【作者】 陆卉；

【导师】 王新平； 李效兰；

【作者基本信息】 天津医科大学 ， 神经病学， 2008， 硕士

【摘要】 目的:进展性缺血性卒中是指发病一周内神经功能缺损症状逐渐进展或呈阶梯式加重的缺血性卒中。它是多种原因、多种机制共同参与的复杂状态。其致死率和远期致残率均较高。早期预测其神经功能恶化,弄清其发病的机制是成功治疗的关键。本研究通过对进展性缺血性卒中患者与非进展性缺血性卒中患者的比较,探讨有哪些临床指标可成为进展性缺血性卒中的危险因素,对其发生有一定的预测意义。对象和方法:将我院2007年6月至2007年11月收治的103例发病后24h内入院的脑梗死患者根据发病一周内NIHSS评分是否增加3分或以上分为两组:进展组评分增加3分或以上,共53例,其余为非进展组,共50例。所有患者入院后进行NIHSS评分,询问高血压病史、糖尿病病史、冠心病病史、心房纤颤病史、脑血管病病史以及吸烟饮酒史的有无,并进行白细胞计数(WBC),中性粒细胞百分比、淋巴细胞百分比、血小板计数(PLT)、平均血小板体积(MPV)、血小板分布宽度(PDW)、凝血酶原时间INR(PT INR)、活化的部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、凝血酶时间(TT)、血钾、肌酐、空腹血糖、甘油三酯(TG)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、载脂蛋白A(ApoA)、载脂蛋白B(ApoB)、ApoB/ApoA、血沉(ESR)、血小板聚集率、同型半胱氨酸(Hcy)及超敏C反应蛋白(hs-CRP)的血液检测;同时进行经颅多普勒(TCD)、颈动脉彩色多普勒超声以及脑部磁共振成像(MRI)或计算机体层摄影(CT)的检查。另外,进展组病情加重后再次行脑部CT或MRI检查及NIHSS评分。对两组的上述研究因素进行统计分析。结果:1单因素分析显示:1.1既往病史:既往有脑血管病史的患者百分比在两组之间有显著差异(P＜0.05)。其它如高血压病史、冠心病史、心房纤颤病史、糖尿病史以及吸烟饮酒史两组之间统计分析均无显著差异。进展组53例患者中既往有脑血管病史者16例(占30.19%);非进展组50例患者中中既往有脑血管病史者7例(占14.00%)。1.2神经功能评分:入院时的NIHSS评分在两组之间有显著差异(P＜0.05)。进展组患者入院时的NIHSS评分平均为12.26±3.80;非进展组患者的NIHSS评分平均为5.64±5.30。1.3血液化验检查:(1)卒中早期空腹血糖增高率在两组之间有显著差异(P＜0.05)。进展组空腹血糖平均值为(6.65±3.49)mmol/L,增高百分率为39.63%;非进展组空腹血糖平均值为(5.95±2.29)mmol/L,增高百分率为26.00%。(2)血脂中总胆固醇、载脂蛋白B的水平和增高率以及高密度脂蛋白胆固醇的水平在两组之间有显著差异(P＜0.05),其它血脂指标在两组之间统计学差异不显著。进展组总胆固醇(TC)平均值为(5.05±0.97)mmol/L,增高率为18.87%,均高于非进展组总胆固醇(TC)的平均值(4.69±0.69)mmol/L和增高率0.00%;进展组载脂蛋白B(ApoB)的平均值为(0.99±0.24)g/L,增高率为37.74%,均高于非进展组ApoB的平均值(0.92±0.16)g/L和增高率20.00%;进展组的高密度脂蛋白胆固醇(HDL-C)的平均值(1.06±0.26)mmol/L,低于非进展组的平均值(0.96±0.24)mmol/L。(3)同型半胱氨酸水平和增高率在两组之间有显著差异(P＜0.05)。进展组同型半胱氨酸(Hcy)平均值(36.66±27.51)μmol/L,按照Hcy水平高于15μmol/L为高同型半胱氨酸血症的诊断标准,有84.91%的患者增高;而非进展组同型半胱氨酸平均值(17.13±10.32)μmol/L,有48.00%的患者增高。(4)超敏C反应蛋白的增高率在两组之间有显著差异(P＜0.05)。进展组有50.94%的患者超敏C反应蛋白(hs-CRP)增高;而非进展组有32.00%的患者hs-CRP增高。1.4颈动脉粥样硬化斑块的发生率和不稳定斑块的发生率在两组之间有显著差异(P＜0.05)。进展组患者中颈动脉粥样硬化斑块的发生率为75.47%,非进展组患者中颈动脉粥样硬化斑块的发生率为58.00%;进展组不稳定斑块的发生率为46.46%,非进展组不稳定斑块的发生率为31.94%。2进展性缺血性卒中危险因素的条件Logistic回归分析显示:高NIHSS评分、卒中早期空腹血糖增高、高甘油三酯血症和高同型半胱氨酸血症是进展性缺血性卒中的危险因素。3高同型半胱氨酸血症与进展性缺血性卒中的研究因素之间的Spearman等级相关分析显示:高血压病史、糖尿病史、脑血管病史、NIHSS评分、颈动脉粥样硬化程度、肌酐和超敏C反应蛋白水平与同型半胱氨酸水平增高呈正相关关系。结论:1 NIHSS评分、卒中早期空腹血糖增高、高甘油三酯血症和高同型半胱氨酸血症是进展性缺血性卒中的危险因素。2高同型半胱氨酸血症是进展性缺血性卒中的独立危险因素。3高血压病史、糖尿病史、脑血管病史、NIHSS评分、颈动脉粥样硬化程度、肌酐和超敏C反应蛋白水平与高同型半胱氨酸血症正相关。更多还原

