本文關(guān)鍵詞： 非癥狀性出血轉(zhuǎn)化 獨(dú)立危險(xiǎn)因素 預(yù)后　出處：《大連醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景及目的:腦血管病是引起人類殘疾的主要原因之一,其中腦梗死占80%。卒中后發(fā)生一系列并發(fā)癥常常使患者病情加重,其中最常見的是梗死后出血性轉(zhuǎn)化[1]。急性腦梗死發(fā)生后血液通過損傷的血管內(nèi)皮溢出即出血轉(zhuǎn)化(hemorrhagic transformation,HT),其可以通過影像學(xué)手段(如MRI、CT)明確診斷。目前,根據(jù)是否出現(xiàn)臨床癥狀加重,可將HT分為非癥狀性出血轉(zhuǎn)化及癥狀性出血轉(zhuǎn)化[2]。前者是指臨床上沒有明顯癥狀,僅在影像上提示出血灶,而后者則定義較多,其中歐洲急性卒中協(xié)作研究(ECASS)將癥狀性出血轉(zhuǎn)化定義為CT發(fā)現(xiàn)的可以解釋臨床癥狀惡化的病灶,且NIHSS評(píng)分提高≥4分。目前已經(jīng)有很多危險(xiǎn)因素被證實(shí)與腦梗死后HT有關(guān),比如梗死部位、梗死面積、循環(huán)再通時(shí)間、梗死嚴(yán)重程度、血壓、血糖、血小板數(shù)量,抗凝、抗血小板、溶栓治療等[3]。溶栓治療是目前有效的治療腦梗死的方法,但其可使HT發(fā)生率顯著增高,且很多研究證實(shí)HT可以顯著促進(jìn)大腦進(jìn)一步損傷,并且與不良預(yù)后有關(guān),因此限制了溶栓治療的使用[4]。非癥狀性出血轉(zhuǎn)化(asymptomatic hemorrhagic transformation,aSHT)與急性腦卒中患者的功能惡化無關(guān),然而,其是否會(huì)影響患者遠(yuǎn)期預(yù)后,至今仍不清楚。因此,了解HT相關(guān)危險(xiǎn)因素,在溶栓及抗栓治療前發(fā)現(xiàn)出血轉(zhuǎn)化高危人群,對(duì)于減少HT的發(fā)生及改善急性缺血性卒中預(yù)后至關(guān)重要。本文的目的就是研究非癥狀性出血性轉(zhuǎn)化對(duì)急性腦梗死后3個(gè)月的功能是否有影響及與其相關(guān)獨(dú)立危險(xiǎn)因素。方法:搜集2015年8月至2016年8月在我院住院的急性缺血性卒中患者448名,均符合中華醫(yī)學(xué)會(huì)第四次全國腦血管病會(huì)議制定的關(guān)于缺血性腦血管病診斷標(biāo)準(zhǔn),并經(jīng)頭顱MRI+DWI證實(shí)為急性腦梗死,其中符合入組標(biāo)準(zhǔn)非癥狀性出血轉(zhuǎn)化患者44例,無出血轉(zhuǎn)化患者404例。詳細(xì)記錄患者性別、年齡、既往史(吸煙、飲酒、既往卒中相關(guān)病史、高血脂、高血壓、高血糖、房顫、腫瘤、家族史等)、入院時(shí)基線血脂(甘油三酯、總膽固醇、低密度脂蛋白、高密度脂蛋白)、腦梗死部位(前循環(huán)、后循環(huán))、腦梗死面積、腦梗死后出血轉(zhuǎn)化情況、入院初始NIHSS評(píng)分等,并對(duì)上述指標(biāo)進(jìn)行單因素分析,對(duì)單因素分析存在統(tǒng)計(jì)學(xué)意義的影響因素進(jìn)行Logistic回歸分析,以闡明影響非癥狀性HT的獨(dú)立危險(xiǎn)因素;并于患者出院3個(gè)月時(shí)進(jìn)行電話隨訪,詳細(xì)詢問并記錄mRS評(píng)分,通過比較HT與非HT兩組間mRS的差異評(píng)估HT是否影響腦梗死患者的遠(yuǎn)期預(yù)后。結(jié)果:448急性缺血性腦卒中患者中發(fā)生非癥狀性出血性轉(zhuǎn)化的共44例,發(fā)生率約為9.82%,其中死亡2例(0.45%),占腦梗死總死亡數(shù)的2/9;腦梗死后非癥狀性出血轉(zhuǎn)化使90天神經(jīng)功能惡化(OR=5.86,P0.001);單因素分析表明高血壓、高血脂、房顫、大面積腦梗死和基線NIHSS高5組變量在兩組之間有統(tǒng)計(jì)學(xué)意義(P分別0.05),另外,本研究發(fā)現(xiàn)后循環(huán)卒中是非癥狀性HT發(fā)生率低的預(yù)測(cè)因素(P0.05);而年齡、性別、吸煙、高血糖、既往卒中史、腫瘤史與非癥狀性出血轉(zhuǎn)化無統(tǒng)計(jì)學(xué)相關(guān)性。以是否存在非癥狀性出血轉(zhuǎn)化為因變量(HT=1,非HT=0),對(duì)高血壓、高血脂、房顫、大面積腦梗死及基線NIHSS評(píng)分進(jìn)行Logistic回歸分析表明房顫(OR=2.096,P=0.047,95%CI 1.923-4.757)、大面積腦梗死(OR=10.455,P0.001,95%CI 4.765-22.940)、初始NIHSS評(píng)分(OR=1.123,P=0.015,95%CI 1.023-1.232)為腦梗死后非癥狀性出血轉(zhuǎn)化的獨(dú)立危險(xiǎn)因素。結(jié)論:(1)腦梗死后非癥狀性出血轉(zhuǎn)化影響患者的遠(yuǎn)期預(yù)后(OR=5.86,p0.001)。(2)asHT相關(guān)獨(dú)立危險(xiǎn)因素有房顫、大面積腦梗死、初始高NIHSS評(píng)分。(3)后循環(huán)腦梗死為非癥狀性出血轉(zhuǎn)化發(fā)生率低的預(yù)測(cè)因素。
[Abstract]:Background and purpose: cerebrovascular disease is the main cause of the disabled people, which accounted for 80%. of cerebral infarction after stroke occurred in a series of complications often increase the patient's condition, is one of the most common hemorrhagic transformation after cerebral infarction [1]. after the onset of acute cerebral infarction by blood vascular endothelial injury is overflow (hemorrhagic transformation, HT hemorrhagic transformation), can learn by means of the image (such as MRI, CT) to confirm the diagnosis. At present, according to the appearance of clinical symptoms, the HT can be divided into non symptomatic hemorrhagic transformation and symptomatic hemorrhagic transformation [2]. the former refers to no obvious clinical symptoms, suggesting hemorrhage only in the image, the latter is more defined among them, the European Cooperative Acute Stroke Study (ECASS) symptomatic hemorrhagic transformation is defined as CT that can explain the clinical symptoms of the deterioration of the lesions, and the NIHSS score increased more than 4. At present there have been Many risk factors were confirmed after cerebral infarction and HT related, such as myocardial infarction, infarct size, circulating recanalization time, infarction severity, blood pressure, blood glucose, platelet count, anticoagulation, antiplatelet, thrombolytic therapy of [3]. thrombolytic therapy is an effective method for the treatment of cerebral infarction, but the incidence rate of HT was significantly increased, and the many studies have confirmed that HT can significantly promote the further brain damage, and associated with poor prognosis, thus limiting the use of thrombolytic therapy for asymptomatic