Gugging吞咽功能评估量表评分对卒中患者发生卒中相关性肺炎的预测价值研究

目的 探讨Gugging吞咽功能评估量表（GUSS）评分对卒中患者发生卒中相关性肺炎（SAP）的预测价值。方法 选取2020年6月至2022年6月江苏省苏北人民医院收治的卒中患者192例，以是否发生SAP将其分为SAP组（n=32）和非SAP组（n=160）。收集所有患者的一般资料、GUSS评分、洼田饮水试验分级。采用多因素Logistic回归分析探讨卒中患者发生SAP的影响因素。绘制决策曲线以探讨GUSS评分对卒中患者发生SAP的预测价值。结果 SAP组年龄大于非SAP组，美国国立卫生研究院卒中量表（NIHSS）评分、洼田饮水试验分级≥3级者占比高于非SAP组，GUSS评分低于非SAP组（P<0.05）。多因素Logistic回归分析结果显示，年龄增长、NIHSS评分升高、洼田饮水试验分级≥3级是卒中患者发生SAP的危险因素，GUSS评分升高是卒中患者发生SAP的保护因素（P<0.05）。决策曲线分析结果显示，当高风险阈值为0～0.38时，GUSS评分预测卒中患者发生SAP的净获益率>0，当高风险阈值为0.16～0.34时，GUSS评分预测卒中患者发生SAP的净获益...     

气管切开后间断声门下吸引对卒中相关性肺炎的预防作用及意义

卒中相关性肺炎（stroke—associatedpneumonia,SAP）是卒中患者主要的并发症,也是卒中患者病情加重和死亡的主要原因之一。许多患者脑卒中后并不是死于脑卒中本身,而是死于并发症,其中SAP是主要原因之一。2003年Hilker等首次提出SAP的概念,指脑卒中患者急性期及后遗症期并发的肺部感染。SAP是患者住院死亡率增加、神经功能预后差的独立危险因素,据报道其发生率为2．4％～47％,大约占卒中患者病死率的35％,而误吸和坠积是SAP的主要危险因素之一。     

卒中相关性肺炎的预测和预防

肺炎是卒中后的最常见内科并发症之一.卒中相关性肺炎(stroke-associated pneumonia,SAP)不仅会延长卒中患者住院时间、增加医疗费用,而且也是卒中患者死亡和残疾的重要危险因素.这些均提示了SAP的预测和预防的重要性.文章对SAP的预测和预防的研究进展进行了综述.     

大面积脑梗死伴卒中相关性肺炎:1例报道

卒中相关性肺炎(stroke associated pneumonia,SAP)是指原无肺部感染的卒中患者罹患感染性肺实质(含肺泡壁,即广义上的肺间质)炎症[1].年龄、卒中严重程度、卒中诱导免疫抑制、意识障碍、喂养方式、吞咽困难、机械通气等均为SAP的危险因素[1-2].伴意识障碍的重症卒中患者SAP发生率明显增高,能否尽早有效控制SAP将直接影响患者的预后、住院时间和医疗费用.     

卒中相关性肺炎与低磷血症的关系

目的 探讨卒中相关性肺炎(SAP)与低磷血症的关系.方法 回顾性分析82例SAP患者和244例无卒中相关性肺炎(nSAP)的卒中患者的血磷及一系列生化指标,并以血磷水平将SAP患者分为低磷血症组(SAP1)和非低磷血症组(SAP2),比较两组患者的住院天数、治疗费用和死亡率.结果 SAP患者的血磷水平低于nSAP患者(P＜0.05),SAP1组患者的住院时间、治疗费用、死亡率均大于SAP2组患者(P＜0.05).结论 低磷血症与卒中相关性肺炎的发生、发展及预后有一定的关系.     

预防卒中相关性肺炎的管饲方法

卒中相关性肺炎(stroke associated pneumonia,SAP)是指原先无肺部感染的卒中患者罹患感染性肺实质(含肺泡壁,即广义上的肺间质)炎症,是导致卒中患者死亡和影响功能恢复的最主要并发症之一.吞咽功能障碍导致误吸是SAP的主要原因,因此,通过早期正确管饲避免误吸预防SAP,对于卒中患者具有重要的意义.文章对预防SAP的管饲方法进行了综述.     

