本文選題：腦卒中 + 血管性認(rèn)知障礙��； 參考：《南京大學(xué)》2016年博士論文

【摘要】：背景與目的：腦卒中患者約有三分之二發(fā)生血管性認(rèn)知障礙(vascular cognitive impairment, VCI),但認(rèn)知評(píng)估缺乏統(tǒng)一標(biāo)準(zhǔn),因此,美國(guó)國(guó)立神經(jīng)疾病與卒中研究院-加拿大卒中網(wǎng)絡(luò)(the National Institute of Neurological Disorders and Stroke and the Canadian Stroke Network, NINDS-CSN)推薦了規(guī)范化的認(rèn)知心理評(píng)估方案(包括60 min,30 min和5 min方案),并倡議在不同語言環(huán)境中推廣。目前,NINDS-CSN認(rèn)知心理學(xué)量表已在韓國(guó)、香港、新加坡和法國(guó)等人群得以普及,但仍缺乏普通話版量表及人群驗(yàn)證。本研究旨在編譯、修訂并驗(yàn)證NINDS-CSN神經(jīng)心理學(xué)量表,并在腦卒中患者中,分析不同神經(jīng)心理學(xué)定義對(duì)認(rèn)知障礙發(fā)生率的影響,以及驗(yàn)證認(rèn)知篩查量表(面對(duì)面評(píng)估和電話評(píng)估)的信效度,而后進(jìn)一步分析腦卒中后發(fā)生VCI的危險(xiǎn)因素。方法：首先進(jìn)行NINDS-CSN普通話版量表的編譯和修訂,并檢測(cè)其信效度。外在效度定義為各方案總分對(duì)腦卒中患者和健康對(duì)照的區(qū)分能力,體現(xiàn)為受試者工作特征曲線分析的曲線下面積(area under the curve, AUC)。信度分析包括內(nèi)部一致性信度和重測(cè)信度,分別由統(tǒng)計(jì)量克朗巴赫α系數(shù)和組內(nèi)相關(guān)系數(shù)(intraclass correlation coefficients, ICC)進(jìn)行評(píng)估。其次,基于驗(yàn)證的普通話版量表,分析不同神經(jīng)心理學(xué)定義,即低于對(duì)照人群均值的1個(gè)標(biāo)準(zhǔn)差(standard deviation,SD)、1.5 SD或2 SD以及認(rèn)知領(lǐng)域的受損由單個(gè)或多個(gè)測(cè)驗(yàn)定義,對(duì)認(rèn)知障礙發(fā)生率的影響；同時(shí),使用簡(jiǎn)易精神狀態(tài)檢查(mini-mental state examination, MMSE)和蒙特利爾認(rèn)知評(píng)估量表(Montreal cognitive assessment test, MoCA)進(jìn)行面對(duì)面評(píng)估、5 min方案和認(rèn)知六項(xiàng)篩查(six item screener, SIS)進(jìn)行電話評(píng)估,驗(yàn)證在腦卒中人群中作為認(rèn)知篩查工具的有效性,并根據(jù)最高約登指數(shù)確定最佳閾值。最后,在腦卒中患者中,按是否存在VCI分為兩組,比較其人口學(xué)、臨床和影像等資料(急慢性腦梗塞和腔梗的數(shù)目、大小和部位,腦白質(zhì)高信號(hào)和腦萎縮的嚴(yán)重程度),使用單因素分析和多因素logistic回歸分析確定腦卒中后發(fā)生VCI的危險(xiǎn)因素。結(jié)果：普通話版量表的驗(yàn)證基于50例輕度腦卒中患者和50例健康對(duì)照,外在效度用AUC表示,60 min方案為0.88(95%可信區(qū)間[confidence interval,CI],0.82-0.95),30 min方案為0.88(95%CI,0.81-0.95),而5 min方案為0.86(95%CI,0.79-0.93)。各個(gè)測(cè)驗(yàn)之間的克朗巴赫a系數(shù)為0.87:60 min,30 min和5 min方案的重測(cè)信度ICC分別為0.90,0.83和0.75。認(rèn)知篩查量表的驗(yàn)證共納入89例腦卒中患者(年齡,62.9±8.6歲；男性,65.2%)進(jìn)行面對(duì)面評(píng)估,其中80例完成間隔一個(gè)月的電話評(píng)估。不同神經(jīng)心理學(xué)定義下,認(rèn)知障礙的發(fā)生率從46.3%-76.3%不等,其中遺忘型單領(lǐng)域的認(rèn)知障礙均較少見；定義越嚴(yán)格,認(rèn)知障礙發(fā)生率越低,并以單領(lǐng)域認(rèn)知受損的患者為主。不同定義下,面對(duì)面量表和電話量表均提示較好的外在效度(AUC0.7)。作為面對(duì)面評(píng)估,MoCA比MMSE與綜合認(rèn)知評(píng)估的一致性更好,認(rèn)知障礙的閾值以MMSE27分,MoCA≤19分為最佳；電話評(píng)估中,5 min量表的評(píng)估時(shí)間為4.3±1.0分鐘,SIS需時(shí)57.3±17.7秒鐘,但5 min方案比SIS與綜合認(rèn)知評(píng)估的一致性更好,最佳閾值為5 min方案≤23分以及SIS≤4分。為了探討腦卒中后發(fā)生VCI的危險(xiǎn)因素,選取具備影像資料的68例患者(年齡,62.7±8.8歲；女性,36.8%),距腦卒中事件中位時(shí)間7個(gè)月后進(jìn)行NINDS-CSN認(rèn)知心理評(píng)估,其中42例(61.8%)存在VCI,以女性居多(P=0.001),教育程度更低(P0.001),有較多淡漠癥狀(P=0.008),陳舊性大梗塞灶的數(shù)目也更多(P=0.046)。多因素回歸分析發(fā)現(xiàn),教育程度(比值比[odds ratio,OR],0.728；95% CI,0.575-0.922;P=0.008)、女性(OR,6.477；95% CI,1.275-32.902;P=0.024)、淡漠評(píng)估分?jǐn)?shù)(OR,0.905;95% CI,0.823-0.995;P=0.039)和皮層萎縮(OR,6.131;95% CI,1.351-27.828;P=0.019)是腦卒中后發(fā)生VCI的獨(dú)立影響因素。結(jié)論：本研究證實(shí),普通話版NINDS-CSN認(rèn)知心理學(xué)量表(包括60 min,30 min和5 min方案)適用于輕度腦卒中患者的認(rèn)知評(píng)估,不同神經(jīng)心理學(xué)定義下,認(rèn)知障礙的發(fā)生率不同,可相差1.6倍。MMSE、MoCA作為面對(duì)面評(píng)估,5 min方案和SIS作為電話評(píng)估,都是簡(jiǎn)便有效的認(rèn)知篩查工具,相應(yīng)的認(rèn)知障礙閾值分別為27分,19分,23分和4分。較低的教育程度、女性、淡漠癥狀和皮層萎縮是腦卒中后發(fā)生認(rèn)知障礙的獨(dú)立危險(xiǎn)因素。
