本文關(guān)鍵詞：自發(fā)性腦出血患者急性期高血糖與預(yù)后的關(guān)系　出處：《南京醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

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【摘要】：卒中已逐漸成為全球主要死亡原因,具有高發(fā)病率、高致死率、高致殘率。自發(fā)性腦出血(spontaneous intracerebral hemorrhage,sICH)是卒中第二大類型,發(fā)病率僅次于缺血性腦卒中,在西方國家占所有卒中患者的10%～15%。與西方國家相比,我國出血性卒中發(fā)病率明顯升高,達18.8%～47.6%。按照發(fā)病原因,腦出血常分為原發(fā)性和繼發(fā)性腦出血。腦出血發(fā)病兇險,病情變化快,超過70%的患者發(fā)生早期血腫擴大或累及腦室,3個月內(nèi)的死亡率為20%～30%,且有相當(dāng)數(shù)量的存活者預(yù)后不良,導(dǎo)致沉重的經(jīng)濟社會負擔(dān),2003年我國統(tǒng)計顯示腦出血的直接醫(yī)療費用為137.2億元/年。腦出血臨床癥狀突發(fā),多在活動中起病,常表現(xiàn)為頭痛、惡心、嘔吐、不同程度的意識障礙及肢體癱瘓等。早期血腫擴大是導(dǎo)致腦出血患者預(yù)后不良的首要因素,早期血腫擴大與年齡、性別、血壓、血糖、冠心病、煙酒史、凝血異常、昏迷評分及使用甘露醇的關(guān)系報道不一。高血糖可分為糖尿病和糖尿病前期兩大類。糖尿病已成為目前最常見的慢性非傳染病之一,在我國人群中患病人數(shù)和患病率呈明顯上升趨勢。我國成人糖尿病患病率高達11.6%,糖尿病患者人數(shù)居全球首位。我國以2型糖尿病為主,占90%以上。糖尿病可增加心血管疾病及某些種類腫瘤的發(fā)病風(fēng)險和死亡風(fēng)險,其影響機制包括高糖血癥、高凝狀態(tài)、高胰島素血癥、胰島素抵抗和氧化應(yīng)激等。糖尿病前期指空腹血漿葡萄糖和(或)口服葡萄糖耐量試驗(oral glucose tolerance test,OGTT)的2h血漿葡萄糖(2hPG)升高但未達到糖尿病的診斷標(biāo)準(zhǔn),包括空腹血糖受損(impaired fasting glucose,IFG)和糖耐量受損(impaired glucose tolerance,IGT),即存在IFG或IGT或兩者兼具(IFG+IGT)。糖尿病前期被認為是一種標(biāo)志或分水嶺,如出現(xiàn)則標(biāo)志著將來發(fā)生心腦血管疾病、糖尿病、微血管病以及腫瘤和癡呆等的危險性增高。高血糖與急性卒中關(guān)系密切。早在1976年,人們就發(fā)現(xiàn)既往沒有糖尿病史的急性卒中患者也會出現(xiàn)高血糖。目前已有大量研究證實,急性期高血糖是缺血性卒中和蛛網(wǎng)膜下腔出血預(yù)后不良的獨立危險因素,高血糖也與缺血性卒中出血轉(zhuǎn)化、溶栓治療的出血轉(zhuǎn)化有關(guān)。腦出血后血糖升高可能與急性期的應(yīng)激反應(yīng)、自身激素變化和代謝變化相關(guān),高血糖與急性自發(fā)性腦出血預(yù)后的關(guān)系尚無定論。有臨床觀察性研究表明,伴有高血糖的腦出血患者急性期病死率增高且預(yù)后不良。也有研究認為,血糖升高只是腦出血急性期的一種應(yīng)激反應(yīng),不能作為預(yù)后不良的預(yù)測因素。本研究采用前瞻性隊列研究的方法,連續(xù)納入2006年3月～2010年5月入住南京市第一醫(yī)院神經(jīng)內(nèi)科的自發(fā)性腦出血患者,測定入院隨機血糖及第二日空腹血糖,分別根據(jù)血糖水平分為高血糖組及正常血糖組,完成標(biāo)準(zhǔn)卒中入院登記表,行神經(jīng)功能缺損評分,發(fā)病90d時用改良Rankin量表(modified Rankin Scale,mRS)評價預(yù)后,觀察腦出血急性期不同的血糖水平與疾病嚴重程度以及90d預(yù)后的相關(guān)性,探討自發(fā)性腦出血患者早期高血糖與疾病嚴重程度及90d預(yù)后的關(guān)系以及影響預(yù)后的相關(guān)因素。第一部分自發(fā)性腦出血患者入院隨機血糖與疾病嚴重程度及90d預(yù)后的關(guān)系目的:研究自發(fā)性腦出血患者入院隨機血糖與疾病嚴重程度及90d預(yù)后的關(guān)系。方法:連續(xù)納入發(fā)病24小時內(nèi)診斷明確的自發(fā)性腦出血患者,以入院隨機血糖≥20mmol/L者作為高血糖組,其余作為正常血糖組。用美國國立衛(wèi)生院卒中量表(National Institute of Health Stroke Scale,NIHSS)進行神經(jīng)功能缺損評分,90d時采用改良Rankin量表(mRS)評價預(yù)后,分為預(yù)后良好組(mRS≤2分)和預(yù)后不良組(mRS≥3分,包括死亡或重殘)。比較兩組的疾病嚴重程度及90d預(yù)后。結(jié)果:共納入228例腦出血患者,其中高血糖組30例(13.2%),血糖正常組198例(86.8%)。共有糖尿病患者26例,高血糖組的糖尿病比例為46.7%,顯著高于血糖正常組的6.06%,差異有統(tǒng)計學(xué)意義(P0.001)。90d預(yù)后不良患者96例,占總數(shù)的45.3%,糖尿病和非糖尿病患者之間沒有明顯差異。Spearman相關(guān)性分析表明,入院隨機血糖與入院NIHSS評分呈顯著正相關(guān)(r=0.183,P=0.009),與90d預(yù)后不良無明顯相關(guān)性(r=0.108,P=0.146)。Logistic回歸分析顯示,年齡(OR:1.053;95%CI:1.015-1.092)、入院時 NIHSS 評分(OR:1.251;95%CI:1.141-1.371)是自發(fā)性腦出血患者90d預(yù)后不良的獨立危險因素(P0.05)。結(jié)論:糖尿病患者在腦出血急性期更易出現(xiàn)血糖升高。入院隨機血糖水平與自發(fā)性腦出血嚴重程度相關(guān),與90d預(yù)后不良無明顯相關(guān)性。影響90d預(yù)后的獨立危險因素是患者年齡和入院NIHSS評分。第二部分自發(fā)性腦出血患者空腹血糖與疾病嚴重程度及90d預(yù)后的關(guān)系目的:研究自發(fā)性腦出血患者空腹血糖與疾病嚴重程度及90d預(yù)后的關(guān)系。方法:連續(xù)納入發(fā)病24小時內(nèi)診斷明確的自發(fā)性腦出血患者,行NIHSS評分,根據(jù)入院第2天空腹血糖水平進行分組,以空腹血糖≥7mmol/L者作為高血糖組,其余作為正常血糖組。90d時采用mRS評分評價預(yù)后,分為預(yù)后良好組(mRS≤2分)和預(yù)后不良組(mRS≥3分,包括死亡或重殘)。比較兩組的疾病嚴重程度及90d預(yù)后。結(jié)果:共納入228例腦出血患者,其中高血糖組59例(25.9%),血糖正常組169例(74.1%)。共有糖尿病患者26例,高血糖組的糖尿病比例為27.1%,明顯高于正常血糖組的5.9%,差異有統(tǒng)計學(xué)意義(P0.001)。90d預(yù)后不良患者96例,占總數(shù)的45.3%。Spearman相關(guān)性分析表明,空腹血糖與入院NIHSS評分呈顯著正相關(guān)(r=0.133,P=0.045),與90d預(yù)后不良無明顯相關(guān)性(r=0.116,P=0.098)。Logistic 回歸分析顯示,年齡(OR:1.070;95%CI:1.033～1.107)、入院時NIHSS評分(OR:1.165;95%CI:1.083～1.253)是自發(fā)性腦出血患者90d預(yù)后不良的獨立危險因素(P0.05)。結(jié)論:糖尿病患者在腦出血急性期更易出現(xiàn)血糖升高�？崭寡撬脚c自發(fā)性腦出血嚴重程度相關(guān),與90d預(yù)后不良無明顯相關(guān)性。影響90d預(yù)后的獨立危險因素是患者年齡和入院NIHSS評分。綜上所述,本研究的主要創(chuàng)新之處在于:1.觀察自發(fā)性腦出血急性期隨機血糖水平與疾病嚴重程度的關(guān)系和對腦出血患者90d預(yù)后的影響按入院隨機血糖水平進行分組,觀察入院隨機血糖水平與入院NIHSS評分及90d預(yù)后的關(guān)系,探討隨機血糖對自發(fā)性腦出血嚴重程度的影響及腦出血90d預(yù)后不良的影響因素。2.觀察自發(fā)性腦出血急性期空腹血糖水平與疾病嚴重程度的關(guān)系和對90d預(yù)后的影響按空腹血糖水平進行分組,觀察不同的空腹血糖與入院NIHSS評分及90d預(yù)后的關(guān)系,探討空腹血糖水平對自發(fā)性腦出血嚴重程度的影響及腦出血90d預(yù)后不良的影響因素。
