本文選題：缺血性腦卒中　切入點(diǎn)：TOAST分型　出處：《吉林大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：背景及目的：缺血性腦卒中(IschemicStroke，IS)是由于供應(yīng)大腦的動(dòng)脈突然堵塞，導(dǎo)致其供應(yīng)的腦組織灌注減低，缺血區(qū)神經(jīng)血管單元壞死�？蓪�(dǎo)致患者記憶力、計(jì)算力、語(yǔ)言表達(dá)等能力下降，嚴(yán)重影響患者的行為能力及生活質(zhì)量。缺血性腦卒中以其高發(fā)病率和高致殘率成為當(dāng)前嚴(yán)重威脅人類健康的一大類重要疾病，是第二位致死性和第一位致殘性疾病，在影響患者身心健康的同時(shí)，也給社會(huì)和家庭帶來了巨大負(fù)擔(dān)。現(xiàn)國(guó)內(nèi)外對(duì)缺血性腦卒中患者急性期治療方案已日漸成熟，但在抗血小板聚集口服藥物的選擇方面仍存爭(zhēng)議，尤其針對(duì)不同病因的個(gè)體化抗血小板聚集藥物治療方案研究更是匱乏。本研究通過回顧我院同期治療的缺血性腦卒中患者263例，利用頭部CT或MRI掃描，頭顱MRA或顱內(nèi)、頸部血管彩超、心電圖等臨床檢查結(jié)果及既往病史，完成病因?qū)W分型分組，觀察不同亞型的疾病轉(zhuǎn)歸情況，并試探討各亞型不同抗血小板聚集藥物方案的獲益及安全性。最終，使一線神經(jīng)內(nèi)科醫(yī)生對(duì)于缺血性腦卒中分層診斷的認(rèn)識(shí)得以加深，，同時(shí)為不同亞型的抗血小板聚集治療方案選擇方面提供借鑒。 研究方法：本研究回顧分析2011年6月至2012年6月間，就診于吉林大學(xué)中日聯(lián)誼醫(yī)院神經(jīng)內(nèi)一科具有完備頭部影像學(xué)檢查、腦血管檢查及腦血管病常見危險(xiǎn)因素檢查的缺血性腦卒中住院患者263例。依據(jù)單用阿司匹林、單用氯吡格雷及聯(lián)合應(yīng)用阿司匹林、氯吡格雷3種抗血小板聚集治療方案進(jìn)行分組，且3組均給予常規(guī)改善循環(huán)、營(yíng)養(yǎng)神經(jīng)藥物靜脈滴注及調(diào)整血壓、血糖治療，根據(jù)患者病情加用脫水劑等。于入院時(shí)、入院第7天、14天及隨訪6個(gè)月，進(jìn)行美國(guó)國(guó)立衛(wèi)生研究院卒中量表（NIHSS）評(píng)分和出血并發(fā)癥評(píng)價(jià)。同時(shí)，按缺血性腦卒中病因?qū)W分型（TOAST分型）分為5種亞型，各亞型亦做如上治療分組評(píng)估。最終，獲得缺血性卒中總體及各個(gè)病因分型中應(yīng)用不同抗血小板藥物治療方案的療效差異及安全性。 結(jié)果：1、雙抗組與各單抗組治療前后神經(jīng)功能評(píng)分比較，三組發(fā)病時(shí)NIHSS評(píng)分比較無(wú)顯著差異（P＞0.05），分別比較各組間治療后7天、14天及6個(gè)月的NIHSS評(píng)分，雙抗組在治療第14天和6個(gè)月時(shí)神經(jīng)功能評(píng)分改善顯著優(yōu)于單用阿司匹林組（P＜0.05）；雙抗組在治療6個(gè)月后的終點(diǎn)時(shí)，NHISS評(píng)分優(yōu)于單用氯吡格雷組（P＜0.05）；2、TOAST各亞型及各組抗血小板聚集藥物治療前后NIHSS評(píng)分比較。CE組發(fā)病時(shí)及治療后7天、14天及6個(gè)月的NIHSS評(píng)分，各單抗組及雙抗組均無(wú)顯著性差異（P0.05）；LAA組發(fā)病時(shí)及治療后7天、14天NIHSS評(píng)分，各單抗組及雙抗組均無(wú)顯著性差異、無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）；LAA組治療6個(gè)月后的NIHSS評(píng)分雙抗組優(yōu)于單用拜阿司匹林組（，P0.01），單用氯吡格雷組介于二者之間，均無(wú)顯著統(tǒng)計(jì)學(xué)意義（P0.05）；SAA組發(fā)病時(shí)及治療后7天NIHSS評(píng)分，各單抗組及雙抗組均無(wú)顯著性差異、無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）；SAA組治療14天及6個(gè)月后的NIHSS評(píng)分雙抗組優(yōu)于各個(gè)單抗組，（P0.01），各個(gè)單抗組之間無(wú)顯著性差異（P0.05）。3、依據(jù)Gusto出血分級(jí)，各組均未出現(xiàn)嚴(yán)重出血事件。僅表現(xiàn)為牙齦出血，單用拜阿司匹林組4例（3.8%），單用氯吡格雷組2例（3.1%），雙抗組4例（4.4%），各組比較出血傾向無(wú)顯著統(tǒng)計(jì)學(xué)意義（P0.05）；4、通過腦血管病危險(xiǎn)因素與雙抗治療治療療效的多元回歸分析明確主要危險(xiǎn)因素為糖尿病所致腦梗死的人群給予雙抗治療療效較好，具有統(tǒng)計(jì)學(xué)意義。 綜上：1、阿司匹林聯(lián)合氯吡格雷在急性腦梗死的治療中能有效改善神經(jīng)功能，短期應(yīng)用不增加出血等并發(fā)癥。 2、終點(diǎn)治療結(jié)束時(shí)對(duì)于改善神經(jīng)功能障礙方面，LAA型患者阿司匹林聯(lián)合氯吡格雷治療優(yōu)于單用阿司匹林，單獨(dú)氯吡格雷組介于兩者之間、且與二者差異不確定；SAA型患者聯(lián)合用藥優(yōu)于單藥，單藥治療間無(wú)差異；本次研究CE型患者單藥及聯(lián)合用藥未見差異。 3.對(duì)于以2型糖尿病為危險(xiǎn)因素腦卒中患者，阿司匹林聯(lián)合氯吡格雷可明顯改善神經(jīng)功能缺損情況。
