本文選題：急性出血性進(jìn)展性卒中 + 亞急性出血性進(jìn)展性卒中��； 參考：《中南大學(xué)》2014年博士論文

【摘要】：目的：出血性腦卒中,又稱(chēng)腦出血,是一種嚴(yán)重的卒中亞型,具有較高的死亡率和致殘率。出血性進(jìn)展性卒中比非進(jìn)展性出血性卒中預(yù)后更差,故對(duì)其病因、發(fā)病機(jī)制、預(yù)測(cè)方法和治療手段的研究具有更加重要的臨床意義。出血性進(jìn)展性卒中按其發(fā)生時(shí)間可分為三類(lèi),即：急性出血性進(jìn)展性卒中、亞急性出血性進(jìn)展性卒中和慢性出血性進(jìn)展性卒中。急性出血性進(jìn)展性卒中的主要臨床表現(xiàn)是早期神經(jīng)系統(tǒng)癥狀?lèi)夯?而主要原因是早期血腫擴(kuò)大；亞急性進(jìn)展性卒中的主要臨床表現(xiàn)是亞急性期神經(jīng)系統(tǒng)癥狀?lèi)夯?而最主要原因是血腫周?chē)X水腫。本實(shí)驗(yàn)擬對(duì)急性出血性進(jìn)展性卒中和亞急性出血性進(jìn)展性卒中分別進(jìn)行前瞻性臨床觀察性研究和回顧性病例對(duì)照研究,探索急性和亞急性出血性進(jìn)展性卒中的主要相關(guān)臨床因素和可能預(yù)測(cè)方法。對(duì)于急性進(jìn)展性出血性卒中,我們主要研究了與早期血腫擴(kuò)大相關(guān)的臨床因素,重點(diǎn)研究了糖化血紅蛋白、血脂水平、血腫密度不勻征與早期血腫擴(kuò)大的關(guān)系,以及利用臨床和影像學(xué)特征對(duì)早期血腫擴(kuò)大進(jìn)行預(yù)測(cè)的方法；對(duì)于亞急性出血性進(jìn)展性卒中,主要通過(guò)識(shí)別亞急性進(jìn)展的病例,分析了發(fā)生亞急性進(jìn)展病例的臨床特點(diǎn)和亞急性進(jìn)展的可能原因,并初步探索了亞急性進(jìn)展的可能預(yù)測(cè)因素。 方法：本實(shí)驗(yàn)分為兩個(gè)部分進(jìn)行。1.前瞻性臨床觀察性研究：收集2013年10月1日至2014年4月1日間由CT診斷為急性自發(fā)性腦出血于湘雅二醫(yī)院住院的病例,依據(jù)納入和排除標(biāo)準(zhǔn)選擇病例,分別對(duì)病例進(jìn)行急診評(píng)估、入院評(píng)估、24-72小時(shí)評(píng)估和治療方案評(píng)估,記錄病例一般情況、入院生命體征、病史、個(gè)人史、初始和復(fù)查CT影像學(xué)征象、治療方案以及是否發(fā)生早期血腫擴(kuò)大或早期神經(jīng)系統(tǒng)癥狀加重,資料進(jìn)行統(tǒng)計(jì)學(xué)分析。2.回顧性病例對(duì)照研究：通過(guò)中南大學(xué)湘雅二醫(yī)院縮微病歷系統(tǒng),查詢(xún)中南大學(xué)湘雅二醫(yī)院神經(jīng)內(nèi)科2007年12月至2010年12月以“腦出血”入院的病例,依據(jù)納入和排除標(biāo)準(zhǔn)選擇病例,從病歷記錄中提取病例各項(xiàng)臨床數(shù)據(jù)如一般情況、生命體征、病史、個(gè)人史、部分初始和復(fù)查CT影像學(xué)征象、病程中有無(wú)加重及治療方案；選擇所有發(fā)生亞急性進(jìn)展的病例作為病例組,按1：2比例選擇對(duì)照組,資料進(jìn)行統(tǒng)計(jì)學(xué)分析。 結(jié)果：1.前瞻性臨床觀察性研究：本實(shí)驗(yàn)共收集病例40例,10例發(fā)生早期神經(jīng)系統(tǒng)癥狀加重,發(fā)生率為25%。有9例進(jìn)展原因?yàn)樵缙谘[擴(kuò)大,1例進(jìn)展原因?yàn)榉尾扛腥尽?0例中,有11例發(fā)生早期血腫擴(kuò)大,發(fā)生率為27.5%。早期血腫擴(kuò)大組發(fā)病-首次CT時(shí)間顯著低于無(wú)早期血腫擴(kuò)大組(p=0.007)。早期血腫擴(kuò)大組PT、INR、APTT值顯著低于無(wú)早期血腫擴(kuò)大組(PT:11.7±0.7sVS12.7±0.9, p=0.002; INR:0.9±0.1VS1±0.1, p=0.002; APTT:33.7±3.1s VS38±5.8s,p=0.033)。早期血腫擴(kuò)大組平均HDL-C顯著高于無(wú)早期血腫擴(kuò)大組(1.17±0.33mmol/L VS0.82±0.29mmol/L, P=0.003)。篩選出發(fā)病-首次CT時(shí)間、年齡、PT、APTT、INR、HDL和APTT與PT交互作用共7個(gè)變量進(jìn)入多因素Logistic回歸分析,最后得出年齡55.5歲、高密度脂蛋白膽固醇≥1.005mmo1/L、APTT37.1s且PT12.05s可能是早期血腫擴(kuò)大的預(yù)測(cè)因素。2.回顧性病例對(duì)照研究：經(jīng)過(guò)仔細(xì)查看病例,共納入發(fā)生亞急性進(jìn)展性腦出血的病例21例。