本文選題：卒中 + 失語(yǔ)　； 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景失語(yǔ)癥是因大腦病變而導(dǎo)致的語(yǔ)言障礙,包括聽、說(shuō)、讀、寫等能力受損。急性缺血性腦卒中后約有1/3的患者伴有不同程度的失語(yǔ)。卒中后認(rèn)知功能障礙(poststroke cognitive impairment,PSCI)現(xiàn)已成為臨床醫(yī)師在卒中康復(fù)進(jìn)程中關(guān)注的熱點(diǎn)問題,但受限于缺少適用的非語(yǔ)言性認(rèn)知評(píng)估量表、患者配合度不高等原因,卒中后失語(yǔ)(post-strokeaphasia,PSA)患者的非語(yǔ)言性認(rèn)知障礙卻常常被忽視。國(guó)內(nèi)外研究發(fā)現(xiàn)在卒中急性期PSA患者非語(yǔ)言性認(rèn)知障礙的發(fā)生率為86%。發(fā)病后3個(gè)月,有88%的PSA患者出現(xiàn)至少一個(gè)非語(yǔ)言認(rèn)知域的損害。而研究對(duì)象為卒中后非失語(yǔ)患者的大樣本調(diào)查顯示卒中發(fā)生后3個(gè)月PSCI的發(fā)生率大約為47.3%-56.6%。表明PSA患者非語(yǔ)言性認(rèn)知障礙的發(fā)生率遠(yuǎn)高于非失語(yǔ)的腦卒中患者。目前臨床常用于評(píng)估認(rèn)知功能的量表主要包括簡(jiǎn)易精神狀態(tài)量表(Mini-mental State Examination,MMSE)、蒙特利爾認(rèn)知評(píng)估量表(Montreal Cognitive Assessment,MoCA)等,因其操作具有較強(qiáng)的語(yǔ)言依賴性,故難以應(yīng)用于PSA患者的認(rèn)知功能評(píng)估。而專用于失語(yǔ)患者的認(rèn)知功能評(píng)估量表,如失語(yǔ)檢查量表(Aphasia Check List,ACL),在識(shí)別PSA患者認(rèn)知障礙方面具有良好的敏感性和特異性,然而目前尚未在我國(guó)經(jīng)過(guò)漢化修訂,更沒有在國(guó)內(nèi)經(jīng)過(guò)大樣本的信效度檢驗(yàn)。為了盡可能客觀地評(píng)估PSA患者的認(rèn)知功能,本課題組在前期研究中編制了非語(yǔ)言性認(rèn)知功能評(píng)估量表(Non-language-based Cognitive Assessment,NLCA),用圖片示范加演示的方式代替?zhèn)鹘y(tǒng)指導(dǎo)語(yǔ),專門用于失語(yǔ)患者的認(rèn)知功能評(píng)估,該量表包括記憶力、視空間、注意力、邏輯推理能力以及執(zhí)行力五個(gè)認(rèn)知域的檢測(cè),經(jīng)過(guò)檢驗(yàn)具有良好的信度和效度。本研究現(xiàn)將NLCA量表應(yīng)用于PSA患者的隨訪研究,并全面評(píng)估語(yǔ)言功能及抑郁情緒、日常生活能力,以了解缺血性腦卒中發(fā)生后3個(gè)月失語(yǔ)患者語(yǔ)言及其他認(rèn)知功能的康復(fù)情況,探討卒中后3個(gè)月失語(yǔ)患者認(rèn)知狀況的重要影響因素,為PSA患者的整體康復(fù)提供新的思路和參考依據(jù)并更進(jìn)一步剖析語(yǔ)言認(rèn)知的復(fù)雜系統(tǒng)。目的1.了解卒中后失語(yǔ)患者語(yǔ)言及其他非語(yǔ)言性認(rèn)知障礙的康復(fù)特點(diǎn);2.卒中后失語(yǔ)患者認(rèn)知障礙康復(fù)的影響因素分析。方法選取自2015年6月至2016年11月在本院神經(jīng)內(nèi)科病房住院的急性缺血性腦卒中后失語(yǔ)患者。納入標(biāo)準(zhǔn):(1)符合中華醫(yī)學(xué)會(huì)神經(jīng)病學(xué)分會(huì)全國(guó)第四屆腦血管病會(huì)議制定的腦卒中診斷標(biāo)準(zhǔn),并經(jīng)CT或MRI證實(shí);(2)發(fā)病時(shí)間大于1周,意識(shí)清楚,病情穩(wěn)定,至少一側(cè)肢體肌力大于3級(jí)且愿意配合檢查;(3)經(jīng)漢語(yǔ)失語(yǔ)檢查量表(Aphasia Battery of Chinese,ABC)評(píng)估確定為失語(yǔ)癥患者;(4)患者及家屬知情同意并已簽署知情同意書。排除標(biāo)準(zhǔn):(1)意識(shí)障礙、嚴(yán)重精神癥狀或嚴(yán)重聽力、視力損害;(2)既往有腦血管病史或本次發(fā)病前已有本人或家屬可察覺的認(rèn)知功能下降癥狀。選擇符合納入標(biāo)準(zhǔn)的首次腦卒中患者,確定為失語(yǔ)癥后判斷失語(yǔ)類型,并采用波士頓診斷失語(yǔ)檢查(Boston Diagnostic Aphasia Examination,BDAE)中的失語(yǔ)嚴(yán)重程度分級(jí)評(píng)估失語(yǔ)嚴(yán)重程度。然后記錄基本資料(年齡、性別、利手、受教育年限、發(fā)病時(shí)間、電話號(hào)碼等)、頭顱MRI/CT結(jié)果(病灶部位,病灶大小按最大直徑≤1cm、1-5cm、≥5cm分為小、中、大病灶)、出院時(shí)是否使用改善認(rèn)知藥物及抗抑郁藥物。所有研究對(duì)象均接受美國(guó)國(guó)立衛(wèi)生研究院腦卒中量表(NIHSS)、非語(yǔ)言性認(rèn)知功能評(píng)估量表量表以及卒中后失語(yǔ)患者抑郁問卷(醫(yī)院版)(Stroke Aphasic Depression Questionnaire Hospital Version,SADQ-H)量表、日常生活活動(dòng)能力量表(activities of daily living scale,ADL)的檢查。發(fā)病后3個(gè)月電話通知患者前來(lái)隨訪,再次使用以上量表對(duì)患者進(jìn)行評(píng)估,并記錄患者出院后的藥物使用情況。所有測(cè)驗(yàn)均由經(jīng)過(guò)正規(guī)神經(jīng)心理測(cè)驗(yàn)培訓(xùn)的神經(jīng)內(nèi)科研究生在安靜無(wú)干擾的環(huán)境下進(jìn)行。共納入卒中后1-2周(作為基線)的PSA患者41例,卒中3個(gè)月后隨訪患者共30例(隨訪率73.17%)。(1)所有患者均為缺血性腦卒中;男24例,女6例;年齡(55.70±15.11)歲;病程(9.40±5.25)天;受教育年限(8.80±4.40)年;均為右利手。(2)失語(yǔ)類型:Broca失語(yǔ)4例(13.33%),Wernicke失語(yǔ)3例(10%),完全性失語(yǔ)5例(16.67%),經(jīng)皮質(zhì)混合性失語(yǔ)2例(6.67%),經(jīng)皮質(zhì)運(yùn)動(dòng)性失語(yǔ)3例(10%),經(jīng)皮質(zhì)感覺性失語(yǔ)7例(23.33%),命名性失語(yǔ)1例(3.33%),傳導(dǎo)性失語(yǔ)3例(10%),未分類失語(yǔ)2例(6.67%)。