發(fā)布時(shí)間：2018-05-13 17:03

  本文選題：急性后循環(huán)腔隙性腦梗死 + 病情進(jìn)展　； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:隨著醫(yī)學(xué)的發(fā)展,對(duì)于腦梗死這一疾病的認(rèn)識(shí)發(fā)生了巨大的變化。近年來(lái)研究發(fā)現(xiàn),后循環(huán)腔隙性腦梗死作為缺血性腦卒中的一種類型,在各種缺血性腦卒中中造成的損傷和死亡尤為突出。迄今為止,急性后循環(huán)腔隙性腦梗死病情進(jìn)展的主要危險(xiǎn)因素研究結(jié)果存在爭(zhēng)議。為進(jìn)一步探討造成急性后循環(huán)腔隙性腦梗死病情加重的主要因素,本研究回顧性觀察了195例急性后循環(huán)腔隙性腦梗死患者的臨床特征及預(yù)后,分析了急性后循環(huán)腔隙性腦梗死患者病情進(jìn)展的危險(xiǎn)因素,以求對(duì)患者的病情進(jìn)展作出早期預(yù)測(cè),及時(shí)采取有效治療措施,最大程度改善預(yù)后降低致殘率和死亡率,提高患者的生活質(zhì)量。方法:2014年8月~2015年7月期間于我院神經(jīng)內(nèi)科住院治療的腦梗死患者635例,經(jīng)磁共振成像(magnetic resonance imaging,MRI)掃描及彌散加權(quán)成像(diffuse weighted imaging,DWI)序列掃描,證實(shí)為急性后循環(huán)腔隙性腦梗死,嚴(yán)格按照入選標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn)納入研究對(duì)象,收集可能引起急性后循環(huán)腔隙性腦梗死患者病情進(jìn)展加重的因素如:年齡、性別、入院時(shí)血壓、就診時(shí)間及既往史中可能引起病情進(jìn)展的危險(xiǎn)因素(包括高血壓病史、糖尿病病史、冠心病病史、腦梗死病史、短暫性腦缺血發(fā)作病史、腦出血病史),記錄患者的膽固醇、低密度脂蛋白、同型半胱氨酸、糖化血紅蛋白、血紅蛋白、平均紅細(xì)胞體積、紅細(xì)胞分布寬度等化驗(yàn)檢查結(jié)果,行頸部動(dòng)脈超聲檢測(cè)以觀察患者后循環(huán)動(dòng)脈斑塊及內(nèi)膜增厚情況,采用頭顱MRI檢查判斷患者是否存在腦白質(zhì)疏松及明確患者病灶部位。應(yīng)用標(biāo)準(zhǔn)化方法對(duì)患者進(jìn)行詳細(xì)查體并記錄患者是否存在吞咽功能障礙,評(píng)估患者入院時(shí)以及入院7天NIHSS評(píng)分,以確定腦梗死病情是否進(jìn)展。將入院7天NIHSS評(píng)分增加2分及以上的患者納入進(jìn)展組,余為非進(jìn)展組。所有患者均接受相同治療方案,即抗血小板以及調(diào)血脂、調(diào)血糖、調(diào)血壓、改善心腦循環(huán)等。使用SPSS軟件分析可能造成急性后循環(huán)腔隙性腦梗死病情進(jìn)展加重的因素及各因素的臨界值。男性124例,女性71例。年齡最小者27歲,最大者91歲,平均年齡(64.8±11.2)歲;進(jìn)展組39例(20%),非進(jìn)展組156例(80%)。單因素分析顯示:兩組性別比較差異無(wú)統(tǒng)計(jì)學(xué)意義(χ2=3.189,P=0.074)。將所有患者年齡分為6個(gè)年齡段組,分別是50歲、50~59歲、60~69歲、70~74歲、75~80歲、80歲,兩組患者年齡段比較無(wú)顯著差異(χ2=1.865,P=0.868),均以60歲組比例最多。進(jìn)展組就診時(shí)間為16(12,24)h,非進(jìn)展組就診時(shí)間為16(8,24)h,兩組患者就診時(shí)間呈非正態(tài)性分布,兩組患者就診時(shí)間經(jīng)秩和檢驗(yàn)差異無(wú)統(tǒng)計(jì)學(xué)差異(Z=0.053,P=0.615)。兩組患者慢性病史高血壓病史、糖尿病史、冠心病史、腦梗死病史、TIA病史、腦出血病史發(fā)生率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。吞咽功能障礙、收縮壓、舒張壓兩組比較無(wú)顯著差異(P0.05)。進(jìn)展組入院時(shí)NIHSS評(píng)分為4(2,7)分,非進(jìn)展組為3(1.25,5.00)分,兩組患者入院時(shí)NIHSS評(píng)分比較差異有統(tǒng)計(jì)學(xué)意義(P=0.023,P0.05),總膽固醇、低密度脂蛋白、同型半胱氨酸、糖化血紅蛋白、血紅蛋白、平均紅細(xì)胞體積、紅細(xì)胞分布寬度比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。進(jìn)展組腦白質(zhì)疏松20例(51.28%),非進(jìn)展組53例(33.97%),進(jìn)展組腦白質(zhì)疏松率明顯高于非進(jìn)展組(P=0.046)。進(jìn)展組動(dòng)脈斑塊24例(61.54%),非進(jìn)展組66例(42.31%),兩組動(dòng)脈斑塊情況比較差異有統(tǒng)計(jì)學(xué)意義(P=0.031)。兩組患者內(nèi)膜增厚比較差異無(wú)顯著差異。兩組患者病灶部位腦干、丘腦、枕葉、小腦、部位多發(fā)比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。將單因素P0.1的變量納入多因素分析,賦值方法如下:性別1=男,2=女;入院時(shí)NIHSS評(píng)分原值代入;腦白質(zhì)疏松0=否,1=是;動(dòng)脈斑塊0=否,1=是。以是否進(jìn)展為因變量,單因素分析P0.1的變量“性別”、“入院時(shí)NIHSS評(píng)分”、“腦白質(zhì)疏松”、“動(dòng)脈斑塊”為自變量,采用全部進(jìn)入法進(jìn)行二分類多因素logistic回歸分析,最終進(jìn)入方程的有“入院時(shí)NIHSS評(píng)分”和“動(dòng)脈斑塊”,提示入院時(shí)NIHSS評(píng)分是急性后循環(huán)腔隙性腦梗死進(jìn)展的危險(xiǎn)因素,有動(dòng)脈斑塊急性后循環(huán)腔隙性腦梗死患者病情進(jìn)展危險(xiǎn)性是無(wú)動(dòng)脈斑塊患者的2.311倍。受試者工作特征曲線(ROC曲線)分析發(fā)現(xiàn),計(jì)算受試者工作特征曲線下面積,入院時(shí)NIHSS評(píng)分的計(jì)算所得為0.617,誤差為0.051,95%CI結(jié)果:本研究最終納入急性后循環(huán)腔隙性腦梗死患者共195例,其中為0.518~0.716,臨界值為7.5分。結(jié)論:急性后循環(huán)腔隙性腦梗死患者入院時(shí)NIHSS評(píng)分和后循環(huán)動(dòng)脈斑塊是病情進(jìn)展的危險(xiǎn)因素,存在后循環(huán)動(dòng)脈斑塊者發(fā)生進(jìn)展危險(xiǎn)性是無(wú)后循環(huán)動(dòng)脈斑塊患者的2.311倍。對(duì)存在后循環(huán)動(dòng)脈斑塊及入院時(shí)NIHSS評(píng)分7.5分的患者,需密切關(guān)注其病情變化,及時(shí)針對(duì)患者的病因給予合理有效的治療,以最大程度改善預(yù)后。
