缺血性脑卒中患者早期复发的临床特征和危险因素

为探讨缺血性脑卒中患者早期复发的临床特点和危险因素，对复发的缺血性卒中患者进行了临床分析和病例－对照研究。结果６３７例完全性缺血性卒中，有２４例复发，其总复发率为３．８％（２４／６３７），其中脑血栓的复发率为３．４％（２０／５９１），脑栓塞为８．７％（４／４６）。大部分病例（７１％，１７／２４）复发发生在原患侧，且多为同卒中类型复发（８３％，２０／２４）。经ＭｃＮｅｍａｒ卡方检验发现高血压史、有ＴＩＡ或脑梗塞史、糖尿病等因素与对照相比有显著性差异，而缺血性心脏病、房颤、入院时高血糖、血脂增高和吸烟与复发无显著相关。认为缺血性脑卒中患者早期复发多为同卒中类型、同部位的复发，高血压、有ＴＩＡ或脑梗塞史、糖尿病可能为卒中早期复发的危险因素。     

症状性颈动脉狭窄对急性缺血性脑卒中患者近期生存状况的影响

目的：探讨症状性颈动脉狭窄对急性缺血性脑卒中患者近期生存状况的影响。方法根据血管影像学结果，252例急性缺血性脑卒中患者分为3组，重度狭窄组32例，中度狭窄组38例以及轻度或无狭窄组182例，观察发病3个月内NIHSS评分及BI评分变化、有无卒中复发、癫痫样发作、死亡。结果与中度狭窄组比较，重度狭窄组患者神经功能恶化（OR＝2.058，95％CI0.771～6.011，P＝0.000）、生活受限更严重（OR＝2.405，95％CI1.011～5.618，P＝0.000），死亡风险升高（OR＝2.587，95％CI0.483～14.017，P＝0.000）；与轻度或无狭窄组比较，重度狭窄组神经功能进一步恶化（OR＝10.389，95％CI4.438～24.317，P＝0.000），生活受限更重（OR＝3.211，95％CI1.691～6.134，P＝0.000），死亡风险更高（OR＝4.182，95％CI1.363～12.805，P＝0.000）。结论症状性颈动脉狭窄是急性缺血性脑卒中患者近期生存状况不佳的独立危险因素，可导致神经功能恶化、生活严重受限、死亡风险升高，应采取早期干预措施。     

缺血性脑卒中患者发生早期神经功能恶化的相关因素分析

目的：探讨缺血性脑卒中患者发生早期神经功能恶化（END）的相关因素。方法对2009‐08－2013‐12收治的96例缺血性脑卒中的临床资料进行回顾性分析,其中发生END 27例,发生率为28.1％,采用单因素和多因素Logistic回归分析患者的性别、年龄等因素与END发生的关系。结果单因素分析结果显示,2组高血压、糖尿病、心房颤动、颈动脉狭窄≥50％比例、白细胞计数、C反应蛋白、D‐二聚体、NIHSS评分及凝血酶原时间比较差异有统计学意义（ P＜0.05）。多因素Logistic回归分析结果显示,与END发生相关的危险因素为高血压（OR＝2.171,95％ CI＝1.08～4.361,P＝0.029）、糖尿病（OR＝3.842,95％ CI＝1.638～9.012,P＝0.002）、心房颤动（OR＝6.573,95％ CI＝1.073～40.286,P＝0.041）、颈动脉狭窄≥50％（OR＝4.242,95％ CI＝0.762～23.617,P＝0.099）和 NIHSS 评分（OR＝3.629,95％ CI＝0.795～16.577,P＝0.096）。结论入院时有高血压、糖尿病、心房颤动、颈动脉狭窄和高NIHSS评分的急性缺血性脑卒中患者临床更易发生END。     

