本文選題：缺血性卒中　切入點：睡眠呼吸暫停低通氣綜合征　出處：《廣州中醫(yī)藥大學》2017年碩士論文

【摘要】：研究目的:課題通過研究缺血性卒中合并與不合并SAHS的患者在證候分布上的差異,尋找缺血性卒中合并SAHS患者的證候分布特點。為進一步分析缺血性卒中合并SAHS的中醫(yī)病機及中藥治療方法提供依據,并有助于進一步挖掘SAHS的中醫(yī)病機內涵,拓寬中醫(yī)藥在現代醫(yī)學領域的研究范圍。研究方法:1.收集廣州中醫(yī)藥大學第一附屬醫(yī)院腦病科住院的缺血性卒中患者33例,其中男性26例,女性7例,所有患者均已完成頭顱CT或MRI檢查(CT或MRI)并發(fā)現明確的腦缺血灶,其中有24為前循環(huán)梗死,2例為后循環(huán)梗死,7例前后循環(huán)均有梗死。全部缺血性卒中患者中有6例為無癥狀性梗死。有顯著神經系統(tǒng)功能缺損的病史缺血性卒中患者,根據梗塞發(fā)生時間分為急性期13例,恢復期20例,卒中發(fā)生兩周以后后為恢復期;根據梗塞發(fā)生次數分為首發(fā)缺血性卒中14例及再發(fā)缺血性卒中13例。其中再發(fā)缺血性卒中患者包括有兩次及兩次以上明確卒中病史的患者以及首次出現明確卒中癥狀但在影像學檢查時發(fā)現有陳舊性梗死病灶的患者。2.所有缺血性卒中患者進行多導睡眠監(jiān)測,檢測通道主要包括腦電圖(Electroencephalogram,EEG),鼻氣流,胸腹運動,血氧飽和度,雙眼眼動電極、下頜肌電、肢體運動以及視頻檢測。通過EEG配合R0C、下頜肌電、肢體運動以及視頻檢測分析患者睡眠及覺醒情況,在結合鼻氣流及血氧飽和度檢測分析計算患者的呼吸暫停低通氣指數(apnea-hypopneaindex,AHI),AHI指數≥5或夜間7小時睡眠呼吸暫停低通氣總數大于30者診斷為SAHS。所有患者在在監(jiān)測前一天內不能飲酒、濃茶及咖啡,不能臨時使用安眠藥物或神經精神類藥物,長期服用上述藥物的患者按照日常劑量繼續(xù)服用。3.在完成PSG檢查分析后,根據是否合并SAHS將缺血性卒中患者分為兩組,分別是缺血性卒中不合并SAHS組和缺血性卒中合并SAHS組。收集兩組患者患者性別、年齡、體重指數等一般情況。對兩組患者進行美國國立衛(wèi)生研究院卒中量表(National Institute of Health stroke scale,NISHH)評分和中風病辨證診斷標準評分。中醫(yī)辨證標準根據1994年《中風病辨證診斷辨證診斷標準》,分為風、火、痰、瘀血、氣虛及陰虛陽亢6種基本證候要素。凡某一項證候要素評分大于或等于7分者認為存在這一證候。研究結果:1.多導睡眠監(jiān)測結果在監(jiān)測的所有33名患者中有17名(51%)存在SAHS,23名(70%)存在夜間低氧血癥。其中輕度的SAHS 11名,中度SAHS 3名,重度SAHS 3名;輕度低氧血癥17名,中度低氧血癥4名,重度低氧血癥2名,SAHS及夜間低氧血癥均以輕度為主。將患者根據有無SAHS分為缺血性卒中伴SAHS組及缺血性卒中不伴SAHS組,兩組人數分別為16人和17人。2.兩組患者性別、年齡分布情況比較兩組患者在性別構成上無明顯差異。收集患者中最年輕的為39歲,最年長者為78歲。缺血性卒中合并SAHS的人數隨年齡增長而逐漸增多,對于大于49歲的患者而言,兩者之間存在有顯著的線性關系(Y=0.3x-12.7,v=1,R=1),缺血性卒中不合并SAHS組則未見顯著相關性。兩組患者年齡均值無顯著差異。3.兩組患者卒中相關情況比較合并SAHS者所占無癥狀卒中、首發(fā)卒中和再發(fā)卒中比例分別為33.3%、50%及61.5%,兩組患者在無癥狀卒中與有癥狀卒中、首發(fā)卒中與再發(fā)卒中的分布情況均無顯著差異。卒中分期方面,合并SAHS的患者占急性期患者總數的46.2%,恢復期患者總數55%,兩組在急性期及恢復期卒中患者人數分布上無顯著差異。卒中部位方面,兩組患者均分別有12人為前循環(huán),1人為后循環(huán),合并SAHS組與不合并SAHS組前+后循環(huán)人數分別為4人及3人,兩組患者人數在各卒中部位中均分布平均。卒中嚴重程度方面,缺血性卒中合并SAHS組NHISS評分均值為2.8±3.49,缺血性卒中不合并SAHS組NHISS評分均值為1.8 ±1.87,兩組未見顯著差異。4.兩組患者各中醫(yī)證素分布情況比較受檢者中排名前五的證候類型依次為氣虛夾痰證(7例)、風證(5例)、風痰證(4例)、痰證(3例)、痰濁瘀血證(3例)。缺血性卒中合并SAHS組主要分布在氣虛夾痰證(85.7%),風痰證(75.0%)以及痰證(66.7%)中;缺血性卒中不合并SAHS組主要分布在風證(100%)及痰證瘀血證(100%)中。各證候要素的分布方面,兩組患者在風證(P=1.00)、火證(P=0.65)、血瘀證(P=0.69)以及陰虛陽亢證(P=0.48)上沒有發(fā)現顯著差異,在氣虛證(P=0.03)及痰證(P=0.00)的分布上具有顯著差異。所有(100%)合并SAHS的患者均有痰證,而不合并SAHS組患者中僅44.0%的患者有痰證。52.9%的合并SAHS患者存在氣虛證,而僅12.5%的缺血性卒中不合并SAHS患者存在氣虛證。缺血性卒中合并SAHS的患者氣虛證及痰濕證的發(fā)病率明顯高于不合并SAHS的患者。5.缺血性卒中合并SAHS的組內分析不同的缺血性卒中嚴重程度(輕微、輕度、中度)中均以輕度SAHS為主,NHISS與卒中程度間無明顯線性關系。急性期與恢復期患者均以輕度SAHS為主,別為66.7%和58.3%。兩者AHI值無顯著差異。無癥狀性卒中、首發(fā)卒中及再發(fā)卒中患者均以輕度SAHS為主,AHI值無明顯差異。前循環(huán)及前+后循環(huán)患者均以輕度SAHS為主,構成比分別為9 0%與5 0%,兩者AHI值無顯著差異。痰證不兼氣虛的患者中輕度SAHS占87.5%,重度SAHS占12.5%,無中度SAHS;痰證兼有氣虛證的患者中輕度SAHS占44.4%,中度SAHS占33.3%,重度SAHS占22.2%。兩類患者的AHI均值分別為13.56土4.83與21.20±14.62,兩者間不具有顯著差異(P=0.28)。研究結論:1.研究未發(fā)現性別與缺血性卒中患者是否合并SAHS的相關性。對大于49歲的患者而言,缺血性卒中患者合并SAHS的患者人數患病年齡見存在顯著線性關系,提示缺血性卒中患者發(fā)生SAHS的概率會隨著年齡增長而增加。2.研究未發(fā)現缺血性卒中是否合并SAHS以及SAHS嚴重程度與卒中次數、部位、分析及NHISS評分的相關性。3.缺血性卒中合并SAHS患者痰證及氣虛證明顯增多。兼有氣虛證的痰證患者可能不兼有氣虛證的痰證患者SAHS更加嚴重。研究中合并SAHS患者均具有痰證,過半患者(52.9%)有氣虛證,以及氣虛兼有痰證的患者其中重度SAHS比例及AHI均值高于痰證不兼有氣虛的患者。從這一結果來看,痰證或許可視為SAHS發(fā)生普遍的病理基礎,而氣虛則可被視作痰邪內伏日久,損傷陽氣所致。