在無(wú)亞急性進(jìn)展發(fā)生的余下病例中,按照1：2比例隨機(jī)選擇42例病例作為對(duì)照組。21例中,9例進(jìn)展可能原因?yàn)槟X水腫；5例可能進(jìn)展原因?yàn)榉尾扛腥荆?例可能進(jìn)展原因?yàn)槟X水腫合并肺部感染；1例可能進(jìn)展原因?yàn)槟X室內(nèi)出血增多；1例可能進(jìn)展原因?yàn)闃蚰X、腦橋再出血；4例可能進(jìn)展原因不詳。所有發(fā)生亞急性進(jìn)展的21名病例中共死亡5例。亞急性期進(jìn)展組入院后空腹血糖值(8.98±3.8VS6.45±3.29,p=0.030)和中性粒細(xì)胞計(jì)數(shù)水平(82.3%±8.43%VS77.3%±8.33%,p=0.037)顯著高于無(wú)亞急性期進(jìn)展組,而淋巴細(xì)胞計(jì)數(shù)水平顯著低于無(wú)亞急性期進(jìn)展組(10.88%±5.99%VS14.99%±5.98%,p=0.014)。中性粒細(xì)胞百分比≥74.6%者發(fā)生亞急性進(jìn)展的風(fēng)險(xiǎn)是中性粒細(xì)胞百分比74.6%者的4.93倍,淋巴細(xì)胞百分比6.75%者發(fā)生亞急性進(jìn)展的風(fēng)險(xiǎn)是淋巴細(xì)胞百分比≥6.75%者的24.62倍。 結(jié)論：1.前瞻性臨床觀察性研究：糖化血紅蛋白水平可能不是早期血腫擴(kuò)大的預(yù)測(cè)指標(biāo)；血腫密度不勻是否為早期血腫擴(kuò)大的預(yù)測(cè)指標(biāo)還需進(jìn)一步研究；高密度脂蛋白膽固醇水平高可能和早期血腫擴(kuò)大有關(guān)；早期脫水藥物應(yīng)用和止血藥物應(yīng)用對(duì)早期血腫擴(kuò)大可能沒(méi)有明顯影響；血壓控制在收縮壓140mmHg可能顯著減少早期血腫擴(kuò)大發(fā)生；年齡55.5歲、高密度脂蛋白膽固醇≥1.005mmol/L、APTT37.1s且PT12.05s可能是早期血腫擴(kuò)大的預(yù)測(cè)因素。2.回顧性病例對(duì)照研究：導(dǎo)致亞急性進(jìn)展性出血性卒中的主要原因是腦水腫加重以及肺部感染,以及腦出血增大或再發(fā)腦出血；空腹血糖高、中性粒細(xì)胞計(jì)數(shù)高和淋巴細(xì)胞計(jì)數(shù)低可能對(duì)亞急性進(jìn)展發(fā)生有提示作用；中性粒細(xì)胞百分比≥74.6%和淋巴細(xì)胞百分比6.75%的病例亞急性進(jìn)展的發(fā)生率可能高。
[Abstract]:Objective: hemorrhagic stroke, also known as cerebral hemorrhage, is a serious subtype of stroke, with high mortality and disability. Hemorrhagic progressive stroke has a worse prognosis than non progressive hemorrhagic stroke, so it has more important clinical significance for its etiology, pathogenesis, prediction methods and treatment methods. It can be divided into three categories according to their occurrence time: acute hemorrhagic progressive stroke, subacute hemorrhagic progressive stroke and chronic hemorrhagic progressive stroke. The main clinical manifestation of acute hemorrhagic stroke is the deterioration of early nervous system symptoms, mainly due to the enlargement of early hematoma and the major subacute progressive stroke. The clinical manifestation is the deterioration of the symptoms of the nervous system in the subacute phase, and the most important reason is the brain edema around the hematoma. This experiment is intended to conduct prospective clinical observational studies and retrospective case control studies on acute hemorrhagic progressive stroke and subacute hemorrhagic