早发性卒中相关性肺炎的危险因素分析

卒中相关性肺炎（stroke associated pneumonia,SAP）是临床确诊的急性卒中患者出现发热、咳嗽、咳痰、呼吸困难等症状,根据特定诊断程序（有微生物学检查依据和／或胸部X线表现）而确诊的肺炎。2003年Hilker等提出这个概念,推测SAP可能有自身独立的临床规律,并进一步将急性卒中发病后72h内发生的SAP称为早发性SAP。     

卒中相关性肺炎的综合防治措施

卒中相关性肺炎(stroke-associated pneumonia,SAP)是指原先无肺部感染的卒中患者罹患的感染性肺实质(含肺泡壁,即广义的肺间质)炎症[1-2].SAP亦被称为卒中后肺炎(post-stroke pneumonia),是指卒中发病时无感染,也不处于感染潜伏期,而是在卒中发病48 h后发生的肺炎[3].SAP是卒中最主要的严重并发症之一,发生率高达10％[4-5],被认为是卒中患者转归不良和死亡的最重要原因之一[6-9].     

间断声门下吸引对ICU卒中相关性肺炎的影响

正卒中相关性肺炎(stroke—associated pneumonia,SAP)是指原来没有肺部感染的卒中患者罹患感染性肺部疾病。据统计,SAP发生率为7%-22%,约占卒中死亡患者的35%,是卒中患者主要的并发症和死亡原因之一~([1-3])。重症医学科(ICU)患者通常病情较重,生命体征不平稳,常需要建立人工气道并且实施机械通气。因此,ICU卒中相关性肺炎的发生率的增加,将增加患者机械通气时间、住院时间及病死率~([4])。传统的气管插管导管或气管切开导管,     

脑卒中相关性肺炎的危险因素及临床特点分析

目的 探讨急性脑卒中患有卒中相关性肿炎(SAP)的发生率、危险因素及病原学特点.方法 回顾性分析山东省立医院神经内科普通病房2009年1月～ 2010年12月642例急性脑卒中患者病历资料,探讨SAP的危险因素,并分析其病原学特点及病死率.结果 642例急性脑卒中患者SAP的发生率为13.2％,其中71.8％的为早发性肺炎.不同卒中类型中,脑梗死、脑出血、蛛网膜下腔出血患者SAP发生率分别为10.9％、19.4％、29.4％ (P＜0 01).不同卒中部位,前循环脑卒中、后循环脑卒中、前+后循环脑卒中SAP发生率分别为8.3％、22.3％、24.6％(P＜0.01).SAP患者的病死率为31.7％.年龄≥65岁、糖尿病、吸烟史、吞咽障碍、低蛋白血症、预防性应用抗生素、脱水剂、H2受体阻滞剂或质子泵抑制剂、鼻饲治疗是SAP的危险因素.病程中共培养出菌株65例,其中革兰阴性菌占67.7％,革兰阳性菌占26.2％,真菌占6.2％.结论 SAP多发生在入院72h内,以革兰阴性菌为主要致病菌;SAP增加患者病死率;不同卒中类型和部位的SAP发生率不同;早发性肺炎和晚发性肺炎的危险因素不同.     

肿瘤患者的缺血性卒中

缺血性卒中是恶性肿瘤的重要并发症之一。肿瘤患者缺血性卒中的病因和发病机制非常复杂,既包括高血压、糖尿病、高脂血症等传统血管危险因素,又包括与肿瘤病理生理学状态相关的危险因素,例如高凝状态、肿瘤栓子、血栓性心内膜炎等。此外,与肿瘤相关的各种治疗方法,例如放疗、化疗和内分泌治疗,也会增高缺血性卒中的风险。由于病因和发病机制的复杂性,肿瘤患者缺血性卒中的治疗方法也与常规有所不同,因此,明确病因并选取针对性的治疗方法对于肿瘤患者缺血性卒中的防治极为关键。随着肿瘤患者生存率的提高,肿瘤患者缺血性卒中也越来越受到重视。文章对肿瘤患者缺血性卒中的病因、发病机制和治疗的研究进展进行了综述。     

Management of acute ischaemic stroke in patients with dementia

An estimated 10% of stroke patients have an underlying dementia. As a consequence, health professionals often face the challenge of managing patients with dementia presenting with an acute stroke. Patients with dementia are less likely to receive thrombolysis (0.56–10% vs. 1–16% thrombolysis rates in the general population), be admitted to a stroke unit or receive some types of care. Anticoagulation for secondary stroke prevention is sometimes withheld, despite dementia not being listed as an exclusion criterion in current guidelines. Studies in this population are scarce, and results have been contradictory. Three observational studies have examined intravenous thrombolysis for treatment of acute ischaemic stroke in patients with dementia. In the two largest matched case–control studies, there were no significant differences between patients with and without dementia in the risks of intracerebral haemorrhage or mortality. The risk of intracerebral haemorrhage ranged between 14% and 19% for patients with dementia. Studies of other interventions for stroke are lacking for this population. Patients with dementia are less likely to be discharged home compared with controls (19% vs. 41%) and more likely to be disabled (64% vs. 59%) or die during hospitalization (22% vs. 11%). The aim of this review was to summarize current knowledge about the management of ischaemic stroke in patients with pre‐existing dementia, including organizational aspects of stroke care, intravenous thrombolysis, access to stroke unit care and use of supportive treatment. Evidence to support anticoagulation for secondary prevention of stroke in patients with atrial fibrillation and antiplatelet therapy in nonembolic stroke will be discussed, as well as rehabilitation and how these factors influence patient outcomes. Finally, ethical issues, knowledge gaps and pathways for future research will be considered.     