[Abstract]:Objective: by study of ischemic stroke patients with and without SAHS in the syndrome distribution of the differences for the characteristics of syndrome distribution of patients with ischemic stroke complicated with SAHS. To provide the basis for Chinese medicine treatment machine and method for further analysis of ischemic stroke in patients with SAHS, and contribute to the pathogenesis of the connotation of further mining SAHS, to broaden the scope of study of traditional Chinese medicine in the field of modern medicine. Methods: 1. patients with ischemic stroke were collected in Guangzhou University of Chinese Medicine Department of the First Affiliated Hospital of encephalopathy in 33 cases, including 26 cases of male, female 7 cases, all patients were completed by CT or MRI (CT or MRI) and found that the focal ischemic brain clear. Of which 24 were anterior circulation infarction and 2 patients with posterior circulation infarction, 7 cases of anterior and posterior circulation infarction. All patients had ischemic stroke in 6 cases of asymptomatic infarction. Significant neurological function The defect of ischemic stroke patients, according to the time of occurrence of infarction was acute in 13 cases, 20 cases of convalescent stroke, two weeks after the recovery period; according to the number of infarction divided into initial ischemic stroke and 14 cases of recurrent ischemic stroke in 13 cases. The patients with recurrent ischemic stroke include two times and more than two patients with clear history of stroke and stroke symptoms first appeared clear but in radiographic inspection found that chronic infarction lesions in patients with.2. all ischemic stroke patients underwent polysomnography, including EEG detection channels (Electroencephalogram, EEG), nasal airflow, abdominal movement, oxygen saturation, binocular eye electrode. Mandibular muscle, limb movement and video detection. By EEG with R0C, mandibular muscle, limb movement and video detection and analysis of patients with sleep and awakening, in combination of nasal airflow and blood Analysis of patients with apnea hypopnea index oxygen saturation detection (apnea-hypopneaindex, AHI), AHI index is more than 5 or 7 hours a night sleep apnea hypopnea total more than 30 of all patients diagnosed with SAHS. in drinking not in a day before the monitoring, tea and coffee, not