本文選題：腦微出血 + 急性缺血性卒中�。� 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：第一部分急性缺血性卒中患者腦微出血危險(xiǎn)因素分析目的:探討急性缺血性卒中(acute ischemic stroke,AIS)患者腦微出血(cerebral microbleeds,CMBs)的危險(xiǎn)因素。方法:連續(xù)收集2014年1月至2015年12月在河北省人民醫(yī)院神經(jīng)內(nèi)科住院的AIS患者226例,根據(jù)是否存在CMBs,分為CMBs組(111例)和無(wú)CMBs組(115例)。收集研究對(duì)象人口統(tǒng)計(jì)學(xué)資料和臨床資料,通過頭顱核磁共振成像(magnetic resonance imaging,MRI)不同序列分別對(duì)CMBs、腦白質(zhì)病變(white matter lesions,WML)及陳舊腔隙性腦梗死(lacunar infarcts,LI)進(jìn)行評(píng)價(jià),并采用t檢驗(yàn)、χ~2檢驗(yàn)、Logistic回歸等統(tǒng)計(jì)學(xué)方法分析AIS患者中發(fā)生CMBs的危險(xiǎn)因素。結(jié)果:1本部分研究共入組患者226例,CMBs的總體發(fā)生率為49.1%(111/226),其中首次發(fā)生AIS的患者CMBs的發(fā)生率為44.0%(66/150),再發(fā)AIS的患者CMBs的發(fā)生率為59.2%(45/76);AIS患者CMBs出現(xiàn)部位的分布情況為:幕下39.6%(44/111),深部58.6%(65/111),腦葉64.9%(72/111);CMBs嚴(yán)重程度分布情況:0級(jí):50.9%(115/226),1級(jí):32.3%(73/226),2級(jí):9.3%(21/226),3級(jí):7.5%(17/226);2與無(wú)CMBs組比較,CMBs組患者年齡大,高血壓病史、陳舊LI、既往腦卒中病史及口服抗血小板藥物的構(gòu)成比例高,高密度脂蛋白水平和WML評(píng)分高;而高脂血癥構(gòu)成比例、空腹血糖、總膽固醇、甘油三脂、極低密度脂蛋白水平均較低,具有統(tǒng)計(jì)學(xué)差異(P0.05);3多因素Logistic回歸分析顯示年齡(OR=1.063,95%CI:1.025~1.104,P0.01)、高血壓病史(OR=3.488,95%CI:1.113~10.927,P0.05)、WML(OR=1.282,95%CI:1.155~1.423,P0.01)及陳舊LI(OR=5.815,95%CI;1.539~21.973,P0.01)是AIS合并CMBs的獨(dú)立危險(xiǎn)因素;4spearman’s等級(jí)相關(guān)分析顯示,cmbs的分級(jí)和wml的分級(jí)(γs=0.354,p0.01)、陳舊li的分級(jí)(γs=0.394,p0.01)均呈正相關(guān);線性趨勢(shì)檢驗(yàn)分析顯示,cmbs的分級(jí)和wml的分級(jí)(χ~2_(線性)=35.07,p0.01;χ~2_(偏離線性)=14.07,p0.05)、陳舊li的分級(jí)(χ~2_(線性)=37.88,p0.01;χ~2_(偏離線性)=6.01,p0.05)均存在線性變化趨勢(shì)。第二部分腦微出血與急性缺血性卒中病因及病灶部位的相關(guān)性研究目的:探討cmbs與ais的病因及卒中病灶部位的相關(guān)性。方法:結(jié)合toast病因分型對(duì)第一部分中ais患者的病因進(jìn)行分類評(píng)估;結(jié)合患者癥狀及體征,利用mri不同序列對(duì)第一部分ais患者責(zé)任病灶的部位進(jìn)行評(píng)估。采用χ~2檢驗(yàn)、kruskal-wallish檢驗(yàn)等統(tǒng)計(jì)學(xué)方法評(píng)估cmbs與ais病因及卒中病灶部位的相關(guān)性。結(jié)果:1幕下、深部、腦葉及多部位卒中病灶組cmbs檢出率分別為51.1%(24/47)、45.1%(23/51)、49.2%(30/61)和50.7%(34/67),各組cmbs檢出率間比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(χ~2=0.472,p=0.925)。cmbs部位分布及卒中病灶部位分布在統(tǒng)計(jì)學(xué)上無(wú)關(guān)聯(lián)性(χ~2=8.514,p=0.519);2小動(dòng)脈閉塞型、大動(dòng)脈粥樣硬化型及其它類型ais中cmbs檢出率分別為59.3%(54/91)、40.0%(32/80)和45.5%(25/55),各組cmbs檢出率間比較,差異有統(tǒng)計(jì)學(xué)意義(χ~2=6.762,p0.05),兩兩比較顯示,小動(dòng)脈閉塞型與大動(dòng)脈粥樣硬化型cmbs檢出率比較差異有統(tǒng)計(jì)學(xué)意義(χ~2=6.370,p=0.0120.017),而小動(dòng)脈閉塞型、大動(dòng)脈粥樣硬化型分別與其它類型相比cmbs檢出率均無(wú)明顯統(tǒng)計(jì)學(xué)差異(χ~2=2.662,p=0.1030.017;χ~2=0.397,p=0.5280.017);3kruskal-wallish檢驗(yàn)發(fā)現(xiàn),小動(dòng)脈閉塞型、大動(dòng)脈粥樣硬化型和其它類型cmbs嚴(yán)重程度水平有統(tǒng)計(jì)學(xué)差異(χ~2=10.134,p=0.006),兩兩比較顯示,小動(dòng)脈閉塞型與大動(dòng)脈粥樣硬化型cmbs嚴(yán)重程度有統(tǒng)計(jì)學(xué)差異(χ~2=9.143,p=0.0020.017),而小動(dòng)脈閉塞型、大動(dòng)脈粥樣硬化型與其它類型相比cmbs嚴(yán)重程度水平無(wú)統(tǒng)計(jì)學(xué)差異(χ~2=4.318,p=0.0380.017;χ~2=0.405,p=0.5250.017)。第三部分腦微出血對(duì)急性缺血性卒中后認(rèn)知功能的影響目的:研究cmbs及其動(dòng)態(tài)變化和卒中后認(rèn)知障礙各認(rèn)知域損害的關(guān)系。方法:從第一部分cmbs組中隨機(jī)選取20例研究對(duì)象為實(shí)驗(yàn)組,第一部分無(wú)cmbs組中選取盡量多的研究對(duì)象為對(duì)照組(與實(shí)驗(yàn)組在年齡的分布、性別、教育年限、wml及陳舊li、新發(fā)卒中病灶的位置、ais的病因分型及既往重要病史方面匹配)。隨訪1年,使用規(guī)范的神經(jīng)心理學(xué)評(píng)估量表評(píng)估ais患者1年后不同認(rèn)知域的情況;復(fù)查磁敏感加權(quán)成像(susceptibilityweightedimaging,swi),評(píng)估cmbs變化的情況。并采用相應(yīng)的統(tǒng)計(jì)學(xué)方法研究cmbs及其動(dòng)態(tài)變化和卒中后認(rèn)知障礙的關(guān)系。