本文選題：閉塞性腦血管病變 + 缺血性卒中��； 參考：《第三軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：背景腦血管病已成為我國(guó)居民的“第一殺手”,每年新發(fā)急性腦血管病(即腦卒中)患者高達(dá)250萬(wàn)人,而每年死于腦卒中的患者則超過(guò)150萬(wàn)人,腦卒中死亡率、發(fā)病率以及國(guó)家對(duì)其醫(yī)療開(kāi)支每年呈穩(wěn)定遞增的趨勢(shì)[1]。加之大多數(shù)卒中存活患者遺留不同程度的殘疾,給家庭帶來(lái)嚴(yán)重的經(jīng)濟(jì)和人力負(fù)擔(dān)。閉塞性腦血管病變(cerebrovascular total occlusive disease,COD)指腦血管100%或接近100%的狹窄,是血管狹窄或非狹窄時(shí)的終末狀態(tài)。它是腦血管病的重要亞型[2],可能是我國(guó)國(guó)民高卒中發(fā)病率的重要因素之一[3],也是腦卒中預(yù)防和治療的重點(diǎn)目標(biāo)[4],尤其是顱內(nèi)大血管的閉塞性病變。COD在人群中的發(fā)病率至今仍不清楚。Horie等[5]對(duì)1053例缺血性卒中患者進(jìn)行磁共振腦血管成像(magnetic resonance angiography,MRA)檢查,結(jié)果發(fā)現(xiàn):7.88%(83/1053)的患者存在腦血管大動(dòng)脈的急性和非急性閉塞(包括心源性以及粥樣硬化性)。COD引起的臨床癥狀多種多樣,側(cè)支循環(huán)形成迅速而良好者可無(wú)任何臨床癥狀,而形成差者可表現(xiàn)為嚴(yán)重的肢體癱瘓,甚至死亡[6]。頸內(nèi)動(dòng)脈(internal carotid artery,ICA)閉塞時(shí),一些患者可以無(wú)任何癥狀,或僅表現(xiàn)頭暈、頭痛等相對(duì)較輕的臨床癥狀,多數(shù)患者表現(xiàn)的卒中或短暫性腦缺血發(fā)作(transient ischemic attack,TIA)癥狀和其他非閉塞病變導(dǎo)致的神經(jīng)功能缺失癥狀相似,如一過(guò)性或永久性的肢體偏癱、偏麻、偏盲或言語(yǔ)障礙等,其中一過(guò)性黑朦(即短暫性偏盲)是眼動(dòng)脈分支近端閉塞的象征性癥狀[6]。ICA閉塞性病變以及大腦中動(dòng)脈(middle cerebral artery,MCA)的M1段閉塞是卒中癥狀惡化的獨(dú)立預(yù)測(cè)因子[7]。我國(guó)大型顱內(nèi)動(dòng)脈粥樣硬化研究(Chinese Intracranial Atherosclerosis Study,CICAS)表明腦血管閉塞的患者,一年內(nèi)再發(fā)卒中的風(fēng)險(xiǎn)高達(dá)7.27%,高于存在中重度頸部或顱內(nèi)血管狹窄患者的卒中再發(fā)率[3]。即使豐富的側(cè)支代償使血管閉塞時(shí)患者無(wú)任何癥狀,但代償?shù)难荛L(zhǎng)期處于負(fù)荷狀態(tài),最終會(huì)出現(xiàn)失代償而導(dǎo)致相應(yīng)的神經(jīng)功能缺失癥狀。缺血性卒中超急性期時(shí)間窗內(nèi),重組組織型纖溶酶原激活物(recombinant tissue plasminogen activator,rt-PA)靜脈溶栓和動(dòng)脈血管內(nèi)治療(endovascular therapy,EVT)是使超急性期閉塞血管再通的有效方法,但這些方法治療的時(shí)間窗過(guò)窄,限于4.5~8小時(shí)內(nèi),致使許多卒中癥狀超過(guò)時(shí)間窗的病人得不到及時(shí)治療,并且時(shí)間窗內(nèi)靜脈溶栓和動(dòng)脈EVT治療的血管再通率極低(就全國(guó)而言平均水平不足20%),大多數(shù)患者經(jīng)過(guò)治療后臨床癥狀緩解但仍然存在頭頸部相應(yīng)血管的閉塞,后續(xù)的治療則主要以二級(jí)預(yù)防為主。這些長(zhǎng)期存在的閉塞性血管病變對(duì)患者以后認(rèn)知功能是否產(chǎn)生影響目前不得而知。全腦數(shù)字減影血管造影術(shù)(digital angiography,DSA)是目前診斷腦血管病變的“金標(biāo)準(zhǔn)”。對(duì)于缺血性腦血管病,DSA不但能清楚地顯示腦血管圖像,還可清楚地顯示動(dòng)脈管腔狹窄、閉塞、側(cè)支循環(huán)建立情況等。不僅如此,經(jīng)DSA診斷明確后,操作者可直接對(duì)血管病變進(jìn)行血管內(nèi)治療,并觀察手術(shù)效果,這種將檢查與治療同時(shí)進(jìn)行的優(yōu)勢(shì),目前其他檢查方法還無(wú)法實(shí)現(xiàn)。自2005年第1例慢性ICA閉塞病變被成功再通后,隨著EVT器械的不斷改進(jìn),介入工作者對(duì)閉塞病變血管內(nèi)再通術(shù)掀起了許多挑戰(zhàn)的熱情。能否應(yīng)用血管內(nèi)介入治療技術(shù)對(duì)錯(cuò)過(guò)超急性期救治的閉塞血管再通,目前也缺乏充足的證據(jù)。目的本研究擬用DSA來(lái)篩選存在COD的患者,同時(shí)評(píng)估相應(yīng)的認(rèn)知功能特點(diǎn),探討腦血管COD病變對(duì)輕度缺血性卒中患者遠(yuǎn)期認(rèn)知功能的影響。對(duì)存在明顯低灌注的閉塞患者行血管內(nèi)介入再通術(shù),探討血管再通后認(rèn)知功能的改變情況,從而為腦血管COD病變患者的血管再通治療提供依據(jù)。方法自2013年5月至2016年7月,從我院卒中患者登記數(shù)據(jù)庫(kù)中連續(xù)納入出現(xiàn)神經(jīng)功能缺損、臨床癥狀在14天以后、90天以內(nèi),經(jīng)DSA證實(shí)存在前循環(huán)大血管閉塞(large artery occlusion,LAO)的輕度缺血性卒中患者170例(即LAO組),納入97例造影證實(shí)無(wú)前循環(huán)大血管閉塞的輕度缺血性卒中患者與其配對(duì)作為對(duì)照組。另外將存在明顯低灌注且手術(shù)再通的23例患者作為L(zhǎng)AO再通組,34例存在明顯低灌注但未手術(shù)再通的患者作為L(zhǎng)AO未再通組,進(jìn)行觀察分析。比較所有納入患者入組后12個(gè)月、24個(gè)月認(rèn)知功能情況,包括簡(jiǎn)易智能精神狀態(tài)檢查量表(mini-mental state examination,MMSE)、蒙特利爾認(rèn)知功能評(píng)分表(Montreal Cognitive Assessment,Mo CA)。結(jié)果隨訪期間,LAO組與對(duì)照組兩組患者認(rèn)知功能存在明顯差異:12個(gè)月后MMSE[LAO組(25.73±2.26)vs對(duì)照組(26.96±1.69),P0.01],Mo CA[LAO組(24.18±3.42)vs對(duì)照組(25.70±1.56),P0.01];24個(gè)月后MMSE[LAO組(25.47±2.09)vs對(duì)照組(26.58±1.63),P0.01)],MoCA[LAO組(24.14±2.57)vs對(duì)照組(25.30±1.80),P0.01)]。LAO再通組與LAO未再通組兩組患者認(rèn)知功能也存在明顯差異:12個(gè)月后MMSE[LAO再通組(27.29±1.31)vs LAO未再通組(26.29±1.36),P0.05],MoCA[LAO再通組(26.29±1.42)vs LAO未再通組(24.91±1.96),P0.05];24個(gè)月后MMSE[LAO再通組(27.50±1.10)vs LAO未再通組(25.57±1.67),P0.01)],Mo CA[LAO再通組(26.75±1.18)vs LAO未再通組(24.29±2.22),P0.01)]。結(jié)論前循環(huán)COD可能導(dǎo)致輕度缺血性卒中患者遠(yuǎn)期認(rèn)知功能下降,血管內(nèi)介入再通術(shù)可以明顯改善該類患者遠(yuǎn)期的認(rèn)知功能。
