACI组和PCI组在高血压病、糖尿病、空腹血糖、糖化血红蛋白、TOAST病因分型、入院时NIHSS评分、梗死体积、部分临床症状和体征(肢体无力、中枢性面神经麻痹、偏身感觉障碍、认知障碍、视觉障碍、眼球震颤、头晕和眩晕、恶心呕吐、呛咳和吞咽困难、共济失调)上差异有统计学意义(P<0.05)。3.预后良好组和预后不良组对比:两组在梗死部位(ACI和PCI)、年龄、性别、糖尿病、冠心病、TOAST病因分型、入院时NIHSS评分、双联抗血小板治疗、梗死体积、颅内外大血管狭窄、大血管病变数量、空腹血糖和纤维蛋白原方面差异有统计学意义,其中PCI、入院时NIHSS评分、大血管病变数量是轻型脑梗死预后不良的独立危险因素(P<0.05)。结论:1.轻型脑梗死患者中,ACI比PCI患者具有更高的入院时NIHSS评分和更大的梗死体积,在TOAST病因分型上大动脉粥样硬化型、心源性栓塞型和其他原因型所占比例高于PCI患者,而PCI比ACI患者合并更多高血压病、糖尿病和更高的空腹血糖、糖化血红蛋白水平,在TOAST病因分型上小血管闭塞型所占比例高于ACI患者。2.与轻型ACI患者相比,轻型PCI患者的临床症状和体征中头晕和眩晕、偏身感觉障碍、共济失调、恶心呕吐、眼球震颤、视觉障碍、呛咳和吞咽困难较常见,而肢体无力、中枢性面神经麻痹、认知障碍在轻型ACI患者中更为常见。3.轻型脑梗死患者中,与ACI患者相比,PCI患者3个月时预后不良的风险较高。更多还原

【Abstract】 Aims:To compare the clinical characteristics and prognosis of mild cerebral infarction between anterior circulation and posterior circulation,and to determine whether different infarct sites(anterior circulation infarction and posterior circulation infarction)are independent influencing factors of poor prognosis.So as to provide reference for early individualized treatment and long-term secondary prevention.Methods:This was a retrospective study of 402 patients of mild cerebral infarction with NIHSS(National Institute of Health stroke scale)score ≤ 5 who were admitted to the department of neurology of the second affiliated Hospital of Dalian Medical University from September 2017 to August 2018.(1)According to the infarct position displayed on magnetic resonance imaging-diffusion weighted imaging(MRI-DWI),the patients were divided into two groups: anterior circulation infarction(ACI)group and posterior circulation infarction(PCI)group.General data of patients were recorded,including baseline data(age,sex,history of smoking,history of alcohol consumption,history of stroke,hypertension,diabetes,coronary heart disease,atrial fibrillation),clinical data(etiological classification of TOAST [Trial of Org 10 172 in acute stroke treatment],NIHSS score at admission,time of visit,intravenous thrombolysis therapy and dual antiplatelet therapy),imaging data(infarct volume calculated from MRI results,intracranial or extracranial macrovascular stenosis,number of macroangiopathy),laboratory indicators for the first time since the onset of the disease(including fasting blood glucose,glycosylated hemoglobin,fibrinogen,total cholesterol,triglyceride,high density lipoprotein cholesterol,low-density lipoprotein cholesterol,apolipoprotein A1,apolipoprotein B)and main clinical symptoms and signs(limb weakness,central facial palsy,dysarthria,hemisensory deficits,cognitive impairment,visual impairment,nystagmus,vertigo,nausea and vomiting,bucking and dysphagia,ataxia).Univariate analysis was used to compare the differences between the ACI group and the PCI group.(2)The prognosis was evaluated by modified Rankin score(mRS).The patients with mild cerebral infarction were further divided into good prognosis group(mRS score ≤ 2)and poor prognosis group(mRS score > 2)according to the prognosis of 3 months after the onset of mild cerebral infarction.Univariate analysis and multivariate Logistic regression analysis were used to find out the independent risk factors for poor prognosis and to determine whether the infarct location(PCI and ACI)was the independent risk factor for poor prognosis 3 months after onset.Results: 1.402 patients with mild cerebral infarction were included in this study,including 249 patients(61.94%)in ACI group,with an average age of 65.32 ± 10.84 years,male 151 cases(60.64%);There were 153 cases(38.06%)in PCI group,with an average age of 63.69 ± 9.76 years old,and 101 cases(66.01%)in male group.The results of follow-up showed that 63 cases(15.67%)had poor prognosis,32 cases(12.85%)in ACI group had poor prognosis and 31 cases(20.26%)had poor prognosis in PCI group.2.Comparison of mild cerebral infarction between anterior circulation and posterior circulation: There were significant differences between the mild ACI group and the PCI group in the following aspects: hypertension,diabetes,fasting blood glucose,glycosylated hemoglobin,etiological classification of TOAST,NIHSS score at admission,infarct volume,and some clinical symptoms and signs(limb weakness,central facial palsy,hemisensory deficits,cognitive impairment,visual impairment,nystagmus,vertigo,nausea and vomiting,bucking and dysphagia,ataxia)(P<0.05).3.Comparison between good prognosis group and poor prognosis group: There were significant differences between the good prognosis group and the poor prognosis group in the following aspects: the infarct site(ACI and PCI),age,sex,diabetes mellitus,coronary heart disease,etiological classification of TOAST,NIHSS score at admission,dual antiplatelet therapy,infarct volume,intracranial or extracranial macrovascular stenosis,number of macroangiopathy,fasting blood glucose and fibrinogen(P<0.05).In addition,PCI,admission NIHSS score and number of macroangiopathy are independent risk factors for poor prognosis of mild cerebral infarction(P<0.05).Conclusion: 1.In patients with mild cerebral infarction,ACI had higher NIHSS score at admission and larger infarct volume than those with PCI,and the proportion of major atherosclerosis type,cardiogenic embolism type and other cause type in TOAST was higher than that in PCI patients,while PCI had more hypertension,diabetes and higher fasting blood glucose and glycosylated hemoglobin levels than those with ACI,The percentage of occlusive type of small vessel disease in TOAST was higher than that in ACI.2.Compared with mild ACI patients,vertigo,hemisensory deficits,ataxia,nausea and vomiting,nystagmus,visual impairment,bucking and dysphagia were more common in mild PCI patients,but limb weakness,central facial palsy and cognitive impairment were more common in mild ACI patients.3.In patients with mild cerebral infarction,PCI patients had a higher risk of poor prognosis at 3 months compared with patients with ACI.更多还原