【摘要】：研究背景腦血管病變在全球的發(fā)病率和死亡率較高[1],尤其是其高的致殘率和致死率給人類及社會帶來極大的危害。急性腦梗死又稱缺血性腦梗死,是臨床常見病、多發(fā)病,大量研究表明其主要的病理學基礎(chǔ)是動脈粥樣硬化(Atherosc1erosis,AS)[2],動脈粥樣硬化性腦梗死占缺血性腦梗死患病率的74%[3]。頸動脈硬化是全身動脈硬化的局部表現(xiàn)。斑塊內(nèi)出血、斑塊破裂、血栓形成、動脈瘤形成等是頸動脈斑塊繼發(fā)性改變。頸動脈作為腦血循環(huán)的上游血管,其內(nèi)不穩(wěn)定斑塊的破裂、脫落造成的動脈到動脈栓塞是缺血性腦梗死的獨立危險因素[4]。血漿脂蛋白相關(guān)磷脂酶 A2(Lipoprotein-associated Phospholipase A2,Lp-PLA2)作為一種新的炎癥反應標志物,受到越來越多的重視。近年來的研究認為AS是由血管的慢性炎癥反應引起,Lp-PLA2參與到AS的發(fā)生發(fā)展中。頸動脈斑塊內(nèi)新生血管是斑塊不穩(wěn)定性的重要因素,有研究表明其與血管的慢性炎癥有關(guān)。超聲造影已經(jīng)成為超聲檢查的一項重要的輔助技術(shù),可以清楚顯示頸動脈管腔外膜滋養(yǎng)血管和斑塊內(nèi)新生血管。既然斑塊內(nèi)新生血管與Lp-PLA2均與血管慢性炎癥有關(guān),兩者之間又有什么聯(lián)系?兩者在急性缺血性腦梗死(Acute cerebral infarction,ACI)的發(fā)生中又發(fā)揮怎樣的作用呢?本項研究即通過超聲造影檢查,半定量分析斑塊內(nèi)新生血管的顯影情況,從新生血管角度分析討論頸動脈斑塊穩(wěn)定性、血漿Lp-PLA2水平與ACI間的關(guān)系。研究目的探討頸動脈斑塊內(nèi)新生血管顯影程度與血漿Lp-PLA2水平在ACI的臨床診斷價值及兩者間的關(guān)系。方法1研究對象本項研究對象分為兩組:ACI組與非ACI組。ACI組為2015年7月至2016年9月在我院神經(jīng)內(nèi)科住院的急性前循環(huán)腦梗死患者44例,非ACI組為同期查體中心體檢有不穩(wěn)定斑塊者41例。2頸動脈常規(guī)超聲及超聲造影檢查采用VividE9超聲診斷儀,9L探頭行頸動脈常規(guī)超聲及超聲造影檢查。連續(xù)掃查頸動脈,選取目標斑塊。選用意大利Bracco公司的聲諾維(SonoVue)造影劑,經(jīng)肘正中靜脈注入。觀察超聲造影圖像并儲存,留后分析。依據(jù)文獻數(shù)據(jù)將斑塊內(nèi)新生血管顯影分級:斑塊內(nèi)無增強的新生血管信號(Ⅰ級);斑塊內(nèi)及周邊新生血管信號呈點狀分布(Ⅱ級);斑塊內(nèi)新生血管信號呈散在點狀及線狀分布(Ⅲ級);斑塊內(nèi)新生血管呈彌漫點狀或多條線狀分布(Ⅳ級)。3血漿Lp-PLA2測定ACI組與非ACI組均清晨空腹于肘部靜脈采血4 mL,枸櫞酸鈉抗凝,混勻后,于標本采集30 min內(nèi),在2～8℃環(huán)境下離心15min(3000 r/min),后分離血漿,置-20℃C以下保存?zhèn)溆�。按照說明書采用雙抗體夾心免疫層析法檢測血漿Lp-PLA2。結(jié)果1 ACI組與非ACI組頸動脈斑塊內(nèi)新生血管顯影分級比較:ACI組Ⅰ級顯影斑塊為3例,占6.82%;Ⅱ級顯影斑塊為8例,占18.18%;Ⅲ級顯影斑塊為23例,占52.27%;Ⅳ級顯影斑塊為10例,占22.73%。非ACI組Ⅰ級顯影斑塊為19例,占46.34%;Ⅱ級顯影斑塊為15例,占36.59%;Ⅲ級顯影斑塊為5例,占12.20%;Ⅳ級顯影斑塊為2例,占4.88%。頸動脈斑塊內(nèi)新生血管分級明顯高于非ACI組,兩組差異有統(tǒng)計學意義(Z=-5.29,P=0.00)。ACI組內(nèi)新生血管分級多為Ⅲ、Ⅳ級,所占比例為75.0%,非ACI組分級多為Ⅰ、Ⅱ級所占比例為82.9%,以大于等于Ⅲ級區(qū)分ACI與非ACI的敏感性為75%,特異性為82.9%。更進一步,ACI組新生血管顯影分級以Ⅲ、Ⅳ級為主,且中位等級為Ⅲ級;非ACI組則以Ⅰ、Ⅱ級為主,中位等級為Ⅱ級。2 ACI組與非ACI組血漿Lp-PLA2水平比較:ACI組血漿Lp-PLA2 水平為247.37 ±58.30μg/L,非 ACI 組血漿 Lp-PLA2 水平為 156.88 ±66.78μg/L,ACI 組明顯高于非ACI組,差異有統(tǒng)計學意義(t= 6.64,P= 0.00)。血漿Lp-PLA2對ACI的診斷效能分析采用ROC曲線分析,以約登指數(shù)最大確定最佳臨界值,其截斷值為199.76 μg/L,靈敏度為84.10%,特異性為68.30%,曲線下面積為0.84,診斷的準確度為84.10%。3斑塊內(nèi)新生血管顯影分級與血漿Lp-PLA2水平之間呈顯著的正相關(guān)(rs =0.60,P0.01),即斑塊內(nèi)新生血管顯影分級越高的患者,其血漿Lp-PLA2水平越高。結(jié)論1 ACI組頸動脈斑塊內(nèi)新生血管的顯影分級與血漿Lp-PLA2水平均高于非ACI組,推測兩者可能是ACI的危險因素。2斑塊內(nèi)新生血管的顯影分級與血漿Lp-PLA2水平呈正相關(guān)。
[Abstract]:In this paper, the incidence and mortality of cerebrovascular disease in the world are high[1], especially the high disability rate and the high mortality rate, which bring great harm to the human and the society. Acute cerebral infarction, also known as ischemic cerebral infarction, is a common and frequently occurring disease. The main pathological basis is atherosclerosis (AS)[2], and the atherosclerotic cerebral infarction accounts for 74% of the prevalence of ischemic cerebral infarction[3]. Carotid arteriosclerosis is a local manifestation of whole body arteriosclerosis. Plaque