[Abstract]:Background cerebrovascular disease has become the "first killer" of Chinese residents, with more than 2 million 500 thousand new patients with acute cerebrovascular disease (stroke) each year, while more than 1 million 500 thousand people die of stroke each year, stroke mortality, morbidity, and the national trend of steady increase in medical expenses and the survival of [1]. combined with most of the stroke survival. Patients with different degrees of disability bring serious economic and human burden to the family. Cerebrovascular total occlusive disease (COD) refers to the stenosis of cerebral vascular 100% or close to 100%, which is the terminal state of vascular stenosis or non stenosis. It is an important subtype of cerebral vascular disease, [2], and may be the high death of our country. One of the important factors in the incidence of the disease, [3], is also the key target of the prevention and treatment of cerebral apoplexy [4], especially the occlusion of the intracranial large vessels, the incidence of.COD in the population is still not clear about.Horie and other [5] in 1053 patients with ischemic stroke (magnetic resonance angiography, MRA), and the result is the result. Now: 7.88% (83/1053) patients have a variety of acute and non acute occlusion (including cardiogenic and atherosclerotic).COD in the patients with large cerebral artery artery (including cardiogenic and atherosclerotic), and the side branch circulation is rapid and the good person can not have any clinical symptoms, and the poor formation can be characterized by severe paralysis of the limb and even the death of the [6]. internal carotid artery (Intern When Al carotid artery, ICA), some patients can have no symptoms, or only have relatively mild clinical symptoms such as dizziness and headache, and most patients exhibit similar symptoms of stroke or transient ischemic attack (transient ischemic attack, TIA) and other non occlusive lesions, such as one perpetual or permanent symptom. Sexual hemiplegia, hemiplegia, hemianamia, or speech disorder, of which an amamamamus (i.e., transient hemianas) is a symbolic symptom of the occlusion of the proximal occluding artery of the ophthalmic artery, [6].ICA occlusion and the middle cerebral artery, MCA, M1 segment occlusion, an independent predictor of stroke like deterioration, [7]. in China, large intracranial artery porridge Chinese Intracranial Atherosclerosis Study (CICAS) shows that patients with cerebral vascular occlusion have a risk of recurrent stroke within one year as high as 7.27%, higher than the recurrence rate of stroke in patients with moderate or severe cervical or intracranial stenosis, [3]. even if rich collateral compensatory causes blood vessels to obliterate patients without any symptoms, but the compensatory vessels For a long time in the state of load, there will be an eventual loss of compensation and the corresponding symptoms of neural dysfunction. In the hyperacute phase of the ischemic stroke, the recombinant tissue type plasminogen activator (recombinant tissue plasminogen activator, rt-PA) intravenous thrombolysis and arterial intravascular therapy (endovascular therapy, EVT) are the hyperacute phase closure. The effective method of blocking vascular recanalization, but the time window of these methods is too narrow, limited to 4.5~8 hours, resulting in many stroke symptoms beyond the time window for patients without timely treatment, and the time window intravenous thrombolytic and arterial EVT treatment of vascular recanalization rate is extremely low (the average level is less than 20% in the country), the majority of patients are treated. After the treatment, the clinical symptoms are relieved but the corresponding blood vessels of the head and neck are still occluded, and the follow-up treatment is