中风病中脏腑早期症状及脑电监测与近期预后的研究

【作者】 张华；

【导师】 孙塑伦；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2009， 博士

【摘要】 两千多年前,古人就认识到脑的重要作用,但两千多年来中医关于脑的理论发展缓慢,明清时期中医对脑的认识逐渐得到重视。近年来,中医对于脑的认识和研究逐渐深入,取得了一些新的进展。中风病是常见的脑病,中风病的研究成果发展和丰富了中医脑病理论,推动了中医对脑功能、脑病的病因病机证治理论的研究。1目的整理中医关于脑的主要理论;分析中风病中脏腑的早期症状特点及近期预后;探讨中风病中脏腑的脑电特点及其对近期预后的作用。2方法2.1理论整理整理《黄帝内经》中关于脑的论述,查阅古籍及现代文献,总结归纳其中关于脑的论述,总结中医对中风病认识的发展。2.2临床症状研究选取973计划课题“缺血性中风病证结合的诊断标准与疗效评价体系研究”纳入临床研究病例中发病7天内出现中脏腑的患者及发病即为中脏腑者,提取其入院当天的症状及NIHSS量表评分,对于7天内出现中脏腑者,提取其中脏腑出现当天的症状及发病3天或7天的NIHSS量表评分中较高者,所有患者提取发病28天NIHSS量表评分,根据死亡或NIHSS评分好转18%为分界将患者分为3组:结局较好组、结局差组和死亡组。对患者症状进行因子分析,以结局为因变量对症状进行logistic回归分析。2.3脑电监测纳入发病48小时内的中脏腑患者,发病72小时内开始进行脑电监测,持续监测24小时。对脑电结果按Synek分级标准分级,按生存与死亡将患者分组,对脑电分级作秩和检验,探讨两组Synek分级的差异。运用数学方法对脑电信号进行波幅和频率特征提取,将患者脑电特征与一组正常人的脑电特征进行比较,探索患者与正常人、生存组与死亡组脑电的差异。3结果3.1理论整理《内经》中已有丰富的脑理论,只是较为分散,一直未被后世医家重视,至明清以后脑的地位逐渐提升,尤其是西医学引进以后,脑的理论更加丰富。中医对中风病的认识经历外风说到内风说的过程,最终在近几十年公认其病位在脑,是脑系疾病中的一种,从而更有利于中风病的研究。3.2缺血性中风中脏腑的早期症状分析因子分析共得出12个因子,12个因子中包括了痰、火、风、气虚、阴虚5个证候要素,风证要素涉及最多,气虚和阴虚所占比重也较大。Logistic回归分析显示神志、两颧潮红、瞳孔不等、呼吸急促、呼吸气粗、发热、自汗、便于、口臭与结局相关。3.3脑电监测结果共纳入患者22例,生存组和死亡组患者无1例正常脑电图表现,特殊类型脑电有1例纺锤波昏迷,3例α、θ昏迷,1例出现棘慢复合波。患者脑电大部分表现为无为主节律,中高幅θ、δ波增多的弥散性慢活动。秩和检验生存组和死亡组的脑电分级差异有显著性。脑电特征提取所有患者均与正常人有差异,死亡组较生存组差异更大。4结论缺血性中风中脏腑的早期症状以风证表现为主,涉及中风病6个证候要素风、火、痰、瘀、气虚、阴虚中除瘀以外的5个。其神志差、两颧潮红、瞳孔不等、呼吸急促、发热预示差的近期预后,呼吸气粗、口臭、自汗、便干提示近期预后较好。脑电监测对于中脏腑的近期预后判断有一定的辅助作用,脑电分级分析和用数学方法提取特征分析都有意义,数学方法尚有待进一步加大样本量证实。长程监测过程中脑电的变化对预后也有意义,需要进一步的定量分析。更多还原