【Abstract】 Objective:Neurological deterioration that appears within the first week following the onset of stroke is progressive ischemic stroke(PIS).It is a complex state involving many causes and mechanisms.PIS is associated with increased mortality and morbidity.Early prediction of neurological deterioration,identification of the responsible mechanisms is the basis of an effective therapy.The aim of the study is to investigate whether the level of Homocysteine(hcy)can predict PIS by comparing the PIS group with the non-progressive ischemic stroke group(NPIS)and mechanism.Methods:A total of 103 patients who presented within the 24 hours after the onset of ischemic stroke were involved.All the patients was scored when they presented and when the state of an illness changed within the first week.PIS was diagnosed when the increase of the patient’s NIHSS exceeded 2 scores,the others diagnosed NPIS.The PIS group involves 53 patients,the NPIS group involves 50 patients.All the patients were recorded the history of hypertension,diabetes,coronary heart disease,atrial fibrillation,cerebrovascular disease,smoke and drink,and detected white blood cell count(WBC),neutrophils percentage,lymphocyte percentage, platelet count(PLT),platelet distribution width(PDW),mean platelet volume(MPV), prothrombin time INR(PT INR),activated partial thromboplastin time(APTT), Fibrinogen(FIB),thrombin time(TT),Serum potassium,Creatinine,fasting blood glucose,Triglycerides(TG),total cholesterol(TC),high density lipoprotein cholesterol(HDL-C),low density lipoprotein cholesterol(LDL-C),apolipoprotein A(ApoA),apolipoprotein B(ApoB),ApoB/ApoA,erythrocyte sedimentation rate(ESR),platelet aggregation rate,Homocysteine(Hcy),high-sensitivity C-Reactive Protein(hs-CRP).Moreover,The patients were assessed by transcranial Doppler(TCD),color doppler ultrasonography of the carotid and basal cerebral arteries,Cranial CT or MRI.They were scored and detected cranial CT or MRI again when the state of illness changed in a week.Compare all these between two groups. Results:1 the results of single factor analysis:There were 16(30.19%)cases with cerebrovascular disease in PIS group(53 cases), and 7(14.00%)cases with cerebrovascular disease in NPIS group(50 cases).The incidence of cerebrovascular disease between two groups have significant difference(P＜0.05).The PIS group’s average score when the patiens presented is 12.26±3.80,the NPIS group’s average score is 5.64±5.30,the two scores have significant difference(p＜0.05).The average level of early fasting blood glucose is(6.65±3.49)mmol/L in PIS group,and(5.95±2.29)mmol/L in NPIS group.There are 39.63%patients with early hyperglycemia in PIS group,26.00%patents with hyperglycemia in NPIS group,the ratio of hyperglycemia differs significantly between the two groups(P＜0.05).In PIS group,the average level of total cholesterol(TC)is(5.05±0.97)mmol/L, high density lipoprotein cholesterol(HDL-C)is(1.06±0.26)mmol/L and apolipoprotein B(ApoB)is(0.99±0.24)g/L.In NPIS group,the average level of TC is(4.69±0.69)mmol/L,HDL-C is(0.96±0.24)mmol/L and ApoB is(0.92±0.16)g/L.there are significant difference between the two groups of TC,HDL-C and ApoB’s levels(p＜0.05).The ratios of increased TC differed significantly between PIS group(18.87%)and NPIS group(0.00%)(P＜0.01).The ratios of increased ApoB differed significantly between PIS group(37.74%)and NPIS group(20.00%)(P＜0.05).There are significant difference of the ratio of increased high-sensitivity C-Reactive Protein(hs-CRP)between PIS group(50.94%)and NPIS group(32.00%)(p＜0.05).In PIS group,the level of Homocysteine(Hcy)is(36.66±27.51)μmol/L,and there are 84.91%patients increased.In NPIS group,the level of Homocysteine(Hcy)is(17.13±10.32)μmol/L,and there are 48.00%patients increased.The two factors differed significantly between the two groups(p＜0.01). 1.4 The positive ratio of carotid atherosclerosis plaque is 75.47%in PIS group, 58.00%in NPIS group.The positive ratio of unstable plaque is 46.46%in PIS group, 31.94%in NPIS group.The two ratios differed significantly between two groups(p＜0.05).2 The multivariate conditional logistic regression analysis shows that NIHSS,fasting blood glucose,Triglycerides(TG)and Homocysteine(Hcy)are the risk factors of progressive ischemic stroke.3 Spearman correlation analysis shows that the history of hypertension,diabetes and cerebrovascular disease,NIHSS,carotid atherosclerosis,creatinine and hs-CRP were positively correlated to hyperhomocysteinemia.Conclusions:1 NIHSS,fasting blood glucose,Triglycerides and Homocysteine are the risk factors of progressive ischemic stroke.2 Hyperhomocysteinemia is the independent risk factor of progressive ischemic stroke.3 The history of hypertension,diabetes and cerebrovascular disease,NIHSS,carotid atherosclerosis,creatinine and hs-CRP have positive correlation to hyperhomocysteinemia.更多还原