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  本文關(guān)鍵詞： 腦卒中 顳前動脈 磁共振成像 梗死模式 大腦中動脈閉塞 側(cè)支循環(huán) 功能預后 卒中預后 神經(jīng)影像 磁共振成像 梗死模式 早期神經(jīng)功能惡化 急性腦梗死 大腦中動脈 靜脈溶栓 磁共振成像 梗死模式 功能預后　出處：《南京大學》2016年博士論文　論文類型：學位論文

【摘要】：第一部分急性動脈粥樣硬化性大腦中動脈M1段閉塞患者顳前動脈與磁共振彌散加權(quán)成像梗死模式及預后的相關(guān)性分析背景與目的：本研究初步探討急性動脈粥樣硬化性大腦中動脈M1段閉塞患者顳前動脈的存在對早期磁共振加權(quán)成像腦梗死模式及與早期功能預后的影響。方法：連續(xù)納入2007年1月至2012年12月于南京卒中注冊系統(tǒng)登記的急性動脈粥樣硬化性大腦中動脈M1段閉塞的患者。所有患者于入院期間均完成頭顱磁共振成像及血管學檢查。采用改良Rankin戥(mRS)評估患者90天功能預后,將mRS≤2定義為預后良好。單因素分析顳前動脈存在與顳前動脈缺失兩組患者組間基線資料、ASPECTS評分、梗死模式及早期功能預后的差異,同時多因素logistic回歸分析顳前動脈和梗死模式與90天功能預后的相關(guān)性。結(jié)果：研究共納入符合入組和排除標準的患者98例。血管成像檢查示44例(44.9%)患者存在顳前動脈,54例(55.1%)患者顳前動脈缺失。同顥前動脈缺失組患者相比,顳前動脈存在組患者穿通支動脈區(qū)域小梗死比率(22.7%vs 5.6%,P=0.013)及DWI-ASPECTS≥7分的比率(65.9%vs 44.4%,P=0.034)顯著升高,而高血壓病比率(52.3%vs 72.2%,P=0.042)、NIHSS平分(7.0 vs 8.5,P=0.043)及大腦中動脈M1段遠端閉塞比率(56.8%vs 11.4%,P0.042)顯著降低,而兩組患者側(cè)支循環(huán)情況并沒有明顯差異。Spearman相關(guān)分析結(jié)果示顳前動脈存在和DWI-ASPECTS評分(R=0.223,P=0.027)及大腦中動脈M1段遠端閉塞(R=0.376,P0.001)顯著正相關(guān)。共有50例(51.0%)患者90天功能預后良好,預后不良48例(49%)。同預后不良組患者相比,預后良好組患者顳前動脈存在比率(62.0%vs 27.1%,P=0.001)、DWI-ASPECTS≥ 7分比率(78.0%vs29.2%,P0.001)及分水嶺梗死比率較高(20.0%vs 4.8%,P=0.099),而入院基線NIHSS評分較低(中位數(shù)5 vs 11.5,P0.001)。經(jīng)多因素logistic回歸分析校正潛在混雜因素(單因素分析中P0.1)后示：顳前動脈存在是急性動脈粥樣硬化性大腦中動脈M1段閉塞患者90天功能預后良好的獨立預測因素[優(yōu)勢比(odds ratio, OR)4.45,95%可信區(qū)間(confidence interval, CI)1.52-13.03：P=0.007]。結(jié)論：急性動脈粥樣硬化性大腦中動脈M1段閉塞顳前動脈存在患者穿通支動脈區(qū)域小梗死比率較高,梗死體積較低。顳前動脈存在是90天功能預后良好的獨立預測因素。第二部分磁共振成像對急性大腦中動脈輕型卒中早期神經(jīng)功能惡化的預測價值背景與目的：早期神經(jīng)功能惡化是腦卒中不良預后的重要危險因素,而磁共振成像檢查有助于更好的明確缺血性腦卒中的梗死模式,對卒中機制亦有較高的診斷價值。因此,本研究初步探討早期磁共振成像對大腦中動脈區(qū)域輕型卒中神經(jīng)功能惡化的預測作用。方法：前瞻性納入起病24小時內(nèi)住院,且經(jīng)影像學檢查證實為大腦中動脈區(qū)域輕型卒中患者。所有患者均于入院24小時內(nèi)完成磁共振檢查。EDN定義72小時內(nèi)任意一次NIHSS評分較基線NIHSS評分增加2分或2分以上。采用單因素分析組間人口學特征、臨床資料、梗死模式及治療方法的差異,同時多因素logistic回歸分析早期磁共振結(jié)果和END的相關(guān)性。結(jié)果：研究共納入2010年1月至2013年12月于南京軍區(qū)南京總醫(yī)院神經(jīng)內(nèi)科住院的大腦中動脈區(qū)域輕型卒中患者211例。END組患者共65例(30.8%),非END患者146例(69.2%)。同非END組患者相比,END患者內(nèi)分水嶺梗死比率較高(35.4%vs 12.3%,P0.001)。同其他類型梗死模式患者相比,內(nèi)分水嶺梗死患者高脂血癥比率(19.5%vs 7.6%,P=0.023)、皮質(zhì)支梗死比率(24.4%vs11.2%,P=0.027)、皮質(zhì)分水嶺梗死比率(31.7%vs 15.9%：P=0.020)及同側(cè)腦大動脈狹窄比率(70.7%vs 45.3%-P=0.003)較高,而穿通動脈梗死比率(22.0%vs 80.6%,P0.001)較低。經(jīng)多因素logistic回歸分析校正混雜因素后示：內(nèi)分水嶺梗死是大腦中動脈區(qū)域輕型卒中END的獨立危險因素[優(yōu)勢比(odds ratiO,OR)2.50-95%可信區(qū)間(confidence interval,CI)1.09-5.74；P=0.031].結(jié)論：內(nèi)分水嶺梗死是大腦中動脈區(qū)域輕型卒中END的獨立危險因素。第三部分磁共振彌散加權(quán)成像梗死模式對大腦中動脈區(qū)域梗死患者靜脈溶栓預后的預測價值背景與目的：從磁共振彌散加權(quán)成像(diffusion weighted imaging, DWI)角度,探討梗死模式對大腦中動脈區(qū)域(middle cerebral artery, MCA)腦梗死患者靜脈溶栓預后的影響。方法：回顧性分析經(jīng)影像學檢查證實的大腦中動脈區(qū)域急性腦梗死患者172例,所有患者均于溶栓前行磁共振檢查。根據(jù)DWI結(jié)果將梗死模式分為區(qū)域性梗死,其他皮質(zhì)梗死,其他深部梗死,內(nèi)分水嶺梗死,淺表小梗死和深部小梗死。根據(jù)改良Rankin量表評分,將90天評分為0-2分的患者定義為預后良好。采用單因素分析比較組間差異,同時多因素logistic回歸分析梗死模式和大腦中動脈區(qū)域梗死患者靜脈溶栓預后不良的相關(guān)性。結(jié)果：研究共納入172大腦中動脈區(qū)域腦梗死患者,其中區(qū)域性梗死或其他深部梗死患者共75例(43.6%),同其他類型梗死模式患者相比,區(qū)域性梗死或其他深部梗死患者基線NIHSS評分(P0.001)、腦大動脈閉塞比率(P0.001)和梗死體積均顯著升高(P0.001)。89例(51.7%)患者90天功能預后良好,同預后不良組相比,預后良好組患者年齡(61.8士15.4 vs 72.5±15.7,P0.001)NIHSS評分[9.0(4.0-15.5)vs 16.0(11.0-20.0),P0.001)、大腦動脈閉塞比率(30.3%vs 51.8%,P=0.004)、梗死體積[17.1(5.0-46.2)vs 35.3(8.3-73.2),P=0.029]及區(qū)域梗死或其他深部梗死模式比率(29.2%vs 59.0%,P0.001)明顯降低。經(jīng)多因素logistic回歸分析校正潛在混雜因素后示：特殊梗死模式(區(qū)域梗死或其他深部梗死模式)是大腦中動脈區(qū)域腦梗靜脈溶栓早期預后不良的獨立危險因素(OR,0.40；95%CI,0.16-0.99；P=0.047)結(jié)論：區(qū)域梗死或其他深部腦梗死模式是大腦中動脈區(qū)域腦梗死靜脈溶栓患者早期預后不良的獨立預測因素。