mainly two stage prevention. The long-term existing occluded angiopathy has no effect on the cognitive function of the patients. Digital angiography, DSA is the diagnosis of the brain at present. The "gold standard" of vascular disease. For ischemic cerebrovascular disease, DSA can not only clearly display the cerebral vascular image, but also clearly show the stenosis, occlusion and collateral circulation of the artery. Not only so, after the diagnosis of DSA, the operator can directly treat the vascular disease in blood vessel, and observe the effect of the operation, this kind of effect will be observed. At the same time, the advantages of examination and treatment are not yet realized. Since first cases of chronic ICA occlusion have been successfully re opened in 2005, with the continuous improvement of the EVT instruments, the intervention workers have raised many challenges to the intravascular recanalization of the occlusive lesions. The aim of this study is to screen the patients with COD, and to evaluate the corresponding cognitive function and to explore the effect of COD lesions on the long-term cognitive function of patients with mild ischemic stroke, and to do intravascular intervention for patients with obvious low perfusion of DSA. The change of cognitive function after vascular recanalization was explored to provide a basis for the treatment of vascular recanalization in patients with cerebral vascular COD lesions. Methods from May 2013 to July 2016, neural function defects were continuously included in the registration database of stroke patients in our hospital. The clinical symptoms were 14 days later, within 90 days and confirmed by DSA. 170 patients with mild ischemic stroke (group large artery occlusion, LAO) with mild ischemic stroke (group LAO) were included in 97 cases with mild ischemic stroke without anterior circulation large vascular occlusion and paired as a control group. In addition, 23 patients with obvious low perfusion and surgical recanalization were used as the LAO Re Group, and 34 cases were obvious. The patients with low perfusion but no surgical recanalization were observed and analyzed as the LAO non recanalization group. The cognitive functions were compared for 12 months and 24 months after the patients were enrolled in the group, including the simple intelligent mental state Checklist (Mini-Mental State Examination, MMSE), and the Montreal recognition function score table (Montreal Cognitive Assessment, Mo CA). During the follow-up period, there were significant differences in cognitive function between the LAO group and the control group: MMSE[LAO group (25.73 + 2.26) vs control group (26.96 + 1.69), P0.01], Mo CA[LAO group (24.18 + 3.42) vs control group (25.70 + 1.56), P0.01], and MMSE[LAO group (25.47 + 2.09) vs control group (25.47 + 2.09) vs control group (P0.01) after 24 months. There was also significant difference in cognitive function between group (25.30 + 1.80), P0.01)].LAO recanalization group and two group of LAO without recanalization group: MMSE[LAO recanalization group (27.29 + 1.31) vs LAO non Re Group (26.29 + 1.36), P0.05], MoCA[LAO Re Group (26.29 + 1.42) vs LAO non Re Group (24.91 + 1.96), P0.05], MMSE[LAO re group after 24 months. O (25.57 + 1.67), P0.01), Mo CA[LAO recanalization group (26.75 + 1.18) vs LAO non Re Group (24.29 + 2.22), P0.01). Conclusion the forward circulation COD may lead to the decline of long-term cognitive function in patients with mild ischemic stroke, and intravascular interventional recanalization can obviously improve the long-term cognitive function of this type of patients.
【學(xué)位授予單位】：第三軍醫(yī)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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