[Abstract]:Objective: with the development of medicine, great changes have taken place in the knowledge of cerebral infarction. In recent years, it has been found that posterior circulating lacunar cerebral infarction is a type of ischemic stroke, and the injury and death in various ischemic stroke are particularly prominent. So far, acute posterior circulation lacunar cerebral infarction In order to further explore the main factors contributing to the exacerbation of acute posterior circulating lacunar infarction, this study reviewed the clinical features and prognosis of 195 patients with acute posterior lacunar cerebral infarction and analyzed the progress of patients with acute posterior lacunar cerebral infarction. Risk factors, in order to make early prediction of the patient's progress, take effective treatment measures in time, improve the prognosis to reduce the rate of disability and mortality, and improve the quality of life. Methods: 635 patients with cerebral infarction hospitalized in the neurology department of our hospital during July ~2015 years, by magnetic resonance imaging (magnetic reso) Nance imaging, MRI) scanning and diffusion weighted imaging (diffuse weighted imaging, DWI) sequence scan proved to be an acute posterior circulating lacunar cerebral infarction, strictly according to the criteria and exclusion criteria, to collect factors that may cause the progression of acute posterior lacunar infarction, such as age, sex, admission. Blood pressure, time of visit and the risk factors that may cause progress in the past history (including history of hypertension, diabetes history, history of coronary heart disease, history of cerebral infarction, history of transient ischemic attack, history of cerebral hemorrhage), records of patients' cholesterol, low density lipoprotein, homocysteine, glycosylated hemoglobin, hemoglobin, Ping Junhong The results of cell volume, red cell distribution and other tests were performed to observe the plaque and intima thickening of the posterior circulation artery by ultrasonic examination of the neck artery. The MRI examination was used to determine the presence of leukoaraiosis and the specific location of the patients. There was dysphagia, assessed the patient's admission and NIHSS score at 7 days to determine whether the disease was progressing. The patients who had increased the NIHSS score of 2 and above 7 days were included in the progression group, and the other was the non progressing group. All the patients received the same treatment, that is, anti blood plate and blood lipid modulation, blood glucose regulation, blood pressure regulation and improvement of the heart. SPSS software was used to analyze the factors and critical values of the progression of acute posterior circulating lacunar infarction. 124 males and 71 females. The youngest was 27 years old, the largest was 91 years, the average age was (64.8 + 11.2) years, 39 cases (20%) and 156 (80%) in the non progressing group (80%). Single factor analysis showed two sex. The difference was not statistically significant (x 2=3.189, P=0.074). The age of all patients was divided into 6 age groups, 50 years old, 50~59 years old, 60~69 years old, 70~74 years old, 75~80 years old and 80 years old. The age segments of the two groups were not significantly different (x 2=1.865, P=0.868), all in the 60 year old group. The time for the treatment of the progress group was 16 (12,24) h, and the time for non progression group visits. For 16 (8,24) h, the time of treatment in the two groups was non normal distribution, and there was no statistical difference between the two groups of patients by rank sum test (Z=0.053, P=0.615). There was no statistical difference between the two