hemorrhage, plaque rupture, thrombosis, aneurysm formation, and the like are secondary changes in carotid plaque. As the upstream blood vessel of the cerebral blood circulation, the carotid artery is the independent risk factor of ischemic cerebral infarction[4]. The plasma lipoprotein-related phospholipase A2 (Lp-PLA2), as a new marker of inflammation, was given more and more attention. In recent years, it is considered that AS is caused by chronic inflammatory reaction of blood vessel, and Lp-PLA2 is involved in the development of AS. Neovascularization in the carotid plaque is an important factor in the instability of the plaque, and it has been shown that it is related to the chronic inflammation of the blood vessel. The ultrasound contrast has become an important auxiliary technique for ultrasonic examination, and it is clear that the adventitia of the carotid artery and the new blood vessels in the plaque can be displayed. Since the new blood vessels in the plaque and the Lp-PLA2 are all related to the chronic inflammation of the blood vessel, what is the connection between them? What is the effect of both in the occurrence of acute ischemic cerebral infarction (ACI)? The relationship between the carotid plaque stability, plasma Lp-PLA2 level and ACI was discussed from the angle of the new blood vessel by means of the ultrasound contrast examination and the semi-quantitative analysis of the development of the new blood vessels in the plaque. Objective To study the relationship between the degree of blood vessel development and the plasma Lp-PLA2 level in the carotid plaque in the clinical diagnosis of ACI. Method 1 The object of this study was divided into two groups: ACI group and non-ACI group. The ACI group was 44 cases of acute pre-circulating cerebral infarction in the Department of Neurology of our hospital from July 2015 to September 2016, In the non-ACI group, there were 41 cases of unstable plaque in the physical examination of the same period. The carotid artery was scanned continuously and the target plaque was selected. The sonoVue contrast agent was selected from Bracco, Italy, and injected through the median of the elbow. The ultrasound contrast image was observed and stored and analyzed. According to the literature data, the new blood vessel in the plaque was developed and classified: there was no enhanced new blood vessel signal in the plaque (stage I), and the signal of the new blood vessel in the plaque was distributed in point (level II), and the new blood vessel signal in the plaque was scattered in the point and the linear distribution (stage III); The plasma Lp-PLA2 (plasma Lp-PLA2) was collected in the early morning of the non-ACI group at the elbow vein for 4 mL, and the sodium gluconate was anticoagulated. After the mixture was mixed, the samples were centrifuged at 2-8 鈩，

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