心房颤动患者卒中预防中的抗凝治疗：安全性和依从性

心房颤动（atrial fibrilation, AF）最主要的危害是卒中和体循环栓塞事件。最新的资料表明,高达1/3的卒中患者的病因可能为AF ,其导致的卒中致残率和致死率均高于其他类型卒中。因此,对AF患者的卒中预防至关重要。抗凝治疗是AF患者卒中预防的核心策略,文章就AF患者抗凝治疗的安全性和依从性研究进展进行了综述。     

Antithrombotic and thrombolytic therapy for ischemic stroke

Antithrombotic therapy is the mainstay of treatment for stroke prevention. Multiple antiplatelet agents are now proven options for patients at risk for stroke, whereas warfarin anticoagulation remains the preferred therapy for most patients with atrial fibrillation. Recent clinical trials have clarified the role of anticoagulation in acute stroke and in secondary prevention of noncardioembolic stroke. Intravenous tissue plasminogen activator is the only approved therapy for patients with acute ischemic stroke. Intra-arterial thrombolysis is emerging as a promising therapy in selected patients.     

Antithrombotic secondary prevention after stroke

Opinion statement In patients with transient ischemic attack (TIA) or ischemic stroke of noncardiac origin, antiplatelet drugs are able to decrease the risk of stroke by 11% to 15%, and decrease the risk of stroke, myocardial infarction (MI), and vascular death by 15% to 22%. Aspirin leads to a moderate but significant reduction of stroke, MI, and vascular death in patients with TIA and ischemic stroke. Low doses are as effective as high doses, but are better tolerated in terms of gastrointestinal side effects. The recommended aspirin dose, therefore, is between 50 and 325 mg. Bleeding complications are not dose-dependent, and also occur with the lowest doses. The combination of aspirin (25 mg twice daily) with slow-release dipyridamole (200 mg twice daily) is superior compared with aspirin alone for stroke prevention. Ticlopidine is effective in secondary stroke prevention in patients with TIA and stroke. For some end points, it is superior to aspirin. Due to its side-effect profile (neutropenia, thrombotic thrombocytopenic purpura [TTP]), ticlopidine should be given to patients who are intolerant of aspirin. Prospective trials have not indicated whether ticlopidine is suggested for patients who have recurrent cerebrovascular events while on aspirin. Clopidogrel has a better safety profile than ticlopidine. Although not investigated in patients with TIA, clopidogrel should also be effective in these patients assuming the same pathophysiology than in patients with stroke. Clopidogrel is second-line treatment in patients intolerant for aspirin, and first-line treatment for patients with stroke and peripheral arterial disease or MI. A frequent clinical problem is patients who are already on aspirin because of coronary heart disease or a prior cerebral ischemic event, and then suffer a first or recurrent TIA or stroke. No single clinical trial has investigated this problem. Therefore, recommendations are not evidence-based. Possible strategies include the following: continue aspirin, add dipyridamole, add clopidogrel, switch to ticlopidine or clopidogrel, or switch to anticoagulation with an International Normalized Ratio (INR) of 2.0 to 3.0. The combination of low-dose warfarin and aspirin was never studied in the secondary prevention of stroke. In patients with a cardiac source of embolism, anticoagulation is recommended with an INR of 2.0 to 3.0. At the present time, anticoagulation with an INR between 3.0 and 4.5 cannot be recommended for patients with noncardiac TIA or stroke. Anticoagulation with an INR between 3.0 and 4.5 carries a high bleeding risk. Whether anticoagulation with lower INR is safe and effective is not yet known. Treatment of vascular risk factors should also be performed in secondary stroke prevention.     