groups of patients with chronic history of hypertension, diabetes, coronary heart disease, cerebral infarction, TIA, and the history of cerebral hemorrhage (P0.05). There was no significant difference in the two groups of pharynx dysfunction, systolic pressure and diastolic pressure (P0.05). The NIHSS score of the progressive group was 4 (2,7), and the non progressive group was 3 (1.25,5.00). The difference in the NIHSS score of the two groups was statistically significant (P=0.023, P0.05), total cholesterol, low density lipoprotein, homocysteine, glycosylated hemoglobin, blood red. There was no significant difference in the protein, average red cell volume and red cell distribution width (P0.05). There were 20 cases of leukoaraiosis in the progressive group (51.28%), 53 cases in non progressive group (33.97%), the rate of leukoaraiosis in the progressive group was significantly higher than that in the non progressing group (P=0.046). 24 cases (61.54%), 66 cases (42.31%) in the non progressing group and two group of atherosclerotic plaques in the progress group. The difference was statistically significant (P=0.031). There was no significant difference in intimal thickening between the two groups. There were no significant differences between the two groups of brain stem, thalamus, occipital lobe, cerebellum and location (P0.05). The variables of single factor P0.1 were divided into multiple factors, and the methods of assignment were as follows: sex 1= men, 2= women; and NIHSS score at admission. The original value was replaced; the leukoplasm was loose 0= or 1=; the atherosclerotic plaque 0= was not, the 1= was. By the variable, the single factor analysis of the P0.1 variable "sex", "the admission NIHSS score", "the leukoaraiosis", "arterial plaque" as the independent variable, the two classification multiple factor Logistic regression analysis was used in all the entry methods, and finally into the equation. Finally the equation entered the equation. There were "admission NIHSS scores" and "arterial plaque", suggesting that the NIHSS score at admission was a risk factor for the progression of acute posterior circulating lacunar infarction. The risk of progressive posterior circulation lacunar infarction in patients with atherosclerotic atherosclerotic cerebral infarction was 2.311 times as high as that of the patients without atherosclerotic plaques. The ROC curve analysis of the subjects was found to be found. The calculation of the area under the characteristic curve of the subjects was 0.617 and the error was 0.051,95%CI results. The results were included in this study, which included 195 cases of acute posterior lacunar cerebral infarction, including 0.518~0.716, and the critical value of 7.5. Conclusion: the acute posterior lacunar cerebral infarction patients were enrolled in the NIHSS score and after admission to the hospital. The plaque of the circulatory artery is a risk factor for the progression of the disease. The risk of the progression of the posterior circulatory artery plaque is 2.311 times as high as that of the patients without the posterior circulation artery. The patients with the posterior circulation artery plaque and the NIHSS score of 7.5 in the hospital need to pay close attention to the change of the disease, and to give a reasonable and effective treatment to the cause of the patient's cause. To improve the prognosis to the greatest extent.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R743.3

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