progressive stroke to explore acute and subacute hemorrhagic progressive stroke. Major clinical factors and possible prediction methods. For acute progressive hemorrhagic stroke, we mainly studied the clinical factors associated with early hematoma enlargement, focusing on glycosylated hemoglobin, blood lipid levels, hematoma density irregularity and early hematoma enlargement, and the use of clinical and imaging features for early blood. The method of predicting the enlargement of the swelling; for subacute and hemorrhagic progressive stroke, mainly through the cases of subacute progress, the clinical characteristics and possible causes of subacute progress in subacute progress were analyzed, and possible predictors of subacute progress were preliminarily explored.
Methods: this experiment was divided into two parts of the.1. prospective clinical observational study: a case of acute spontaneous intracerebral hemorrhage diagnosed by CT in Xiangya No.2 Hospital from October 1, 2013 to April 2014 was collected. According to the inclusion and exclusion criteria, the cases were selected for emergency evaluation, admission assessment and 24-72 hour assessment respectively. And the treatment program assessment, record case general situation, admission to life signs, medical history, personal history, initial and reexamination of CT imaging signs, treatment plans, and whether early hematoma enlargement or early nervous system symptom aggravation, statistical analysis.2. retrospective study of venereal diseases: through Xiangya No.2 Hospital of Central South University The medical record system, inquiring the cases of "cerebral hemorrhage" in the Department of Neurology of Xiangya No.2 Hospital of Central South University from December 2007 to December 2010, and selecting cases according to the inclusion and exclusion criteria and extracting the clinical data from the record of the medical records, such as general conditions, vital signs, history and personal history, and the course of initial and review of the CT image, the course of disease, and the course of disease. All patients with subacute progression were selected as case group, and the control group was selected according to 1:2 ratio, and the data were analyzed statistically.