[Abstract]:Background and purpose: ischemic stroke (IschemicStroke, IS) is due to the supply of the arteries of the brain suddenly blocked, resulting in the supply of brain tissue perfusion defect, ischemic necrosis. The neurovascular unit can lead to patients with memory, calculation, decline such as language ability, seriously affect the capacity and quality of life in patients with ischemic stroke. Stroke with high incidence and high disability rate has become a serious threat to human health is a kind of important diseases, second fatal and disabling disease in the first place, affect the health of patients at the same time, also to the society and family brought a huge burden. The treatment of patients with acute ischemic stroke time has become more mature, but still controversial aspects in the choice of antiplatelet aggregation of oral drugs, especially individualized antiplatelet aggregation drug treatment for different causes. It is the case Lack. By reviewing 263 patients with ischemic stroke in our hospital during the same period for patients in this study, using CT or MRI scan head, head MRA or intracranial and neck vascular ultrasound, electrocardiogram and clinical findings and medical history, complete etiological typing group, observation of different subtypes of disease prognosis, and discuss the benefit and the safety of various subtypes of different antiplatelet drugs scheme. Finally, the first neurologist to deepen the understanding on the hierarchical diagnosis of ischemic stroke, and to provide reference for selection of aggregation treatment of different subtypes of platelet.
Methods: This study retrospectively from June 2011 to June 2012, visiting neurology in China Japan Union Hospital of Jilin University Department of internal medicine has a complete examination of imaging, ischemic cerebrovascular examination and common cerebrovascular disease risk factors examined 263 hospitalized patients. According to the single use of aspirin, clopidogrel and aspirin alone. 3 kinds of clopidogrel antiplatelet therapy program group, and the 3 groups were given conventional improve circulation, nerve nutrition drugs intravenously and adjust blood pressure, blood sugar treatment, according to the condition of patients with dehydration agent. At the time of admission, admission seventh days, 14 days and 6 months of follow-up, the National Institutes of Health Stroke Scale (NIHSS) score and bleeding complications were evaluated. At the same time, according to ischemic stroke subtypes (TOAST type) were divided into 5 subtypes, each subtype is above treatment group. Finally, the difference in efficacy and safety of different antiplatelet drugs for the overall and various etiological types of ischemic stroke were obtained.
緇撴灉錛

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