結(jié)果:1對(duì)照組與實(shí)驗(yàn)組在年齡的分布、性別、教育年限、wml評(píng)分、陳舊li數(shù)目、高血壓病史、糖尿病病史、既往腦卒中病史、新發(fā)卒中病灶的位置及ais的病因分型方面相匹配(以上因素p0.5);2與對(duì)照組比較,1年后cmbs組tmtb用時(shí)延長(zhǎng),差異有統(tǒng)計(jì)學(xué)意義(p0.05);其余神經(jīng)心理學(xué)評(píng)估,包括mmse總分、moca總分、tmta耗時(shí)、scwta耗時(shí)、scwtb耗時(shí)、scwtc耗時(shí)、dsmt評(píng)分、dst評(píng)分、bd評(píng)分、vft評(píng)分,兩組比較均無(wú)明顯統(tǒng)計(jì)學(xué)意義(p0.05);3隨訪1年后,psci總體發(fā)生率為64%(32/50),不同認(rèn)知域的評(píng)估中,以執(zhí)行功能損害最為常見,為52%(26/50),其他認(rèn)知域也均有不同程度損害。與對(duì)照組比較,cmbs組執(zhí)行功能損害發(fā)生率高,差異有統(tǒng)計(jì)學(xué)意義(p0.05);其它認(rèn)知域的損害,包括總體認(rèn)知功能、注意力及信息處理速度、視空間能力、語(yǔ)言能力、記憶力,兩組比較均無(wú)明顯統(tǒng)計(jì)學(xué)意義(p0.05);4隨訪1年后執(zhí)行功能障礙的二元回歸分析結(jié)果顯示,年齡(or=1.11,95%ci:1.01~1.23)、基線期cmbs(or=3.5,95%ci:1.05~11.7)、及cmbs的動(dòng)態(tài)變化(or=3.8,95%ci:1.09~13.3)是卒中1年后執(zhí)行功能障礙發(fā)生的危險(xiǎn)因素(p0.05)。其它因素如教育程度、高血壓、whl及陳舊li與執(zhí)行功能障礙發(fā)生無(wú)明顯統(tǒng)計(jì)學(xué)意義(p0.05)。結(jié)論:1年齡、高血壓病史、wml及陳舊li是ais合并cmbs的獨(dú)立危險(xiǎn)因素。2 CMBs嚴(yán)重程度隨WML、陳舊LI的嚴(yán)重程度增加而增高。3 AIS患者CMBs檢出率與不同AIS病因有關(guān),在小動(dòng)脈閉塞型導(dǎo)致的AIS中更易被發(fā)現(xiàn)。4 CMBs嚴(yán)重程度與AIS病因有關(guān),在小動(dòng)脈閉塞型導(dǎo)致的AIS中CMBs的嚴(yán)重程度較高。5 PSCI發(fā)病率高,可伴有多個(gè)不同認(rèn)知域損害,其中以執(zhí)行功能損害最常見。6基線CMBs與AIS患者1年后執(zhí)行功能障礙的發(fā)生有關(guān)。7年齡、基線CMBs及CMBs的動(dòng)態(tài)變化可能是AIS后執(zhí)行功能障礙發(fā)生的危險(xiǎn)因素。
[Abstract]:Part 1 Analysis of risk factors for cerebral microhemorrhage in patients with acute ischemic stroke Objective: To explore the risk factors for cerebral microhemorrhage (cerebral microbleeds, CMBs) in patients with acute ischemic stroke (AIS). Methods: 226 consecutive AIS patients hospitalized in Hebei People's Hospital from January 2014 to December 2015 were collected. According to the presence of CMBs, it was divided into group CMBs (111 cases) and no CMBs group (115 cases). The demographic data and clinical data of the subjects were collected, and CMBs, white matter lesions (white matter lesions, WML) and old lacunar cerebral infarction were respectively carried out by different sequences of magnetic resonance imaging (MRI). T test, t test, chi square ~2 test, Logistic regression and other statistical methods were used to analyze the risk factors of CMBs in AIS patients. Results: 1 the total of 226 patients were enrolled in this study, and the overall incidence of CMBs was 49.1% (111/226), and the incidence of CMBs in the first AIS patients was 44% (66/150), and the incidence of CMBs was again in the AIS patient. To 59.2% (45/76), the distribution of CMBs in patients with AIS was: sub episodes 39.6% (44/111), deep 58.6% (65/111), 64.9% (72/111); CMBs severity distribution: 0 level: 50.9% (115/226), 1: 32.3% (73/226), 9.3% (21/226), 3 grade: 7.5% (17/226); 2 and CMBs group, age, hypertension, obsolete, past, past, past, past, past, past, past, past, past, past, past, past, past, past, past, past, and past The history of stroke and the proportion of oral antiplatelet drugs were high, high density lipoprotein level and WML score, and the proportion of hyperlipidemia, fasting blood glucose, total cholesterol, glycerin three fat, extremely low density lipoprotein level were lower, with statistical difference (P0.05); more than 3 factor Logistic regression analysis showed age (OR=1.063,95%CI:1.025~1 .104, P0.01), the history of hypertension (OR=3.488,95%CI:1.113~10.927, P0.05), WML (OR=1.282,95%CI:1.155~1.423, P0.01) and old LI (OR=5.815,95%CI; 1.539~21.973, P0.01) are independent risk factors for AIS together. 