【作者】 刘洋；

【导师】 张继；

【作者基本信息】 大连医科大学 ， 神经病学（专业学位）， 2023， 硕士

【摘要】 目的探讨急性缺血性卒中患者入院后早期神经功能恶化的发生率及脑小血管病影像标志物、脑小血管病总体负荷与急性缺血性卒中患者早期神经功能恶化的相关性。方法本研究连续收集了2021年9月至2022年6月于泰州市人民医院神经内科住院治疗的急性缺血性卒中(Acute ischemic stroke,AIS)患者202名。全部患者均在发病后3d内于我院行头颅磁共振检查。收集患者一般资料、实验室资料及影像资料,并对脑小血管病(Cerebral small vessel disease,CSVD)影像标志物:腔隙、脑白质高信号(White matter hyperintensity,WMH)、扩大的血管周围间隙(Enlarged perivascular space,EPVS)、脑微出血(Cerebral microbleed,CMB)进行诊断和评估,并计算CSVD总体负荷。所有患者入院时均采用美国国立卫生研究院卒中量表(National institutes of health stroke scale,NIHSS)进行神经功能评估,并于入院后72h内进行多次复评。将早期神经功能恶化(Early neurological deterioration,END)定义为患者入院后72h内任意时刻复评NIHSS评分较入院时增加≥2分或NIHSS 1a、1b或1c(意识水平)增加≥1分,或NIHSS 5、6(运动)增加≥1分。根据有无END将患者分为END组与无END组,首先进行单因素分析筛选出与END相关的危险因素,再将其纳入多因素logistic回归分析,确定与END相关的独立危险因素。结果1.最终共202名患者纳入了本研究,其中35例发生了早期神经功能恶化,约占17.3%。2.END组与无END组间一般临床资料单因素分析显示:在年龄、性别、身高、体重、吸烟史、饮酒史、基线舒张压、既往病史、同型半胱氨酸、尿酸、空腹血糖、TC、TG、HDL-C、LDL-C、梗死部位及入院后治疗方案组间差异无统计意义(P>0.05)。基线收缩压、糖化血红蛋白、入院NHISS评分组间差异有统计学意义(P<0.05)。影像资料中,腔隙、CMB及CSVD总体负荷评分组间差异无统计学意义(P>0.05),中重度EPVS(43.1%VS 62.9%,P=0.03)、中重度WMH(40.1%VS 74.3%,P<0.001)、WMH总体积组间比较差异具有统计学意义(P<0.05)。3.以基线收缩压、糖化血红蛋白、入院NIHSS评分、中重度WMH、WMH总体积和中重度EPVS为自变量,进行多因素Logistic回归分析,结果显示中重度WMH(OR=0.292,95%CI 0.119-0.715,P=0.004)、入院NIHSS评分(OR=1.263,95%CI 1.077-1.481,P=0.007)、WMH总体积(OR=1.025,95%CI 1.002-1.049,P=0.03)是END独立危险因素。4.线性趋势卡方检验结果显示,随着WMH程度逐渐加重,END发生率更高,WMH严重程度与END发生率间存在线性关系(x~2=8.275,P=0.004)。随着EPVS严重程度加重,END发生率更高,EPVS严重程度与END发生率间存在线性关系(x~2=7.277,P=0.007)。5.END与无END组侧脑室旁WMH体积分别为6.53(4.47,11.84)mm~3、3.10(1.16,7.35)mm~3,组间差异存在统计学意义(P<0.001)。进一步进行Spearman相关性分析,结果显示侧脑室旁WMH体积与END发生的关联有显著的相关性(R=0.28,P=0.001)。结论1.CSVD影像标志物中,中重度EPVS及中重度WMH、WMH总体积与END的发生有关,而腔隙、CMB及CSVD总体负荷与END的发生无关。2.中重度WMH、WMH总体积和入院NIHSS评分是发生END的独立危险因素。3.随着WMH程度逐渐加重,END的发生率更高;随着EPVS严重程度加重,END发生率更高。4.侧脑室旁WMH体积与END的发生有显著的相关性。更多还原