(3)入組時(shí)情況..NIHSS 評(píng)分(5.70±4.53),SADQ-H 評(píng)分(17.53±10.48),ADL 評(píng)分(45.97±18.39)。所有數(shù)據(jù)通過(guò)SPSS20.0軟件進(jìn)行統(tǒng)計(jì)學(xué)處理。以P0.05表示差異有統(tǒng)計(jì)學(xué)意義。結(jié)果1.PSA患者卒中后3個(gè)月對(duì)比基線,流利性[(21.80±6.08)分,(15.83±7.39)分]、聽理解[(203.33±35.30)分,(139.70±72.82)分]等語(yǔ)言評(píng)估各項(xiàng)分?jǐn)?shù)均明顯提升,差異有統(tǒng)計(jì)學(xué)意義(P0.01);2.卒中后3個(gè)月NLCA總分[(65.83±13.02)分,(48.00±25.11)分]及記憶力[(17.23±2.49)分,(13.30±5.42)分]、視空間能力[(10.67±2.43)分,(8.07±3.75)分]、邏輯推理能力[(6.53±1.48)分,(4.97±2.43)分]、注意力[(25.57±5.79)分,(17.43±12.33)分]、執(zhí)行力[(5.77±3.47)分,(4.20±4.23)分]各項(xiàng)均較基線明顯改善,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。3.卒中后3個(gè)月失語(yǔ)未完全康復(fù)患者NLCA總分[(62.40±14.23)分]及視空間能力[(9.95±2.67)分]、邏輯推理能力[(6.05±1.54)分]兩個(gè)亞項(xiàng)評(píng)分均顯著低于失語(yǔ)完全康復(fù)患者[分別為(72.70±6.34)分、(12.10±0.74)分、(7.50±0.71)分],且日常生活能力[(32.55±12.57)分,(23.40±5.82)分]及抑郁評(píng)分[(10.35±7.85)分,(2.40±2.37)分]更高,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。4.多元回歸分析提示與失語(yǔ)患者卒中后3個(gè)月內(nèi)認(rèn)知功能改善情況顯著相關(guān)的因素為基線NLCA評(píng)分(β=-0.603,P=0.000)。結(jié)論1.PSA患者非語(yǔ)言性認(rèn)知功能的康復(fù)特點(diǎn)同語(yǔ)言功能類似,在卒中后3個(gè)月內(nèi)能明顯改善。2.卒中后3個(gè)月失語(yǔ)未完全康復(fù)患者非語(yǔ)言性認(rèn)知功能及日常生活能力更差,抑郁情緒更嚴(yán)重。3.卒中1-2周的認(rèn)知功能是PSA患者卒中后3個(gè)月認(rèn)知結(jié)局的良好預(yù)測(cè)因子。
[Abstract]:Background aphasia is a language disorder caused by brain lesions, including impaired listening, speaking, reading, writing, and so on. Patients with 1/3 after acute ischemic stroke are associated with varying degrees of aphasia. Cognitive impairment after stroke (poststroke cognitive impairment, PSCI) has become a fever for clinicians in the process of stroke rehabilitation. The problem is limited, but it is limited to the lack of a nonverbal cognitive assessment scale, and the nonverbal cognitive impairment of patients with post-strokeaphasia (PSA) is often neglected. The incidence of nonverbal cognitive impairment in PSA patients at acute stroke is 3 months after the onset of 86%., 88% of PSA patients had at least one nonverbal cognitive impairment. The study of a large sample of non aphasic patients after apoplexy showed that the incidence of PSCI was about 47.3%-56.6%. after 3 months of stroke, indicating that the incidence of non verbal cognitive impairment in PSA patients was much higher than that of nonverbal apoplexy. The scale of cognitive function assessment mainly includes the Mini-mental State Examination (MMSE), the Montreal cognitive assessment scale (Montreal Cognitive Assessment, MoCA) and so on. Because of its strong language dependence, it is difficult to apply to the cognitive function assessment of the PSA patients. It is used for the cognitive function of the aphasia patients. The assessment scale, such as the Aphasia Check List (ACL), has a good sensitivity and specificity in identifying the cognitive impairment of patients with PSA. However, it has not yet been revised in China by Sinization and has not been tested in large samples in China. In order to evaluate the cognitive function of PSA patients as objectively as possible, this subject is