01) positive correlation; linear trend test analysis showed that CMBS classification and WML classification (x ~2_ (linear) =35.07, P0.01; X ~2_ (deviating linear) =14.07, P0.05), the classification of old Li (x ~2_ (linear) =37.88, P0.01; chi square (deviation linear), there are linear trends. The second part of cerebral microhemorrhage and acute ischemic stroke cause and cause Objective: To investigate the correlation between the causes of CMBS and AIS and the correlation between the location of the focus of the stroke. Methods: the cause of the AIS patients in the first part of the first part was classified and evaluated according to the toast etiological classification. Combined with the symptoms and signs of the patients, the location of the responsible focus of the first part of the patients with AIS was evaluated with the different sequence of MRI. The X ~2 was used. Test, kruskal-wallish test and other statistical methods to evaluate the correlation between the CMBS and the cause of AIS and the location of the stroke. Results: the detection rates of CMBS in the 1 episodes, the deep, lobar and multi site stroke group were 51.1% (24/47), 45.1% (23/51), 49.2% (30/61) and 50.7% (34/ 67), and the difference was not statistically significant (x ~2=0.472, P). =0.925) the distribution of.Cmbs and the location of the focus of the stroke were not statistically correlated (x ~2=8.514, p=0.519), and the detection rates of CMBS in 2 arterioles occlusion, large atherosclerotic and other types of AIS were 59.3% (54/91), 40% (32/80) and 45.5% (25/55), and the difference was statistically significant (chi ~2=6.762, P0.05), 22 comparison showed that there was significant difference in the detection rates of arteriosclerosis obliterans and large atherosclerotic CMBS (x ~2=6.370, p=0.0120.017), but there was no significant difference in CMBS detection rates of arteriosclerosis obliterans and large atherosclerotic types, respectively (x ~2=2.662, p=0.1030.017; Chi ~2=0.397, p=0.5280.017); 3kr Uskal-wallish test found that the severity of arterioles occlusion, large atherosclerotic and other types of CMBS were statistically different (x ~2=10.134, p=0.006). 22 compared with the severity of large atherosclerotic CMBS, there was a statistically difference (x ~2=9.143, p=0.0020.017), while the arterioles were obliterans and large movements. There is no significant difference in the level of CMBS severity compared with other types of atherosclerosis (x ~2=4.318, p=0.0380.017; Chi ~2=0.405, p=0.5250.017). The effect of third partial cerebral microhemorrhage on cognitive function after acute ischemic stroke: To study the relationship between CMBS and its dynamic changes and cognitive impairment of poststroke cognitive impairment. The first part of the CMBS group randomly selected 20 subjects as the experimental group. The first part of the group no CMBS group selected as many subjects as the control group (the distribution