【Abstract】 Objective To investigate the incidence of early neurological deterioration in patients with acute ischemic stroke and the correlation between the imaging markers of cerebral small vessel disease,total cerebral small vessel disease burden and early neurological deterioration in patients with acute ischemic stroke.Methods A total of 202 patients with acute ischemic stroke(AIS)who were hospitalized in the Department of Neurology,People’s Hospital of Taizhou from September 2021 to June 2022 were enrolled in this study.All patients underwent cranial magnetic resonance imaging(MRI)in our hospital within 3 days after admission.The general data,laboratory data and imaging data of the patients were collected,and the imaging markers of cerebral small vessel disease(CSVD)were:lacunar,white matter hyperintensity(WMH),enlarged perivascular space(EPVS),cerebral microbleed(CMB)were diagnosed and evaluated,and the total CSVD burden was calculated.All patients were evaluated by the National institutes of health stroke scale(NIHSS)at admission,and they were re-evaluated twice within 24 hours,48 hours and 72 hours after admission.Early neurological deterioration(END)was defined as an increase of≥2points in the NIHSS score or an increase of≥1 point in the NIHSS 1a,1b,or 1c(level of consciousness)or an increase of≥1 point in NIHSS 5 and 6(exercise)at any time within72 hours after admission.The patients were divided into END group and non-END group according to the presence or absence of END.First,univariate analysis was performed to screen out the risk factors related to END,and then they were included in multivariate logistic regression analysis to determine the independent risk factors related to END.Results 1.A total of 202 patients were finally enrolled in this study,of whom 35(17.3%)had early neurological deterioration.2.Univariate analysis of general clinical data between END group and non-END group showed that:There were no significant differences in age,gender,height,weight,smoking history,drinking history,baseline diastolic blood pressure,past medical history,homocysteine,uric acid,fasting blood glucose,TC,TG,HDL-C,LDL-C,infarct location and treatment plan after admission between the two groups(P>0.05).There were significant differences in baseline systolic blood pressure,glycosylated hemoglobin,and admission NHISS score between the two groups(P<0.05).In imaging data,there was no significant difference in lacunar,CMB and total burden of CSVD between the groups(P>0.05).There were significant differences in moderate to severe EPVS(43.1%vs 62.9%,P=0.03),moderate to severe WMH(40.1%vs 74.3%,P<0.001),and total WMH volume between the two groups(P<0.05).3.Baseline systolic blood pressure,glycosylated hemoglobin,admission NIHSS score,moderate to severe WMH,total WMH volume and moderate to severe EPVS were used as independent variables,a multifactorial logistic regression analysis was performed and showed that moderate to severe WMH(OR=0.292,95%CI 0.119-0.715,P=0.004),admission NIHSS score(OR=1.263,95%CI 1.077-1.481,P=0.007),and total WMH volume(OR=1.025,95%CI 1.002-1.049,P=0.03)were independent risk factors for END.4.According to the results of the chi-square test for linear trend,with the aggravation of WMH,the incidence of END was higher.There was a linear correlation between the severity of WMH and the incidence of END(x~2=8.275,P=0.004).With the aggravation of EPVS,the incidence of END was higher.There was a linear relationship between the severity of EPVS and the incidence of END(x~2=7.277,P=0.007).5.The volumes of periventricular WMH in the END group and the non-END group were 6.53(4.47,11.84)mm~3 and 3.10(1.16,7.35)mm~3 and the difference between the two groups was statistically significant(P<0.001).Further Spearman correlation analysis showed that there was a significant correlation between periventricular WMH volume and END(R=0.28,P=0.001).Conclusion1.Among the CSVD imaging markers,moderate to severe EPVS,moderate to severe WMH and total volume of WMH are related to the occurrence of END,while lacunar,CMB and total CSVD burden are not related to the occurrence of END.2.Moderate to severe WMH,total WMH volume and admission NIHSS score were independent risk factors for END.3.With the aggravation of WMH,the incidence of END is higher.With the aggravation of EPVS,the incidence of END is higher.4.There is a significant correlation between the volume of periventricular WMH and the occurrence of END.更多还原