【作者】 金凤艳；

【导师】 张哲成；

【作者基本信息】 天津医科大学 ， 神经病学， 2011， 硕士

【摘要】 目前对缺血性卒中的防治进行了许多研究,其中绝大多数对于干预效果的关注焦点集中在卒中的复发或躯体功能障碍的严重程度上,而对于干预对卒中后认知功能状态和精神心理状态的影响研究不多。抑郁障碍是缺血性脑损害或局灶性脑血管病变的直接后果,卒中后功能障碍越重抑郁障碍的可能性越大,抑郁障碍直接影响脑血管病的发生、发展和患者功能康复。近年来,高同型半胱氨酸血症(hyper-homocysteinemia, Hey)作为一个脑血管性病变的高危因素受到关注。Hcy与CVD存在着密切关系,目前大量的研究工作己证实Hcy是导致CVD发生的独立危险因素。脑卒中后发生PSD临床较多见。本研究旨在探讨B族维生素是否降低Hhcy对缺血性脑卒引发的卒中后抑郁(Post Stroke Depression,PSD)有防治作用。目的本研究对缺血性卒中患者Hhcy进行干预,目的在于评价卒中后不同时间患者卒中后抑郁与血浆Hcy水平的关系,从而了解降低血浆Hcy水平是否有助于缺血性卒中患者卒中后抑郁的改善。方法1.采用前瞻性、平行开放对照试验方法,对2006年8月至2007年10月期间来源于天津市第三中心医院神经内科住院或门急诊就诊的新发(病程=1周)脑梗死1000例患者进行了为期2年的观察。2.将1000例Hhcy脑梗死患者根据年龄、性别及影响卒中的主要危险因素匹配分成干预组(treatment group, T组)和对照组(control group, C组1,每组各500例。干预组患者在常规二级预防基础上加用复合B族维生素。对照组仅采用除B族维生素外的常规治疗,两组患者平行定期随访观察。3.记录患者入组时、干预后3个月、12个月和24个月的空腹血浆tHcy水平并于患者入组时、干预后1/2个月、3个月、6个月、12个月、18个月和24个月分别采用HAMD评分评估卒中后抑郁的发生情况;HAMD>7分病例为可能有抑郁,HAMD=24分病例为严重抑郁。结果1.干预组与对照组基线时血浆tHcy水平差异无统计学意义(p>0.05)。2.复合B族维生素干预3个月后,干预组血浆tHcy,与对照组比较差异有统计学意义(p<0.05),干预至24个月时,干预组血浆tHcy水平,与对照组比较差异有统计学意义(p<0.05)。3.两组基线时HAMD评分干预组和对照组,差异无统计学意义(p>0.05)。4.随访1/2个月、3个月、6个月时干预组与对照组HAMD评分两组间差异均无统计学意义(p>0.05)。随访12个月、18个月、24个月时,干预组HAMD评分低于对照组,两组间差异有统计学意义(p<0.05)。干预组患者随访全程中曾出现过HAMD>7分的发生率,两组间差异无统计学意义(p>0.05)。干预组患者随访24个月时HAMD>7分的发生率,两组间比较差异无统计学意义(p>0.05)。随访6个月时干预组新发HAMD>7分病例,两组间差异无统计学意义(p<0.05);余各随访时间点两组间差异均无统计学意义(p>0.05)。随访3个月、12个月、18个月时干预组HAMD>7分病例的发生低于对照组,两组间比较差异有统计学意义(p<0.05)；其余随访时间点两组HAMD>7分病例的发生组间比较差异均无统计学意义(p>0.05)。随访3个月时干预组严重抑郁病例(HAMD=24分)的发生率高于对照组,两组间比较差异有统计学意义(p<0.05);其余随访时间点两组严重抑郁病(?)(?)(HAMD=24分)的发生率组间比较差异均无统计学意义(p>0.05)。结论患者复合B族维生素干预3个月后,干预组血浆tHcy水平较基线时下降2.88μmol/L,下降幅度为14.7%,与对照组比较差异有统计学意义,干预12个月至24个月时,干预组血浆tHcy水平有进一步下降趋势。提示对Hhcy的脑卒中患者进行复合B族维生素干预,在用药后3个月即可显著降低血浆tHcy水平,而且复合B族维生素在2年以内能够持续有效地控制血浆tHcy水平。患者的卒中后抑郁情况以HAMD评分评价,随访12-24个月时,干预组HA评分低于对照组,两组间差异有统计学意义。随访全程中和随访终末时HAMD>7的患者例数两组间比较差异均无统计学意义。提示复合B族维生素干预在有效降低Hhcy的脑卒中患者血浆tHcy水平的基础上,可能有助于减轻脑卒中后1至2年的抑郁程度,但对抑郁的发生并无影响。更多还原