[Abstract]:Stroke has gradually become the main cause of death in the world, with high morbidity, high mortality, high disability rate. Spontaneous intracerebral hemorrhage (spontaneous intracerebral hemorrhage, sICH) are the second major types of stroke, after the incidence of ischemic stroke in the western countries, accounting for all stroke patients 10% ~ 15%. compared with western countries, China's bleeding the stroke incidence rate increased significantly, up to 18.8% ~ 47.6%. according to the cause of disease, often divided into primary and secondary cerebral hemorrhage cerebral hemorrhage. The incidence of dangerous cerebral hemorrhage, the condition changes quickly, there are more than 70% patients with early hematoma enlargement or involving the ventricle, mortality within 3 months was 20% ~ 30%, and the survivors a considerable number of adverse prognosis, resulting in heavy economic and social burden, in 2003 China's statistics show that the direct medical cost of cerebral hemorrhage was 13 billion 720 million yuan / year. The clinical symptoms of sudden cerebral hemorrhage, at the onset of the illness, often The performance of headache, nausea, vomiting, different levels of consciousness and limb paralysis. Early hematoma enlargement is a leading cause of cerebral hemorrhage in patients with poor prognosis, early hematoma enlargement and age, gender, blood pressure, blood glucose, coronary heart disease, smoking and alcohol use, coagulopathy, report coma score and mannitol or not. High blood sugar can be divided into two major categories of diabetes and pre diabetes. Diabetes has become one of the most common chronic non infectious diseases, in Chinese population prevalence and prevalence showed a rising trend. China's adult diabetes disease rate is as high as 11.6%, ranking first in the world. The number of patients with diabetes type 2 in China diabetes, accounting for more than 90%. Diabetes can increase the risk of cardiovascular disease and some types of cancer risk and the risk of death, the influence mechanism including hyperglycemia, hypercoagulable state, high blood insulin, insulin resistance Pre diabetes and oxidative stress. The fasting plasma glucose and (or) oral glucose tolerance test (oral glucose tolerance test, OGTT) 2H plasma glucose (2hPG) increased but did not reach the diagnostic standard of diabetes, impaired fasting glucose (impaired fasting, glucose, IFG) and impaired glucose tolerance (impaired glucose tolerance IGT, namely IFG or IGT), or both (IFG+IGT). Pre diabetes is considered to be a sign or watershed, such as marks of occurrence of cardiovascular disease, the future risk of diabetes, microvascular disease, cancer and dementia increased. High blood glucose and acute stroke are closely related. As early as 1976 and it was found that acute stroke patients had no history of diabetes also had high blood sugar. There are a number of studies have demonstrated that acute hyperglycemia is lower in ischemic stroke and subarachnoid hemorrhage prognosis The independent risk factors, high blood sugar and hemorrhagic transformation of ischemic stroke, thrombolytic therapy of hemorrhagic transformation