Results: 1. prospective clinical observational study: 40 cases were collected in this experiment, 10 cases had early neurological symptom aggravation, the incidence was 25%., 9 cases were caused by early hematoma enlargement, 1 cases were caused by pulmonary infection in.40 cases, 11 cases had early hematoma enlargement, the incidence of early hematoma enlargement group of 27.5%. was the first time. The time of CT was significantly lower than that of no early hematoma enlargement group (p=0.007). The value of PT, INR, APTT in the early hematoma enlargement group was significantly lower than that of no early hematoma enlargement group (PT:11.7 + 0.7sVS12.7 + 0.9, p=0.002; INR:0.9 + 0.1VS1 + 0.1, p=0.002; APTT:33.7 +) was significantly higher than that in the non early hematoma enlargement group (1. 17 + 0.33mmol/L VS0.82 + 0.29mmol/L, P=0.003). Screening out the onset of the first CT time, age, PT, APTT, INR, HDL and APTT and PT interact with 7 variables into multiple factor Logistic regression analysis. Finally, the age of 55.5 years and high density lipoprotein cholesterol (HDL) were predicted to be the cause of early hematoma enlargement. .2. retrospective case control study: after careful examination of cases, 21 cases of subacute progressive cerebral hemorrhage were included. In the remaining cases without subacute progress, 42 cases were randomly selected as.21 cases in the control group according to the proportion of 1:2. The possible cause of the progression was brain edema in 9 cases; the 5 cases may be progressing to the lung. Infection; 1 patients may progress in the cause of brain edema and pulmonary infection; 1 may progress in the cause of increased intraventricular hemorrhage; 1 may progress in the bridge brain, pontine rebleeding; 4 may progress in unknown reasons. All 21 cases of subacute progress in 5 cases. The subacute progression group after admission to the fasting blood glucose value (8.9) The levels of 8 + 3.8VS6.45 + 3.29, p=0.030) and neutrophils count (82.3% + 8.43%VS77.3% + 8.33%, p=0.037) were significantly higher than those in the non subacute stage, but the lymphocyte count level was significantly lower than that in the non subacute stage (10.88% + 5.99%VS14.99% 5.98%, p=0.014). The risk of subacute progress in the percentage of moderate granulocyte percentage more than 74.6% The percentage of neutrophils was 4.93 times more than that of 74.6%. The risk of subacute progress in the percentage of lymphocyte percentage 6.75% was 24.62 times the percentage of lymphocyte percentage more than 6.75%.
Conclusions: 1. prospective clinical observational studies: glycosylated hemoglobin levels may not be a predictor of early hematoma enlargement; whether hematoma density unevenness is a predictor of early hematoma enlargement needs further study; high density lipoprotein cholesterol levels may be associated with the expansion of early hematoma; early dehydrating drugs are used and The use of hemostatic drugs may not significantly affect the expansion of early hematoma; blood pressure control at systolic pressure 140mmHg may significantly reduce early hematoma enlargement; age 55.5, high density lipoprotein cholesterol (HDL) or 1.005mmol/L, APTT37.1s and PT12.05s may be a pretest factor for early hematoma enlargement: a retrospective case control study of.2.: leading to a retrospective case control study The main cause of subacute progressive hemorrhagic stroke is the aggravation of brain edema and pulmonary infection, as well as the increase of cerebral hemorrhage or recurrent cerebral hemorrhage; high fasting blood glucose, high neutrophils count and low lymphocyte count may be suggestive of subacute progress; the percentage of neutrophils is more than 74.6% and the percentage of lymphocyte is 6.75. The incidence of subacute progress in% of cases is likely to be high.
【學(xué)位授予單位】：中南大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R743.3

【共引文獻(xiàn)】

相關(guān)期刊論文 前1條

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相關(guān)碩士學(xué)位論文 前3條

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3 申楠楠;腦出血血腫擴(kuò)大相關(guān)因素的分析及預(yù)測(cè)評(píng)分量表的建立[D];吉林大學(xué);2014年

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本文編號(hào)：1971656