【作者】 张卉；

【导师】 张梅； 王茜；

【作者基本信息】 山东大学 ， 内科学（心血管病）（专业学位）， 2024， 硕士

【摘要】 研究背景:脑卒中(stroke)俗称“中风”,占全球总死亡人数的11.9%,是全世界第二大死亡原因。是我国成人致死、致残的首位病因。脑卒中因其高发病率,高致残率和高死亡已成为严重危害人类健康的疾病之一,其中以缺血性卒中(Ischemic Stroke,IS)最为常见,IS会对大脑造成不可逆转的损伤。颈动脉疾病主要病因是动脉粥样硬化(atherosclerosis,AS),约占90%以,AS是一种慢性进展性血管疾病,由多种原因所致的复杂性疾病,主要累及大、中动脉血管床的血管内膜。颈动脉粥样硬化(Carotid Atherosclerosis,CAS)斑块的形成是卒中发作的高危因素之一,CAS斑块造成血管腔狭窄,斑块破裂形成的栓子阻塞远端血管导致大脑远端供血障碍,这是导致缺血性脑卒中发生的根本原因。CAS斑块引发IS的潜在病理机制是颅内血流动力学损害,原因是由于不稳定(易损)斑块的栓塞或官腔狭窄导致的。2020年Lancet子刊上发表的一项调查数据显示,我国有近2亿人患有颈动脉斑块。血管壁高分辨率磁共振成像(HRMR-VWI)具有较高的软组织分辨率和高灵敏度以及较高的信噪比,对斑块内部成分的识别提供较高价值,其有多序列对比,如黑血、亮血等,能够非常清晰地评估斑块、血管腔、管壁和周围结构的关系,准确了解颈动脉斑块的风险性并对其做出早期诊断,并可以作为预测和评估脑卒中风险的重要工具,对于预防和治疗缺血性脑卒中起到了重大作用。2017年欧洲心脏病学会(ESC)临床实践指南建议评估斑块成像特征的存在,这些特征可能表明无症状患者除颈动脉狭窄程度外,患同侧卒中的风险增加。同样,欧洲血管外科学会(ESVS)的临床实践指南也强调了斑块易损性评估的重要性,尽管已经提出了单一模式的评分系统(如美国心脏协会(AHA)的病变类型改进的磁共振AHA病变类型颈动脉斑块超声评分等等),目前还没有针对各种成像方式的通用分类系统,能够根据斑块的形态和组成来评分动脉粥样硬化病变的严重程度。2023年9月,全球三大洲十一个国家的51位专家共同推出了新的斑块分类系统(Plaque-RADS),旨在通过一种标准化的跨模态系统,用于报告颈动脉斑块的组成和形态,以更好地评估颈动脉疾病并预测脑血管事件的风险,颈动脉斑块-RADS评分系统综合了斑块形态和狭窄程度,可更为全面的评估斑块是否稳定,能预测易损斑块发生脑血管病事件的风险。但是与斑块AHA分型相比在预测缺血性脑卒中事件发生中是否更具有诊断价值尚不明了。那么与斑块AHA分型相比,斑块-RADS评分系统在预测缺血性脑卒中事件发生中是否较AHA分型更具有诊断价值?为此,本研究旨在探讨用3.0T HRMR-VWI测量斑块组成特征与缺血性脑卒中风险的相关性,并评估用这种方法预测缺血性脑卒中发生的可能性。并进一步比较斑块-RADS评分对比斑块AHA分型在预测缺血性卒中的价值。研究目的:1.分析基于3.0T HRMR-VWI测量斑块组成特征与缺血性脑卒中风险的相关性。2.探讨AHA分型斑块稳定性及斑块-RADS评分与缺血性卒中的关系;3.评估应用新的斑块分类系统(Plaque-RADS)预测缺血性卒中发生的临床价值。研究方法:我们回顾性纳入2021年9月至2023年12月在我院住院期间接受HRMR-VWI检查的患者。其中至少有一条颈动脉存在斑块的患者总数为128人,其中106人符合研究的纳入标准。在这106名患者中,男性77人,女性29人,年龄从33岁到79岁之间。根据颈动脉系统是否存在急性缺血性卒中,我们将患者分为AIS组(71例,142支血管)和非AIS组(35例,70支血管),并对两组患者的一般临床数据、管腔狭窄程度、斑块成分进行分析,并应用单因素及多因素logistic回归模型来分析和预测影响缺血性卒中的独立危险因素。以修正的AHA斑块分型标准分为稳定型斑块与易损斑块。并用卡方检验分析AIS组与非AIS组易损斑块检出差异。根据新的斑块分类系统(Plaque-RADS)评分,分为1～2分、3分、4分三组。用卡方检验及操作者工作特征曲线(ROC曲线)分析斑块-RADS评分与缺血性卒中的关系及对比斑块-RADS评分和斑块AHA分型对缺血性卒中的诊断价值。研究结果:1.AIS组和非AIS组在主要临床参数上没有统计学意义差异(P>0.05)。AIS组中IPH、LRNC、FCR以及血栓和活动性炎症的检出率高于非AIS组(P<0.05)。研究显示活动性炎症和血栓与缺血性脑卒中有显著相关性,其中血栓危险性最高(OR=8.333,95%CI:1.857～37.393),其次是活动性炎症;2.AIS组71例患者共117个斑块,检出稳定斑块30个,易损斑块87个,易损斑块检出率为74.36%(87/117);非AIS组35例患者共59个斑块,检出稳定斑块30个,易损斑块29个,易损斑块检出率为49.15%(29/59),AIS组与非AIS组颈动脉斑块易损检出率差异有统计学意义(P<0.05);3.斑块-RADS评分中,AIS组中1～2分的比例为14.89%,3分的比例为77.55%,4分的比例为90.00%,AIS组中4分占比最高,非AIS组中1～2分的占比最高,三组评分的比例存在统计学差异(P<0.05);4.斑块-RADS评分对诊断缺血性卒中的灵敏度为94%,特异度为67.8%(P<0.05)。斑块-RADS评分诊断AIS的ROC曲线下面积(AUC)大于斑块AHA分型,大于活动性炎症(0.844比0.766比0.660,P<0.05)。活动性炎症联合斑块-RADS评分诊断AIS 最佳(AUC:0.960,P<0.05)。研究结论:1.基于高分辨磁共振检查分析颈动脉斑块成分特征与脑卒中发病风险存在显著相关,血栓和活动性炎症对缺血性脑卒中患者近期发病具有较高的预测价值,其中血栓的预测能力最强,活动性炎症次之。2.颈部血管高分辨磁共振检查进行斑块-RADS评分可准确评估斑块稳定性,与斑块AHA分型比较可更好的预测缺血性卒中的发生。更多还原

【Abstract】 Background:Stroke(stroke),commonly known as "stroke",accounts for 11.9%of all global deaths and is the second leading cause of death in the world.Ischemic stroke(Ischemic Stroke,IS)is the most common cause of death and disability among adults in China.IS will cause irreversible damage to the brain.Atherosclerosis(atherosclerosis,AS)is a complex disease caused by many causes,which mainly involves the intima of the vascular bed of large and middle arteries.The formation of carotid atherosclerotic plaque(Carotid Atherosclerosis,CAS)is one of the high risk factors of stroke.Atherosclerotic plaque causes vascular lumen stenosis,and emboli formed by plaque rupture block distal blood vessels,resulting in distal cerebral blood supply disorder.This is the root cause of ischemic stroke.The underlying pathological mechanism of IS caused by CAS plaque is the damage of