【Abstract】 Chinese people realized the important role of brain before 2000 years,but the theory of brain developed slowly untile Ming and Qing dynasty it’s importance was attached little by little.The recognition and researches of brain in Chinese Medicine are penetrating deeply and have got some new progressions for the past few years.Apoplexy is one of the common brain diseases.Achievements of researches in Chinese Medicine about apoplexy enriched the theories of brain,impulsed researches in function of brain,causes and pathogenesis of brain diseases.1 ObjectiveSum up the main theories of brain in Chinese Medicine.Analyze the feature of early symptoms and short-term prognosis in apoplexy involving the fu or zang -organs.Research in the electroencephalogram（EEG） characteristic of apoplexy involving the fu or zang-organs and it’s short-term prognosis significance.2 Methods2.1 Theories summarySum up the theories in Huangdi Neijing,refer to antiquity books and contemporary literatures to sum up the discussions about brain and the development of apoplexy recognition.2.2 Clinical symptom analysisSelect the clinical data of National Point Foundation Research Development Plan（973 plan） ’Ischemic Stroke Diagnosis Combining Symptoms and Signs of Disease and Effect Evaluation System Research’ of patients in apoplexy involving the fu or zang-organs in 7 days afer apoplexy onset.For patients of initial appear apoplexy involving the fu or zang-organs collect the symptoms and score of NIHSS the day admission,for patients who were appear apoplexy involving the fu-organs or zang-organs in 7 days of apoplexy involving meridians onset collect the symptoms the day apoplexy involving the fu-organs or zang-organs onset and the higher score of NIHSS.Collect every patients’ score of NIHSS of 28^th day after apoplexy onset.Divide the patients into 3 groups according died or NIHSS score improve 18%:good outcome,poor outcome and died groups.Use factor analysis and logistic regression analysis to analyse the data.2.3 Electroencephalography monitoringInclude patients of apoplexy involving the fu or zang-organs in 48h of symptoms onset and start 24h electroencephalography monitoring befor symptoms onset.Grade the electroencephalogram according Synek standard and use rank sum test to approach the contrast of electroencephalogram between died and survived groups.Use mathematical technique to extract the feature of amplitude and frequency of wave and compare the difference between normal people and survived and died groups.3 Results3.1 Theory summaryWe could make out that the theories about brain in Huangdi Neijing are very aplenty though the discussion is scattered so the latecomer didn’t pay attention to it.Till Ming and Qing dynasty especially after the introduction of Western medicine the position of brain theories were promoted and the theories became more abundant.The knowledge of apoplexy in Chinese Medicine experienced a procedure from exogenous pathogenic wind to endogenous wind theory,and in several decades it’s generally accepted that the location of apoplexy is in brain. Apoplexy is one of the brain diseases.These knowledges profit the research of apoplexy.3.2 Symptoms analyse of ischemic stroke involving the fu or zang-organsThere are 12 factors obtained through factor analysis include 5 syndrome essential factors phlegm,fire,wind,deficiency of qi and deficiency of yin.Wind factor is the most important one involved and the factor of deficiency of qi and deficiency of yin also account large proportion.Logistic regression analysis discovered that the symptoms correlate with outcome are consciousness,flushed cheeks,anisocoria,accelerated breathing,gruff breathing,fever,spontaneous perspiration,dry stool and foul breath.3 Electroencephalography monitoring22 patients were included and no patient’s electroencephalogram was normal. Special types of electroencephalogram include 1 spindle coma and 3α,θcoma, and 1 patient’s electroencephalogram appeared spike and slow wave complex. Most electroencephalogram appeared no main rhythm,middle or high amplitudeθ,δwave diffusibility.Rank sum test discover that grades of electroencephalogram are different in survived and died groups.The feature extractioned display that all patients were different from normal people,the died group were more different.4 ConclusionThe principal early symptoms of ischemic stroke involving the fu or zang-organs are wind syndrome appearance and involve in 5 of the 6 syndrome essential factors phlegm,fire,wind,deficiency of qi and deficiency of yin except blood stasis.Poor consciousness,flushed cheeks,anisocoria,accelerated breathing and fever indicate poor short-term prognosis while gruff breathing,foul breath, spontaneous perspiration,dry stool indicate good short-term prognosis.Electroencephalography monitoring can help to define short-term prognosis in apoplexy involving the fu or zang-organs by grade the electroencephalogram or mathematical technique.The mathematical technique remain to be confirmed by large sample trail.The changes within long time monitoring can also help judge prognosis and quantitative analysis should be made in the future.更多还原