subject to the objective evaluation of the cognitive function of the patients. In the previous study, the Non-language-based Cognitive Assessment (NLCA) was developed to replace the traditional guidance with a picture demonstration and demonstration, which was used to evaluate the cognitive function of the aphasia, including memory, visual space, attention, logical reasoning, and execution. Five The test of cognitive domain has good reliability and validity. The NLCA scale is applied to the follow-up study of PSA patients, and the language function and depression, daily life ability are evaluated in order to understand the rehabilitation of the language and other cognitive functions of aphasia patients after 3 months of ischemic stroke, and to explore the 3 after stroke. The important influencing factors of cognitive status in patients with aphasia for the month of aphasia provide new ideas and references for the overall rehabilitation of PSA patients and further analyze the complex system of language cognition. Objective 1. to understand the rehabilitation characteristics of language and other nonverbal cognitive impairment after apoplexy; 2. the image of cognitive impairment after apoplexy aphasia patients Methods the patients with apoplexy after acute ischemic stroke hospitalized in the neurology ward of our hospital from June 2015 to November 2016 were selected. (1) the standard of stroke diagnosis was established in accordance with the fourth session of the National Conference on cerebrovascular disease of the Chinese Medical Association, which was confirmed by CT or MRI; (2) the onset time was more than 1 weeks. Clear consciousness, stable condition, at least one side of the limb muscle strength greater than 3 and willing to cooperate with the examination; (3) the Chinese aphasia Checklist (Aphasia Battery of Chinese, ABC) was evaluated as aphasia; (4) the patients and their families informed consent and signed informed consent. (1) consciousness disorder, severe mental symptoms or severe hearing, visual Force impairment; (2) the symptoms of cognitive impairment that had already been perceived by the patient or family before the history of cerebrovascular disease or this disease. Select the first stroke patients in accordance with the inclusion criteria, determine the type of aphasia after the aphasia, and use the Boston Diagnostic Aphasia (Boston Diagnostic Aphasia Examination, BDAE) and the aphasia. The severity of aphasia was assessed by the degree of severity. Then the basic data (age, sex, benefit, time of education, time of disease, telephone number, etc.), and the results of the head MRI/CT (the location of the focus, the size of the lesion at the maximum diameter less than 1cm, 1-5cm, > 5cm were divided into small, medium, large), and the use of improved cognitive and antidepressant drugs at discharge. The subjects received the National Institutes of Health Stroke Scale (NIHSS), the nonverbal cognitive function assessment scale and the post apoplexy aphasia depression questionnaire (hospital Edition) (Stroke Aphasic Depression Questionnaire Hospital Version, SADQ-H), the