after cerebral hemorrhage. The stress hyperglycemia may be associated with acute period, related changes in their hormones and metabolism, relationship between prognosis of hyperglycemia and acute cerebral hemorrhage is inconclusive. Clinical observational studies show that with high blood glucose in patients with cerebral hemorrhage in acute stage of higher mortality and poor prognosis. Some studies suggested that hyperglycemia is a stress reaction of cerebral hemorrhage in the acute phase can not be used as a predictor of poor prognosis. This study adopts the method of prospective cohort study, consecutive patients with spontaneous brain from March 2006 to May 2010 in the First Hospital of Nanjing City Department of Neurology bleeding, determination of admission glucose and two days of fasting blood glucose, respectively according to the blood glucose level is divided into the high blood glucose group and normal blood glucose group, complete Standard stroke admission registration form for the neurological deficit score, incidence of 90d when using the modified Rankin scale (modified Rankin Scale, mRS) to evaluate the prognosis, blood glucose level and the severity of acute disease of different correlation of 90d and prognosis observation of cerebral hemorrhage, to explore the relationship between early hyperglycemia and disease severity and prognosis in patients with spontaneous intracerebral 90d hemorrhage and prognostic factors. The first part admission random blood glucose levels and disease severity and prognosis of 90d spontaneous intracerebral hemorrhage Objective: admission random blood sugar and disease severity and prognosis of spontaneous cerebral hemorrhage of 90d. Methods: consecutive patients within 24 hours of onset of spontaneous cerebral hemorrhage patients with clear diagnosis. The admission glucose was larger than 20mmol/L as high blood glucose group, the other as the normal blood glucose group. With the National Institutes of Health Stroke Scale (National Institu Te of Health Stroke Scale, NIHSS) neurological function was evaluated, the modified Rankin scale using 90d (mRS) to evaluate the prognosis, divided into good prognosis group (mRS = 2) and poor prognosis group (mRS = 3, including death or severe disability). Disease severity and prognosis of 90d were compared between the two groups. Results: a total of 228 cases of cerebral hemorrhage patients, the high glucose group 30 cases (13.2%), 198 cases of normal blood sugar (86.8%). A total of 26 cases of diabetic patients, the proportion of diabetic hyperglycemia group was 46.7%, significantly higher than the normal blood glucose group 6.06%, there were statistically significant differences in the prognosis of.90d (P0.001) patients with 96 cases, accounting for 45.3% of the total, no significant difference of.Spearman analysis show that the correlation between patients with and without diabetes mellitus, admission glucose and admission NIHSS score was positively correlated (r=0.183, P=0.009), and no significant correlation between the prognosis of 90d (r=0.108, P=0.146).Logistic regression Analysis showed that age (OR:1.053; 95%CI:1.015-1.092), admission NIHSS score (OR:1.251; 95%CI:1.141-1.371) is an independent risk factor of poor prognosis of 90d patients with spontaneous intracerebral hemorrhage (P0.05). Conclusion: diabetic patients in acute stage of cerebral hemorrhage is more prone to hyperglycemia. Admission random blood glucose levels and the severity of spontaneous intracerebral hemorrhage, and the