intracranial blood flow mechanics,which is caused by embolization of unstable(vulnerable)plaques or stenosis of the visceral cavity.According to a survey published in Lancet in 2020,nearly 200 million people in China suffer from carotid plaque.High resolution magnetic resonance imaging(HRMR-VWI)of vascular wall has high soft tissue resolution,high signal-to-noise ratio and multi-sequence contrast,such as black blood,bright blood,etc.,which provides high value for the identification of plaque internal components.It can clearly evaluate the relationship between plaque,vascular lumen,vessel wall and surrounding structure,accurately understand the risk of carotid plaque and make early diagnosis.It can be used as an important tool to predict and evaluate the risk of stroke,and plays an important role in the prevention and treatment of ischemic stroke.The 2017 European Society of Cardiology(ESC)Clinical practice guidelines recommend the assessment of the presence of plaque imaging features that may indicate an increased risk of ipsilateral stroke in asymptomatic patients in addition to the degree of carotid stenosis.Similarly,the clinical practice guidelines of the European Society of Vascular surgery(ESVS)also emphasize the importance of plaque vulnerability assessment.Although a single-mode scoring system has been proposed(such as the American Heart Association(AHA)lesion type improved magnetic resonance AHA lesion type carotid plaque score,etc.),there is no general classification system for various imaging methods.The severity of atherosclerotic lesions can be scored according to the shape and composition of plaques.In September 2023,51 experts from 11 countries on three continents launched a new plaque classification system(Plaque-RADS),which aims to report the composition and morphology of carotid plaques through a standardized cross-modal system to better assess carotid disease and predict the risk of cerebrovascular events.The carotid plaque-RADS score system combines plaque morphology and stenosis.The stability of plaque can be evaluated more comprehensively and vulnerable plaque can be predicted risk of cerebrovascular disease events.However,compared with plaque AHA classification,it is not clear whether it has more diagnostic value in predicting ischemic stroke events.So compared with plaque AHA classification,does plaque-RADS scoring system have more diagnostic value in predicting ischemic stroke events than AHA classification?The purpose of this study was to explore the correlation between plaque composition characteristics measured by 3.0T HRMR-VWI and the risk of ischemic stroke,and to evaluate the possibility of using this method to predict the occurrence of ischemic stroke.The value of plaque-RADS score compared with plaque AHA classification in predicting ischemic stroke was further compared.Objectives:1.The correlation between plaque composition characteristics measured by 3.0T HRMR-VWI and the risk of ischemic stroke was analyzed.two。