daily living ability scale (activities of daily living), 3 months after the onset of the disease, the patients were followed up 3 months after the onset of the disease, and the above scale was used again to assess the patients and to record the use of the patients after discharge. All the tests were conducted in a quiet, silent environment trained by a regular neuropsychological test for 1-2 weeks after a stroke (as a result of a stroke). A total of 41 patients with PSA and 3 months after stroke were followed up in 30 cases (73.17%). (1) all patients were ischemic stroke, 24 men, 6 women, age (55.70 + 15.11) years, course (9.40 + 5.25) days and years of Education (8.80 + 4.40); all were right hand. (2) aphasia, Wernicke aphasia 5 cases (16.67%) had sexual aphasia, 2 cases (6.67%), 3 cases of motor aphasia (10%), 7 cases of sensory aphasia (23.33%), 1 named aphasia (3.33%), 3 (10%) conduction aphasia (10%), and unclassified aphasia (3.33%), SADQ-H score, ADL score, ADL score. 18.39). All data were statistically treated with SPSS20.0 software. The difference was statistically significant by P0.05. Results the contrast baseline of 1.PSA patients after 3 months of stroke, fluency [(21.80 + 6.08), (15.83 + 7.39)]), listening comprehension [(203.33 + 35.30), (139.70 + 72.82)], and other scores were significantly improved, and the differences were statistically significant 2. ((65.83 + 13.02) points, (48 + 25.11) points) and memory [(17.23 + 2.49) points, (13.30 + 5.42) points], visual space capability [10.67 + 2.43), (10.67 + 2.43) points, logical reasoning ability [(25.11 + 17.23) points], attention [(25.11 + 25.11) points]. The scores, (4.20 + 4.23) points, were obviously improved compared with the baseline, and the difference was statistically significant (P0.05) in the 3 months after.3. apoplexy, the total score of NLCA [(62.40 + 14.23)] and the visual space ability [(9.95 + 2.67)], and the logical reasoning ability [(6.05 + 1.54)] were significantly lower than those of the complete rehabilitation patients [(72] (respectively) .70 + 6.34), (12.10 + 0.74) points, (7.50 + 0.71) points, and the daily living capacity [(32.55 + 12.57), (23.40 + 5.82)] and depression score [(10.35 + 7.85), (2.40 + 2.37)] was higher, and the difference was statistically significant (P0.05).4. multiple regression analysis suggested that the cognitive function improvement of aphasia patients was significantly related to cognitive function within the period of stroke. Conclusion the baseline NLCA score (beta =-0.603, P=0.000). Conclusion the non verbal cognitive function of 1.PSA patients is similar to the language function. In the 3 months after stroke, the patients with.2. stroke can obviously improve the non verbal cognitive function and daily living ability of the patients with the 3 months of apoplexy after.2. stroke, and the depression is more serious for 1-2 weeks of.3. stroke. Knowledge function is a good predictor of cognitive outcomes in PSA patients at 3 months after stroke.

【學(xué)位授予單位】：南方醫(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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