短暂性脑缺血发作后缺血性脑卒中的危险因素

目的探讨TIA后缺血性脑卒中的危险因素。方法收集184例TIA患者的临床资料,分析TIA后缺血性脑卒中的危险因素。结果与无缺血性脑梗死组比较,缺血性脑梗死组高龄(≥60岁)、高血压、糖尿病以及有吸烟、饮酒史的比率显著升高(P0.05~0.01),性别及高血脂比率差异无统计学意义(均P0.05)。与无缺血性脑梗死组比较,缺血性脑梗死组发作时间≥30 min、发作次数≥3次、病程≥24 h(P0.05~0.01),而TIA类型差异无统计学意义(均P0.05)。Logistic回归分析显示,高龄、高血压、糖尿病以及吸烟、饮酒史与TIA进展为缺血性脑卒中呈正相关(OR=29.799,95%CI:2.189~405.569,P=0.011;OR=0.649,95%CI:0.038~6.850,P=0.005;OR=8.569,95%CI:1.314~55.862,P=0.025;OR=0.158,95%CI:0.025~0.980,P=0.048)。结论高龄、高血压、糖尿病、有吸烟饮酒史是TIA发展为缺血性脑卒中的独立危险因素。     

脑卒中复发的危险因素分析

目的探讨影响脑卒中1年复发率的主要因素。方法登记我院2004-05～2006-07住院的首次卒中患者，前瞻性随访病后1年的复发情况，并登记影响卒中复发的各种可能因素，采用Logistic回归模型对这些因素进行分析。结果共纳入300例首次卒中患者，其中脑出血106例（35．5％），缺血性脑卒中194例（64．5％）。卒中1年的总体复发率为13．5％．其中脑梗死复发率为11．2％。脑出血复发率为17．3％。校正年龄和性别后，多因素分析显示房颤、糖尿病、高脂血症、高血压、吸烟是脑卒中复发的独立危险因素。结论脑卒中后1年复发率约为13．5％，应加强脑卒中患者房颤、糖尿病、高脂血症、高血压、吸烟的监测和预防．以减少卒中再发。     

脑血栓形成复发的危险因素研究

目的：探讨脑血栓形成复发的危险因素。方法：收集首发441例脑血栓形成患者的临床资料,采用前瞻性队列研究,随访1年,记录终点事件。结果：脑血栓形成1年复发率为t3．8％;年龄（P=0．002,OR=1．044,95％CI=1．015～1．073）、高血压病史（P=0．040,OR=I．944,95％CI=1．032～3．663）、纤维蛋白原（P=0．000,OR=I．932,95％CI=1．386～2．666）为影响脑血栓形成复发的因素。结论：高龄、高血压病史及纤维蛋白原升高是脑血栓形成复发的重要危险因素。     

缺血性卒中首发患者复发危险因素分析

目的 研究缺血性卒中患者卒中复发的危险因素以及不同TOAST分型复发情况,为预防 缺血性卒中复发提供依据。方法 连续收集2014 年10 月1 日—2015 年2 月1 日在河北医科大学第二医 院神经内科住院治疗的首次发作的缺血性卒中患者,采用自行设计问卷,问卷内容包括患者一般人口学 资料、既往疾病史、化验结果、影像学资料等信息,将患者发病入院作为起始事件,采用电话联系方式对 患者跟踪随访1 年,以卒中复发、失访、死亡为终点事件,随访内容包括复发情况、口服药物服用情况等。 结果 本研究共收集501 例,其中资料不全者28 例,失访23 例,最终450 例纳入研究。男性306 例,女 性144 例;年龄16～81 岁,中位年龄59.5 岁;复发组76 例,未复发组374 例;TOAST分型中大动脉粥样硬 化型327 例（72.7%）,小动脉闭塞型92 例（20.4%）,心源性栓塞型18 例（4.0%）,其他明确病因型5 例（1.1%）, 不明病因型7 例（1.5%）。随访3 个月卒中复发率4.9%,6 个月累积复发率8.4%,1 年累积复发率16.9%。 回归分析显示缺血性卒中复发危险因素为高同型半胱氨酸血症（OR=2.376,95%CI=1.349～4.183）、TIA 史（OR=2.791,95%CI=1.538～5.066）、抗血小板药物依从性不好（OR=1.941,95%CI=1.116～3.374）、心源 性栓塞型（OR=6.639,95%CI=2.322～18.982）。结论 缺血性卒中具有一定的复发率,高同型半胱氨酸、 TIA、颈动脉斑块形成、抗血小板药物依从性不好是缺血性卒中复发的独立危险因素,TOAST分型可以作 为卒中复发的预测因子,其中心源性栓塞型是缺血性卒中复发的独立危险因素。     