Sleep-disordered breathing: implications in cerebrovascular disease

Stroke and sleep-disordered breathing (SDB) are both common and are associated with significant morbidity and mortality. Several recent large epidemiologic studies have shown a strong association between these two disorders independent of known risk factors for stroke. This review will outline the scientific basis for this relationship and suggest SDB as a modifiable risk factor for stroke. Several studies have shown a characteristic circadian rhythmicity in stroke. The authors discussed the influence of normal sleep states as well as the effect of SDB on cerebral hemodynamics. The hemodynamic, metabolic, and hematologic changes during SDB in the form of decreased cerebral perfusion and increased coagulability are the possible pathogenetic mechanisms for stroke. There are accumulating lines of evidence that SDB may indeed cause diurnal hypertension. However, the increased risk of stroke in patients with SDB appears to be independent of coexisting hypertension, but the presence of hypertension would greatly increase the risk even further. Furthermore, several studies have documented high prevalence of sleep apnea in patients with transient ischemic attacks and stroke. SDB appears to contribute as a risk factor for stroke through hemodynamic and hematologic changes. Because of high prevalence of SDB in this population, patients with transient ischemic attacks and stroke should be screened for these disorders.     

Probability of stroke in Korean hypertensive patients visiting community-based hospitals: using a risk profile from the Framingham study

Hypertension is the most important single modifiable risk factor of stroke. The purpose of this study was to investigate the distribution patterns of risk factors of stroke and 10-year probability of stroke in hypertensive patients visiting community-based hospitals. A total of 1088 hypertensive patients who visited 61 community-based hospitals nationwide were enrolled. Risk factors of stroke were evaluated using a series of laboratory tests and physical examinations, and the 10-year probability of stroke was determined by applying the Framingham stroke risk equation. The proportion of patients who have uncontrolled hypertension despite the use of antihypertensives was 63.3% (59.6% women, 68.7% men; P=0.006). The average 10-year probability of stroke in hypertensive patients was 16.05% (14.68% women, 17.99% men; P<0.001). The 10-year probability of stroke in patients with hypertension gradually increased in proportion to age. In patients treated with antihypertensives, 10-year probability of stroke gradually increased in proportion to blood pressure. The 10-year risk of stroke in hypertensive patients was approximately 4.6 times higher than that of stroke in the general population. In conclusion, as the 10-year risk of stroke in hypertensive patients was approximately 4.6 times higher than that of stroke in the general population, more aggressive interventions are needed to reduce blood pressure and stroke risk in hypertensive patients.     

The Management of Stroke in Antiphospholipid Syndrome

Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.     

卒中后认知功能障碍的转归及其影响因素

卒中后认知功能损害是脑卒中常见的并发症,其发病率为21．8％-50．O％。卒中后认知功能损害不仅影响患者的生存质量,也给家庭和社会带来负担。但是在度过急性期后,卒中后发生认知功能损害的患者也出现了不同的转归。年龄比较小、卒中前认知功能状态良好的患者相对容易出现认知功能的好转,但是年龄偏大、卒中前认知状况差、文化程度低、血压控制偏低、脑白质变性程度较重、合并糖尿病的患者即使度过了卒中急性期仍易出现认知功能的进一步恶化。而性别,卒中部位,卒中常见的危险因素,如高血压、高血脂、心脏病病史、饮酒史等,对卒中后认知功能障碍的临床转归产生的影响有待于进一步证实。     

Patent foramen ovale: The never-ending story

Opinion statement Several uncontrolled studies suggested a relationship between patent foramen ovale (PFO) and stroke. But recent data indicate that previous studies may overestimate the association between PFO and stroke. First, among patients who have had a cryptogenic stroke under treatment (with either warfarin or aspirin), the main data from the French PFO/atrial septal aneurysm (ASA) and PICSS (Patent Foramen Ovale in Cryptogenic Stroke Study), analyzed separately and in combination, indicate that PFO alone does not announce a significantly increased risk of recurrent stroke or death. But a small increase or decrease in risk cannot be excluded by this metaanalysis. Second, the data concerning the association between PFO and ASA are not clear and variable: the French PFO/ASA study found a significantly increased risk of recurrent stroke in patients with cryptogenic stroke and an association between PFO and ASA when treated medically. In contrast, PICSS found no association between the combined PFO-ASA with stroke or death, but the two populations had meaningful differences. Patients in the PICSS were much older than those in the French PFO/ASA study and had more risk factors for stroke, such as hypertension, diabetes, and history of prior stroke. Third, there were inadequate data to conclude about ASA alone. Possible practice recommendations could come from this meta-analysis: the evidence indicates that the risk of recurrent stroke or death is not different for patients with a PFO who underwent cryptogenic stroke compared to patients without a PFO who underwent a cryptogenic stroke under treatment with either aspirin or warfarin. But aspirin is more preferable (300 mg/d). However, it seems that the association between PFO and ASA confers an increased risk of recurrent stroke in medically treated patients who are less than 55 years of age. This subgroup of younger stroke patients may benefit from other treatments, such as the percutaneous closure of PFO or mini-invasive surgery to a lesser extent, but their efficacy and safety are not yet assessed by large randomized trials. However, we must also keep in mind that some stroke patients with PFO are psychologically attached to their PFO and prefer to close it.