poor prognosis of 90d. There was no significant correlation between independent risk factors for the prognosis of 90d patients are age and admission NIHSS score. The purpose of the relationship between fasting blood glucose and disease severity and prognosis in patients with 90d second part of spontaneous intracerebral hemorrhage: relationship between fasting blood glucose and the disease severity and prognosis of 90d patients with spontaneous cerebral hemorrhage. Methods: the study included 24 consecutive patients hours of diagnosis of spontaneous intracerebral hemorrhage were clear, the scores of NIHSS were grouped according to the admission of second daysfasting glucose levels in fasting blood glucose More than 7mmol/L as high blood glucose group, the other as the normal blood glucose group.90d mRS score was used to evaluate the prognosis, divided into good prognosis group (mRS = 2) and poor prognosis group (mRS = 3, including death or severe disability). Disease severity and prognosis of 90d were compared between the two groups. Results: Na in 228 cases of cerebral hemorrhage patients, the high glucose group 59 cases (25.9%), 169 cases of normal blood sugar (74.1%). A total of 26 cases of diabetic patients, the proportion of diabetic hyperglycemia group was 27.1%, significantly higher than the normal blood glucose group 5.9%, the difference was statistically significant (P0.001.90d) a poor prognosis in 96 patients of the total, accounted for 45.3%.Spearman correlation analysis showed that fasting blood glucose and NIHSS scores on admission showed a significant positive correlation (r=0.133, P=0.045), and the poor prognosis of 90d had no significant correlation (r=0.116, P=0.098).Logistic regression analysis showed that age (OR:1.070 CI:1.033; 95% ~ 1.107), admission NIHSS score (OR:1.165 95%CI:1.083; - 1.253) was an independent risk factor of poor prognosis of 90d patients with spontaneous intracerebral hemorrhage (P0.05). Conclusion: diabetic patients prone to hyperglycemia in patients with acute cerebral hemorrhage. The fasting blood glucose level and the severity of spontaneous cerebral hemorrhage associated with poor prognosis of 90d. There was no significant correlation between the independent risk factors for the prognosis of 90d is age and admission scores in patients with NIHSS. To sum up, the main innovation of this study lies in: 1. to observe the relationship between the random blood glucose level and disease severity of spontaneous intracerebral hemorrhage and the prognosis of 90d in patients with cerebral hemorrhage were divided into two groups according to the admission random blood glucose levels, to observe the relationship between admission glucose level and NIHSS scores on admission and prognosis of 90d to investigate the effect of random blood glucose, the severity of spontaneous cerebral hemorrhage and cerebral hemorrhage and 90d factor of poor prognosis of.2. observation of acute spontaneous intracerebral hemorrhage Effect of fasting glucose level and the severity of the disease and the prognosis of 90d were grouped according to the level of fasting blood glucose, fasting blood glucose and observe the relationship between NIHSS scores on admission and prognosis of different 90d, to investigate the effects of fasting blood glucose on the severity of spontaneous cerebral hemorrhage and cerebral blood factors which affect the prognosis of 90d.

【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R743.34;R587.2

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