预防脑梗死复发的随访研究

目的 探索预防脑梗死复发的医疗干预措施。方法 对我院住院的324例脑梗死病人出院后进行随访跟踪，将病人分为对照组和治疗组；治疗组针对复发危险因素进行三方面预防复发的医疗干预：（1）药物控制脑卒中的危险因素；（2）改掉不良的生活习惯，坚持运动锻炼；（3）定期专科门诊复诊；对照组未进行预防复发的医疗干预，患者自我管理。结果 治疗组中脑梗死病人复发率为：1－3年内2．8％，3－5年内13．6％；5－9年内14．7％；对照组1－3年内8．9％，3－5年内27．8％，5－9年内33．3％。两组差别明显（P＜0．01），有统计学意义。结论 对脑梗死病人的预防干预，使降低复发率有着积极意义。     

缺血性脑卒中的病因分型与危险因素

目的探讨缺血性脑卒中病因分型与不同危险因素的关系。方法回顾性分析连续登记的急性缺血性卒中患者,记录其危险因素,并按急性卒中治疗试验（TOAST）标准将缺血性卒中分为5种类型分析相关危险因素对其发生风险的影响。结果在纳入分析的205例患者中,大动脉粥样硬化性卒中（LAA）100例（48．9％）、心源性卒中（CE）17例（8．3％）、小动脉闭塞性卒中（SAO）38例（18．5％）、其他原因所致卒中（SOE）12例（5．8％）、不明原因卒中（SUE）38例（18．5％）。分析显示,高血压与LAA的发生有关（OR=2．40,P=0．0028）;心房颤动对CE发生有显著作用（OR=365．90,P〈0．0001）;饮酒与SAO的发生可能有一定关联（OR=2．73,P=0．036）,而白细胞则在CE患者显著升高（OR=8．00,P=0．0013）。结论不同类型缺血性脑卒中与不同的危险因素有关。该结果对临床个体化预防与治疗有一定提示意义。     

影响青年脑卒中短期预后危险因素的系统评价

目的 评估影响青年脑卒中短期预后的危险因素.方法 计算机检索Cochrane图书馆、PubMed、中国学术期刊全文数据库、中国生物医学文献数据库和万方数据库,收集影响青年脑卒中短期预后危险因素的相关文献.应用RevMan 4.2.10软件对各个纳入研究的结果进行一致性检验和数据合并,并评估发表偏倚.结果 共纳入4项研究.系统评价显示危险因素影响短期预后的结果为:发病年龄[WMD=0.32,95％CI( -0.49～1.14)];男性[OR=1.11,95％CI(0.88～1.4)];女性[OR＝0.90,95％CI(0.71～1.13)];高血压病[OR＝1.04,95％CI(0.81～1.33)];糖尿病史[OR＝0.53,95％CI(0.39～0.71)];既往脑卒中家族史[OR=0.61,95％CI(0.37～1.01)];既往TIA史[OR＝2.46,95％CI(1.47～4.12)];甘油三酯水平[WMD＝0.09,95％CI(-0.10～0.27)];胆固醇水平[WMD＝-0.09,95％CI( -0.23～0.05)];入院时血糖水平[WMD=-0.71,95％CI( -1.05～ -0.37)].结论 糖尿病史、既往TIA病史、入院时血糖水平是青年脑卒中患者短期预后的独立预测因子,未发现发病年龄、性别、高血压病史、脑卒中家族史、TG、CHO对青年脑卒中患者短期预后的影响,有待于进一步研究.     