[Abstract]:Background and purpose: about 2/3 of cerebral apoplexy patients have vascular cognitive impairment (VCI), but there is a lack of unified standard for cognitive assessment. Therefore, the National Institute of neurodisease and apoplexy of the United States, Canada Stroke Network (the National Institute of Neurological Disorders and Stroke) Troke Network, NINDS-CSN) recommends a standardized cognitive psychological assessment scheme (including 60 min, 30 min and 5 min), and advocates promoting in different language environments. Currently, the NINDS-CSN cognitive psychology scale has been popularized in Korea, Hongkong, Singapore and France, but still lacks the Putonghua scale and population verification. To compile, modify and verify the NINDS-CSN neuropsychological scale, and to analyze the effects of different neuropsychological definitions on the incidence of cognitive impairment in stroke patients, and to verify the reliability and validity of the cognitive screening scale (face-to-face assessment and telephone evaluation), and then further analyze the risk factors for the occurrence of VCI after stroke. Carry out the compilation and revision of the NINDS-CSN Putonghua scale and examine its reliability and validity. The external validity is defined as the ability to distinguish between stroke patients and health controls by the total score of each scheme, which is the area under the curve of area under the curve (AUC). Reliability analysis includes internal consistency reliability and retest letter. Degrees were evaluated by the statistics Krone Bach alpha coefficient and intraclass correlation coefficients (ICC). Secondly, based on a verifying Putonghua scale, the definition of different neuropsychology was analyzed, that is, 1 standard deviations (standard deviation, SD), 1.5 SD or 2 SD, and cognitive domain. The effect on the incidence of cognitive impairment was impaired by a single or multiple test definition; meanwhile, the face-to-face assessment was performed using the simple mental state examination (Mini-Mental State Examination, MMSE) and the Montreal cognitive assessment scale (Montreal cognitive assessment test, MoCA), and the 5 min scheme and cognitive six screening (six item) A telephone evaluation was conducted to verify the effectiveness of the cognitive screening tool in the stroke population and to determine the best threshold according to the highest index. Finally, in the stroke patients, the VCI was divided into two groups, and the number, size and location of the acute cerebral infarction and the infarct and the infarct, and the high white matter were compared. Signal and brain atrophy severity), using single factor analysis and multiple factor Logistic regression analysis to determine the risk factors for VCI after stroke. Results: the verifying of the Putonghua scale was