2.To explore the relationship between plaque stability and plaque-RADS score and ischemic stroke according to AHA classification.3.To evaluate the clinical value of the new plaque classification system(Plaque-RADS)in predicting ischemic stroke.Methods:We retrospectively included patients who underwent HRMR-VWI examination during hospitalization in our hospital from September 2021 to December 2023.The total number of patients with plaque in at least one carotid artery was 128,of which 106 met the inclusion criteria of the study.Of the 106 patients,there were 77 males and 29 females,aged from 33 to 79 years old.According to the presence of acute ischemic stroke in the carotid system,patients were divided into AIS group(71 cases,142 vessels)and non-AIS group(35 cases,70 vessels).The general clinical data,lumen stenosis degree and plaque composition of the two groups were analyzed,and univariate and multivariate logistic regression models were used to analyze and predict the independent risk factors of ischemic stroke.According to the modified AHA plaque classification criteria,the plaques were divided into stable plaques and vulnerable plaques.Chi-square test was used to analyze the difference of vulnerable plaques between AIS group and non-AIS group.According to the new plaque classification system(Plaque-RADS),the patients were divided into three groups:1-2 points,3 points and 4 points.Chi-square test and operator operating characteristic curve(ROC curve)were used to analyze the relationship between plaque-RADS score and ischemic stroke,and to compare the diagnostic value of plaque-RADS score and plaque AHA classification in ischemic stroke..Results:1.There was no significant difference in the main clinical parameters between the AIS group and the non-AIS group.The detection rates of IPH,LRNC,FCR,active inflammation and thrombus in AIS group were higher than those in non-AIS group.Studies showed that thrombus and active inflammation were significantly correlated with ischemic stroke,with the highest risk of thrombosis(OR=8.333,95%CI:1.857～37.393),followed by active inflammation.2.In 71 patients in AIS group,30 stable plaques were detected,87 vulnerable plaques were detected,and the detection rate of vulnerable plaques was 74.36%.There were 59 plaques in 35 patients in non-AIS group,including 30 stable plaques and 29 vulnerable plaques.The detection rate of vulnerable plaques was 49.15%(29/59).There was significant difference in the detection rate of vulnerable carotid plaques between AIS group and non-AIS group.3.In the plaque-RADS score,the proportion of 1-2 score in AIS group was 14.89%,the proportion of 3-score was 77.55%,the proportion of 4-score was 90.005%,the proportion of 4-score was the highest in the non-AIS group,and the proportion of 1-2 score was the highest in the non-AIS group.4.The sensitivity and specificity of plaque-RADS score in the diagnosis of ischemic stroke were 94%and 67.8%respectively(P<0.05).The area under the ROC curve(AUC)of plaque-RADS score in diagnosis of AIS was larger than that of plaque AHA classification and active inflammation(0.844 vs 0.766 vs 0.660 P<0.05).Active inflammation combined with plaque-RADS score was the best diagnosis of AIS(AUC:0.960,P<0.05).Conclusion:1.Based on the analysis of the characteristics of carotid plaque based on high-resolution magnetic resonance imaging,there is a significant correlation between the characteristics of carotid plaque and the risk of stroke.Thrombus and active inflammation have high predictive value for the short-term onset of ischemic stroke,among which the predictive ability of thrombus is the strongest.Active inflammation took second place.2.Plaque-RADS score of cervical vascular high-resolution magnetic resonance imaging can accurately evaluate plaque stability and can better predict the occurrence of ischemic stroke compared with plaque AHA classification.更多还原