脑白质疏松和陈旧性腔隙性脑梗死对首发缺血性卒中患者预后的影响

目的 探讨脑白质疏松和陈旧性腔隙性脑梗死对于首发缺血性卒中患者预后的影响。 方法 连续选取791例7 d以内首次发病的非心源性缺血性卒中患者。收集患者的人口学信息和脑血 管病的危险因素,评价患者的头颅磁共振成像包括脑白质疏松的严重程度、无症状性腔隙性脑梗死 的数量、缺血性卒中的病因分型以及急性梗死灶的分布特征,通过多因素Logistic回归分析脑白质疏 松和陈旧性腔隙性脑梗死与缺血性卒中患者预后相关的危险因素。 结果 分别有14例（1.8%）、38例（4.8%）患者在缺血性卒中发病1年内死亡、缺血性卒中或短暂性脑 缺血发作（transient ischemic attack,TIA）复发。多元Logistic回归发现：存在陈旧性腔隙性脑梗死、有 皮层新发脑梗死灶、入院后未给予抗血小板药物、出院时未服用他汀药物是缺血性卒中患者1年内 死亡的危险因素;而脑白质疏松对于缺血性卒中患者1年内的死亡无显著影响。冠状动脉粥样硬化性 心脏病、入院美国国立卫生研究院卒中量表（National Institute of Health stroke scale,NIHSS）评分<4 分、新发梗死灶的责任脑动脉闭塞或狭窄程度≥70%、出院时未给予抗血小板药物是缺血性卒中患 者1年内缺血性卒中或TIA复发的危险因素;而脑白质疏松和陈旧性腔隙性脑梗死对于缺血性卒中患 者1年内缺血性卒中或TIA的复发无显著影响。 结论 陈旧性腔隙性脑梗死是缺血性卒中患者1年内死亡的危险因素。而脑白质疏松和陈旧性腔隙 性脑梗死对于缺血性卒中患者1年内缺血性卒中或TIA的复发无显著影响。     

Can we predict early recurrence in acute stroke?

BACKGROUND: The prevention of early recurrent stroke, which worsens outcomes after a cerebral infarction, is a major objective for acute stroke therapy. The ability to predict which patients are at risk for early recurrence would be useful for both the management and design of clinical trials. METHODS: Using the prospective database with the 1,266 stroke patients admitted in the TOAST study, we analyzed all the patients who had suffered either a transient ischemic attack (TIA) or a recurrent stroke within 3 months after stroke, and their possible association with 20 selected clinical variables. Both univariate and stepwise regression analyses were performed. RESULTS: Sixty-two patients (4.9%) had a second stroke, and 47 patients (3.7%) had at least one TIA. No particular high-risk period was observed. Early recurrent stroke was associated with the large artery atherosclerosis subtype. A prior history of TIA increased the odds for recurrent stroke (OR = 2.52; 1.16-5.46) or poststroke TIA (OR = 3.46; 1.59-7.48). In addition, patients who had a TIA after the stroke had a 17% chance of having an early recurrent stroke, as compared with 4.4% among those that did not (p = 0.001). CONCLUSION: Our present ability to identify patients at risk for early recurrence based on baseline clinical features remains limited. While the presence of TIA before or after the stroke denotes a subgroup of acute stroke patients at higher risk for early recurrence in the first 3 months, no other factors reliably identify high-risk patients.     

非心源性缺血性卒中复发危险因素分析

目的 分析非心源性缺血性卒中患者1年复发的危险因素。 方法 连续入选1978例发病7 d内的非心源性缺血性卒中患者。收集患者的人口学信息、血管病危险 因素和发病时的主要症状及体征,评价患者的头颅磁共振成像结果,包括梗死灶的部位、数量、急 性梗死灶的分布特征及责任动脉、责任动脉有无严重狭窄、缺血性卒中的病因分型。随访患者1年内 有无缺血性卒中或短暂性脑缺血发作（transient ischemic attack,TIA）的复发,通过多元Cox回归分析缺 血性卒中患者复发的危险因素。 结果 95例(4.8%)患者1年内缺血性卒中或TIA复发。冠状动脉粥样硬化性心脏病病史、缺血性卒中病 史、缺血性卒中发病前3个月内反复TIA、责任脑动脉狭窄程度≥70%和后循环缺血性卒中是1年内复发 的危险因素。 结论 后循环梗死、有责任脑动脉严重狭窄及缺血性心脑血管病病史的非心源性缺血性卒中患者复 发的风险较高。     