[Abstract]:The first part of acute atherosclerotic middle cerebral artery occlusion of the M1 segment in patients with anterior temporal artery infarction and diffusion-weighted magnetic resonance imaging pattern and prognosis analysis of the correlation between background and purpose: This study was to explore the influence of early magnetic resonance imaging and cerebral infarction patterns and prognosis of early functional arterial occlusion of the M1 segment in patients with acute anterior temporal artery atherosclerosis the brain. Methods: arterial occlusion of the M1 segment were included in January 2007 to December 2012 in Nanjing stroke registration system registration of acute atherosclerotic brain. All patients were completed during cranial magnetic resonance imaging and vascular pathology. Using modified Rankin and (mRS) the 90 day evaluation function and prognosis of patients, the definition of mRS = 2 for the good prognosis. The single factor analysis of anterior temporal artery and anterior temporal artery deletion of two groups of patients between groups at baseline, ASPE The CTS score, different infarction patterns and early functional outcomes at the same time, logistic regression analysis and correlation of anterior temporal artery infarction model and functional outcome 90 days. Results: the study included 98 patients met the inclusion and exclusion criteria. Angiography showed that 44 cases (44.9%) patients had anterior temporal artery, 54 cases (55.1%) patients with anterior temporal artery deletion. Compared with Hao artery deletion group patients, anterior temporal artery of patients perforating artery region small infarction ratio (22.7%vs 5.6%, P=0.013) and the ratio of DWI-ASPECTS is more than or equal to 7 points (65.9%vs 44.4%, P=0.034) was significantly increased, and the ratio of hypertension (52.3%vs 72.2%, P=0.042 NIHSS (7), split vs 8.5, P=0.043) and M1 segment of middle cerebral artery occlusion distal ratio (56.8%vs 11.4%, P0.042) decreased significantly, while the two group patients with collateral circulation was no significant difference in the results of.Spearman correlation analysis showed anterior temporal artery. In the score and DWI-ASPECTS (R=0.223, P=0.027) and M1 segment of middle cerebral artery occlusion distal (R=0.376, P0.001) were significantly correlated. There were 50 cases (51%) 90 days function prognosis of patients with good prognosis in 48 cases (49%). Compared with the poor prognosis of patients, patients with good prognosis in patients with temporal artery ratio (62.0%vs 27.1%, P=0.001), DWI-ASPECTS = 7 (78.0%vs29.2%, P0.001) and the ratio of watershed infarction ratio is higher (20.0%vs 4.8%, P=0.099), and the admission baseline NIHSS score was lower (median 5 vs 11.5, P0.001). Multivariate logistic regression analysis adjusted for potential confounding factors (univariate analysis showed P0.1) there is a temporal artery in acute atherosclerotic middle cerebral artery occlusion of the M1 segment of the advantages of independent predictors of patients [90 days a good functional outcome than (odds ratio, OR (confidence) 4.45,95% CI interval, CI) 1.52-13.03:P=0.007]. conclusion Acute atherosclerotic middle cerebral artery occlusion of the M1 segment of anterior temporal artery in the patients with perforating artery infarction area ratio is higher, the infarct volume was lower. Anterior temporal artery are independent predictors of 90 day prognosis is good. In the second part, functional magnetic resonance imaging of acute middle cerebral artery stroke light early neurological deterioration prediction value background and objective: early neurological deterioration is an important risk adverse prognostic factors for stroke, and magnetic resonance imaging examination is helpful to better understand the ischemic stroke infarction model, also has high diagnostic value for stroke mechanism. Therefore, this study was to explore the predictive effect on arterial regions of the brain in light of stroke early magnetic resonance imaging deterioration. Methods: We prospectively enrolled within 24 hours of hospitalization, and confirmed by imaging of arterial regions of the brain in the light Stroke patients. All patients completed the MRI in.EDN within 24 hours after admission within 72 hours of the definition of any NIHSS score compared to the baseline NIHSS score increased 2 points or 2 points or more. The single factor analysis between group differences in demographic characteristics, clinical data, infarction patterns and treatment methods, and multivariate logistic regression correlation analysis early magnetic resonance imaging results and END. Results: the study included from January 2010 to December 2013 in the Nanjing military region, the middle cerebral artery in the Department of Neurology, Nanjing general hospital in the area of light stroke patients in 211 cases of.END group were 65 cases (30.8%), 146 cases of non END patients (69.2%). Compared with non END patients, END patients. Watershed infarction ratio is higher (35.4%vs 12.3%, P0.001). Compared with other types of patterns in patients with watershed infarction infarction, patients with hyperlipidemia ratio (19.5%vs 7.6%, P=0.023), cortex infarct ratio (24.4%vs11 .2%, P=0.027), cortical watershed infarction ratio (31.7%vs 15.9%:P=0.020) and ipsilateral cerebral artery stenosis ratio (70.7%vs 45.3%-P=0.003) high, and perforating artery infarction ratio (22.0%vs 80.6%, P0.001) is low. Through logistic regression analysis after adjusting for confounding factors showed: watershed infarction is an independent risk factor [odds ratio the middle cerebral artery territory stroke END (odds light ratiO, OR (confidence) 2.50-95% CI interval, CI) 1.09-5.74; P=0.031]. conclusion: watershed infarction is an independent risk factor of middle cerebral artery area light stroke END. In the third part, diffusion weighted magnetic resonance imaging model of middle cerebral artery infarction patients with venous infarction prognosis area background and purpose: the prognostic value of diffusion-weighted magnetic resonance imaging (diffusion weighted, imaging, DWI) to investigate the angle model of middle cerebral artery infarction area (middle cerebral artery, MCA) effect of intravenous thrombolysis in patients with cerebral infarction prognosis. Methods: retrospective analysis of the imaging area of the brain artery examination confirmed 172 cases of acute cerebral infarction patients, all patients before thrombolysis MRI. According to the results of DWI infarction model is divided into regional infarction, other cortical infarction, other deep within the watershed infarction, infarction, superficial small infarction and deep small infarction. According to the modified Rankin scale score, the patients defined 90 days 0-2 score for the prognosis is good. The single factor analysis to the difference between the groups at the same time, the multi factor Logistic model and correlation analysis of infarction of middle cerebral artery venous infarction patients thrombolysis prognosis regression. Results: the study included 172 patients with cerebral infarction of middle cerebral artery area, regional infarction or other deep infarction patients in 75 cases (43.6%), with other types of Compared with the regional pattern of infarction, infarction or other deep infarction in patients with baseline NIHSS score (P0.001), cerebral artery occlusion ratio (P0.001) and infarct volume were significantly increased (P0.001).89 cases (51.7%) of 90 days compared with the functional prognosis of patients with good prognosis group and good prognosis group (61.8 patients with age 15.4 vs 72.5 + 15.7 P0.001), NIHSS [9.0 (4.0-15.5) vs score 16 (11.0-20.0), P0.001), middle cerebral artery occlusion ratio (30.3%vs 51.8%, P=0.004), infarct volume (5.0-46.2) vs 35.3 [17.1 (8.3-73.2), P=0.029] and regional infarction or other deep infarction model ratio (29.2%vs 59%, P0.001) significantly reduced. Through logistic regression analysis after adjusting for potential confounders: special infarction patterns (regional infarction or other deep infarction model) is an independent risk factor of cerebral artery vein thrombolysis in early cerebral infarction area of poor prognosis (OR, 0.40; 95%CI 0.16-0.99, P=0.047) conclusion: regional infarction or other deep cerebral infarction models are independent predictors of poor early prognosis in patients with cerebral infarction in middle cerebral artery area.

【學位授予單位】：南京大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R743.3

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