the temporary use of hypnotic drugs or psychotropic drug and nerve long-term use of the drug, the patients according to daily dose continued to take.3. in the examination of PSG analysis, with SAHS in patients with ischemic stroke were divided into two groups, respectively, ischemic stroke and ischemic stroke patients without SAHS group with SAHS group. The two groups were collected in patients with gender, age, body mass index of the general case. Two groups of the National Institutes of Health Stroke Scale (National Institute of Health stroke scale, NISHH) score and the diagnostic standard of TCM score. According to the 1994 differentiation standard < diagnostic diagnosis criteria >, divided into the wind, fire, phlegm, blood stasis, Qi deficiency and yin deficiency and yang hyperactivity syndrome. 6 basic elements where a syndrome factor score greater than or equal to 7 points that the existence of this syndrome. Results: 1. polysomnography the monitoring results in all 33 patients monitored in 17 patients (51%) SAHS, 23 (70%) of nocturnal hypoxemia. Among them 11 mild SAHS, moderate SAHS 3, SAHS 3 were severe; mild hypoxemia 17, moderate hypoxemia 4, severe hypoxemia in 2 SAHS, and nocturnal hypoxemia were mainly mild. The patients according to whether the SAHS is divided into SAHS group and ischemic stroke patients with ischemic stroke without SAHS group, the number of the two groups were 16 and 17.2. patients in the two groups of gender, age distribution were compared between the two groups in gender has no significant difference. Most patients were collected Young is 39 years old, the oldest is 78 years old. The number of ischemic stroke patients with SAHS with age gradually increased, for more than 49 year old patients, there is a significant linear relationship exists between the two (Y=0.3x-12.7, v=1, R=1), ischemic stroke patients without SAHS group did not see significant correlation with comparison. There was no significant difference between the two groups of patients with mean age of.3. patients in the two groups of SAHS stroke related accounts for no symptoms of stroke, stroke and initial stroke rates were 33.3%, 50% and 61.5%, two patients without symptoms of stroke and stroke symptoms, there were no significant differences between the first stroke and the stroke of the distribution. Stroke staging in patients with SAHS, accounting for 46.2% of the patients with acute period, recovery period a total of 55% patients, two groups in the acute period and recovery period no significant difference in the distribution of the number of patients with stroke. Stroke, two groups of patients respectively. 鏈，

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