of age, sex, education years, WML and old Li, the location of the new stroke focus, the AIS etiological classification and the previous important history of medical history). A model of neuropsychological assessment was used to assess the situation in different cognitive domains of AIS patients after 1 years; to review the susceptibilityweightedimaging (SWI) and evaluate the changes in CMBS. The relationship between the dynamic changes of CMBS and the disturbance of recognition after stroke was studied by the corresponding statistical methods. Results: the 1 control group and the experimental group were in the year of the year. The distribution of age, sex, years of education, WML score, the number of old Li, the history of hypertension, the history of diabetes, the history of the brain stroke, the position of the new stroke and the etiology of AIS (above factors p0.5); 2 compared with the control group, the difference was statistically significant (P0.05) in the CMBS group after 1 years (P0.05); the rest of the neuropsychology was not statistically significant. Evaluation, including MMSE total score, MOCA total score, tmta time consumption, scwta time-consuming, scwtb time-consuming, scwtc time-consuming, DSmT score, DST score, BD score, VFT score, two groups were no significant statistical significance (P0.05); 3 after 1 years of follow-up, the overall incidence of PSCI was 64% (52%), the most common, 52% The cognitive domain also had different degrees of damage. Compared with the control group, the CMBS group performed a high incidence of functional impairment (P0.05), and the other cognitive impairment, including the overall cognitive function, attention and information processing speed, visual spatial ability, language ability and memory, had no significant statistical significance (P0.05), and 4 (P0.05). The two yuan regression analysis of executive dysfunction after 1 years showed that age (or=1.11,95%ci:1.01~1.23), baseline CMBS (or=3.5,95%ci:1.05~11.7), and CMBS dynamic changes (or=3.8,95%ci:1.09~13.3) were risk factors for executive dysfunction after 1 years of stroke (P0.05). Other factors such as education, hypertension, WHL, and obsolete Li and obsession There was no significant statistical significance (P0.05). Conclusion: 1 age, history of hypertension, WML and old Li are independent risk factors of AIS combined with CMBS, the severity of.2 CMBs is associated with WML, the increase in the severity of old LI and the increase in.3 AIS is associated with the different etiology, and is more likely to be found in the arteriolo occlusive type. The severity of.4 CMBs is associated with the cause of AIS. The severity of CMBs in AIS caused by arteriolo occlusive type is higher than that of.5 PSCI, which can be accompanied by multiple cognitive impairment. The most common.6 baseline, which is the most common.6 baseline for performing functional impairment, is related to the.7 age, baseline CMBs, and the dynamic change of AIS after 1 years. Chemotherapy may be a risk factor for the occurrence of executive dysfunction after AIS.
【學(xué)位授予單位】：河北醫(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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