based on 50 cases of mild stroke patients and 50 healthy controls, the external validity was expressed with AUC, and the 60 min scheme was 0.88 (95% confidence interval [confidence InterVA). L, CI], 0.82-0.95), the 30 min scheme was 0.88 (95%CI, 0.81-0.95), and the 5 min scheme was 0.86 (95%CI, 0.79-0.93). The Krone Bach a coefficient between each test was 0.87:60 min. The 30 and 5 scheme's retest reliability included 89 cases of stroke patients (age, 62.9 + 8.6 years old; male, 6). 5.2%) face to face assessment, of which 80 patients completed a one month telephone assessment. Under different neuropsychological definitions, the incidence of cognitive impairment ranged from 46.3%-76.3%, of which all cognitive disorders in the amnestic single domain were less common; the more strict the definition, the lower the incidence of cognitive impairment, and the difference in the patients with single domain cognitive impairment. Under the definition, both the face scale and the telephone scale showed good external validity (AUC0.7). As a face to face assessment, the consistency of MoCA was better than that of the comprehensive cognitive assessment. The threshold of cognitive impairment was MMSE27 and MoCA < 19 as the best. The evaluation time of the 5 min scale was 4.3 + 1 minutes in the telephone evaluation, and 57.3 + 17.7 seconds when SIS was required, but it was 57.3 + 17.7 seconds for SIS. The 5 min scheme was better than the SIS and the comprehensive cognitive assessment, the best threshold was 5 min schemes less than 23 and SIS < 4. To explore the risk factors of VCI after stroke, 68 patients with imaging data (age, 62.7 + 8.8 years, women, 36.8%) were selected and the cognitive psychology of the event was 7 months after the event in the stroke. Among them, 42 (61.8%) had VCI, with P=0.001, P0.001, P=0.008, and older large infarcts (P=0.046). Multiple regression analysis found that education (ratio ratio [odds ratio, OR], 0.728; 95% CI, 0.575-0.922; P=0.008), and women (OR, 6.477; 95%, 1.275) -32.902; P=0.024), the indifference assessment score (OR, 0.905; 95% CI, 0.823-0.995; P=0.039) and cortical atrophy (OR, 6.131; 95% CI, 1.351-27.828; P=0.019) are independent factors of VCI after stroke. Conclusion: This study confirms that the Putonghua NINDS-CSN cognitive psychology scale (including 60, 30 and 5) is suitable for mild stroke. Patients' cognitive assessment, different neuropsychological definitions, the incidence of cognitive impairment is different, can differ 1.6 times.MMSE, MoCA as a face-to-face assessment, 5 min scheme and SIS as a telephone evaluation, is a simple and effective cognitive screening tool, the corresponding cognitive impairment threshold of 27, 19, 23 and 4 points. Lower education, women, Apathy symptoms and cortical atrophy are independent risk factors for cognitive impairment after stroke.

【學(xué)位授予單位】：南京大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R743.3

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