【Abstract】 Objectives This study to ischemic stroke patients with Hhcy intervene, aimed at assessing different time after stroke patients with depression and plasma after stroke Hcy level relations, so as to understand the lowering of plasma Hcy level are beneficial to ischemic stroke patients after stroke depression improved.Methods1.Adopt forward-looking and parallel controlled trials method of open in August 2006-2007 October period from tianjin of hospital of the 3rd center nerve medicine hospital or clinic of this new hair more than 1 week (course) cerebral infarction 1,000 patients for 2 years of observation.2.1000 cases of patients with cerebral infarction Hhcy according to age, gender and affecting stroke risk factors of matching into interention group (treatment group, and group T) and the control group (control group, the group C), each group every 500 cases. Intervention group in patients with secondary prevention based on conventional add a composite B vitamins. The control group only used except B vitamins outside the routine therapy, two groups of patients with parallel regular follow-up.3.Record patients into group, intervention after 3 months,12 and 24 months fasting plasma tHcy level and in patients into group, intervention after 1/2 months,3 months, 6 months,12 months,18 months and twenty-four months respectively by means HAMD score evaluation of depression after stroke occur, depression in decline. HAMD> 7 points for may have depression cases, HAMD> 24 points cases of severe depression in.Results1.Intervention ergometry baseline plasma tHcy level, difference was statistically significant (p> 0.05).2.Composite B vitamins intervention after 3 months, the intervention group plasma tHcy, compared with controls difference was statistically significant (p< 0.05). Intervention to 24 months, intervention group plasma levels for tHcy, compared with controls difference was statistically significant (p< 0.05). 3.Two groups at baseline HAMD score intervention group and measured group no statistically significant difference (p> 0.05).4.Follow-up 1/2 months,3 months and 6 months intervention ergometry HAMD score difference between the two groups were not statistically significant (p> 0.05). Follow-up of 12 months,18 months,24 months, intervention group HAMD score below the control group, the difference between the two groups was statistically significant (p< 0.05). Patients were followed up for the whole of intervention group appeared in the incidence of HAMD> 7 points, the difference between the two groups was statistically significant (p> 0.05). Intervention group patients were followed up for 24 months and the incidence of HAMD> 7 points, comparative differences between the two groups was statistically significant (p> 0.05). Follow-up of 6 months intervention group new hair HAMD> 7 points cases, the difference between the two groups have statistically significant (p< 0.05). Over the follow-up time point difference between the two groups were not statistically significant (p> 0.05). Follow-up of 3 months,12 months,18 months intervention group HAMD> 7 points cases occur lower than those of the control group, compared between the two groups was statistically significant difference (p< 0.05). The remaining follow-up time point two groups HAMD> 7 points cases occur between groups comparative differences are not statistically significant (p> 0.05). Follow-up of 3 months intervention group severe depression cases (HAMD=24score) incidence, than in control group, comparative differences between the two groups was statistically significant (p< 0.05). The remaining follow-up time point two groups of severe depression cases (HAMD=24score) the incidence of comparative differences between groups were not statistically significant (p> 0.05).Conclusions Composite B vitamins intervention after 3 months, the intervention group tHcy level is relatively baseline plasma dropped, compared with controls, the difference was statistically significant intervention 12 to 24 months, intervention group plasma tHcy level has further decline. Clew to Hhcy of patients with cerebral apoplexy composite B vitamins intervention, in 3 months after drug can significantly reduced plasma tHcy levels and composite B vitamins within two years, can continue to effectively control plasma tHcy level. Patients with depression after stroke HAMD score index, follow-up of 12-24 months, intervention group HAMD score below the control group, the difference between the two groups was statistically significant. Follow-up the whole and the time of the latest follow-up HAMD> 7 patients,it difference were compared between the two groups was statistically significant. Clew composite B vitamins intervention in effectively reduce the Hhcy in patients with cerebral apoplexy plasma tHcy level of basic, may help to alleviate after stroke 1 to 2 years, but levels of depression on depression occurs and without influence.更多还原