hemorrhagic transformation ([4]. asymptomatic hemorrhagic transformation, aSHT) and the function of patients with acute stroke progression free, however, whether it will affect the long-term prognosis of patients, is still unclear. Therefore, understand the HT risk factors in thrombolytic and antithrombotic therapy before the discovery of hemorrhagic transformation in high risk population, to reduce the incidence of HT and improve the prognosis of acute ischemic stroke. Important. The purpose of this paper is to study the non symptomatic hemorrhagic transformation of acute cerebral infarction after 3 months if there is an effect function and related independent risk factors. Methods: collected from August 2015 to August 2016 in our hospital in patients with acute ischemic stroke in 448, are in line with the Huayi Institute of the fourth national cerebrovascular disease conference set about the diagnosis of ischemic cerebrovascular disease, and confirmed by brain MRI+DWI for acute cerebral infarction, which met the inclusion criteria for non symptomatic hemorrhagic transformation in patients with 44 cases, 404 cases without conversion. Detailed records of patients with hemorrhage in patients with sex, age, smoking, alcohol drinking, past medical history (related to a history of previous stroke, hyperlipidemia, hypertension, high blood glucose, atrial fibrillation, cancer, family history), admission baseline lipids (triglycerides, total cholesterol, low density lipoprotein, high density lipoprotein), cerebral infarction area (anterior circulation, posterior circulation cerebral infarction). The area, the transformation of hemorrhage after cerebral infarction, initial admission NIHSS score, and the above indexes were analyzed by single factor analysis, single factor analysis of the factors influencing the statistical significance of Logistic regression analysis, to clarify the influence of non independent risk factors of symptomatic HT; telephone follow-up and 3 months after discharge in patients when asked in detail and record the mRS score, by assessing whether the difference between the HT and non HT mRS between the two groups of HT affect the long-term prognosis of patients with cerebral infarction. Results: asymptomatic hemorrhagic transformation of a total of 44 cases occurred in 448 patients with acute ischemic stroke, the incidence rate is about 9.82%, of which 2 cases died (0.45%), accounting for cerebral infarction the total number of deaths of 2/9; symptoms of hemorrhagic transformation of the 90 day non neurological deterioration after cerebral infarction (OR=5.86, P0.001); single factor analysis showed that hypertension, hyperlipidemia, atrial fibrillation, large area cerebral infarction and 5 groups of variables in the baseline NIHSS Between the two groups was statistically significant (P = 0.05), in addition, the study found that the posterior circulation stroke is a predictor of low rate of occurrence of asymptomatic HT (P0.05); age, gender, smoking, high blood glucose, stroke history, history of tumor and non symptomatic hemorrhagic transformation had no correlation to the existence. Non symptomatic hemorrhagic transformation as the dependent variable (HT=1, non HT=0), hypertension, hyperlipidemia, atrial fibrillation, large area cerebral infarction and baseline NIHSS scores of Logistic regression analysis showed that atrial fibrillation (OR=2.096 P=0.047,95%CI 1.923-4.757), large area cerebral infarction (OR=10.455, P0.001,95%CI, 4.765-22.940), the initial NIHSS score (OR=1.123, P=0.015,95%CI 1.023-1.232) were the independent risk factors of non symptomatic hemorrhagic transformation after cerebral infarction. Conclusion: (1) symptomatic hemorrhagic transformation affect the long-term prognosis of patients with non cerebral infarction (OR=5.86, p0.001). (2) the risk factors of asHT are real Tremor, large area cerebral infarction, initial high NIHSS score. (3) posterior circulation cerebral infarction was a predictor of low incidence of non symptomatic hemorrhage.

【學(xué)位授予單位】：大連醫(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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本文編號(hào)：1462755