L-arginine-mediated vasoreactivity in patients with a risk of stroke

OBJECTIVES:L-arginine is the substrate for nitric oxide (NO) production and has been shown to induce an endothelium-dependent increase in cerebral blood flow in humans. We studied the hypothesis that L-arginine-mediated vasoreactivity is impaired in patients with cardiovascular risk factors and a risk of stroke. METHODS: 55 patients with cardiovascular risk factors (mean age 63.0 +/- 8.5 years) were included in the study. 45 of them had a history of previous minor stroke or transient ischemic attack (TIA) while 10 patients had cardiovascular risk factors but no previous cerebral ischemic event. Endothelium-dependent changes in cerebral blood flow during the infusion of 30 g L-arginine were assessed by continuous transcranial Doppler sonography of both middle cerebral arteries, intima-media thickness (IMT) of the common carotid artery, by Duplex sonography. Associations between risk factors, IMT, L-arginine reactivity and previous cerebrovascular events were analyzed by stepwise multiple linear regression analysis and patient groups were compared. RESULTS: Normal young volunteers showed an L-arginine-mediated increase in mean flow velocity of 22 +/- 8%; L-arginine reactivity of the 55 patients was 28 +/- 10%. Patients with a history of stroke or TIA had significantly higher flow velocity responses to L-arginine (29 +/- 10%) than patients with cardiovascular risk factors but no previous cerebrovascular event (21 +/- 8%, p < 0.05). Stepwise multiple linear regression analysis showed a significant association of enhanced L-arginine reactivity with previous stroke/TIA (p < 0.001) and elevated fibrinogen levels (p < 0.05) but not with age, IMT, hypertension, cholesterol or other risk factors. The same regression model showed an association between IMT and previous stroke/TIA (p < 0.001) and serum cholesterol levels (p < 0.05) but not L-arginine reactivity. CONCLUSIONS: L-arginine reactivity of the cerebral vessels may be assessed by Doppler sonography and was enhanced in patients with a history of stroke or TIA. It was independent of IMT of the carotid arteries. We conclude that enhanced L-arginine reactivity is a potential marker for cerebral endothelial dysfunction and an independent indicator for an increased risk of stroke.     

Risk factors and treatment of stroke at the time of recurrence

The profile of recurrent ischemic strokes has not been much investigated. The aim of this study was to evaluate how the therapeutic strategies recommended for secondary prevention after an ischemic stroke are implemented in the real world of clinical practice. All patients admitted for a recurrent ischemic stroke or TIA were prospectively registered. The etiology was determined according to the TOAST classification. The risk factors and cardiovascular treatment at the time of the recurrence were recorded. A total of 168 patients were evaluated. Most of the patients (61%) recurred after 1 year. The recurrent stroke was not associated with a particular etiological subtype. The most frequent risk factor was hypertension (79%), followed by hypercholesterolemia (43%), smoking (25%), and diabetes (22%). Most of the patients had more than 1 risk factor (84%). Hypertension was not satisfactorily controlled in 38% of patients, hypercholesterolemia in 42%, and diabetes in 59%. A significant minority of patients (15%) were not taking any antithrombotic agent despite a history of stroke or TIA. Only 34% of the cases with a known atrial fibrillation were on anticoagulant therapy and the International Normalized Ratio was < 2.0 in 71% of them. In conclusion, stroke prevention needs to be improved by better implementation of therapeutic strategies in clinical practice. The patients should also be better informed about target values as well as the importance of physical activity and smoking cessation.     

β2-Glycoprotein I – dependent anticardiolipin antibodies in ischemic stroke

Our study was undertaken to investigate whether beta2-glycoprotein I (GPI) is relevant for enhancing anticardiolipin antibody (aCL) binding in stroke patients, in particular view of vascular risk factors and recurrence of previous cerebral ischemic events. One-hundred and twenty-one sera from patients with ischemic stroke and 154 control sera from patients with non-ischemic neurological disorders ( n = 43) and healthy subjects ( n = 111) were included in the study. All sera were tested for either GPI-independent aCL and GPI-dependent aCL. GPI-independent aCL were detected in two (1.7%) stroke patients. When GPI was added to the assay system, 13 (10.8%) sera were positive. Of the 43 sera in the neurological control group one was positive for both GPI-independent aCL and GPI-dependent aCL. Multiple linear regression in the stroke group revealed that GPI-dependent aCL are marginally associated with sex, prior TIA/strokes and embolism. More importantly, GPI-dependent aCL were significantly more frequent in stroke patients with a history of prior TIA/strokes compared with patients with a first ischemic stroke ( p = 0.029).
The present study demonstrates that aCL in stroke patients are of the GPI-dependent type and emphasizes the importance of adding GPI in the immunoassay for the optimal detection of aCL. Furthermore, it supports the recommendation of testing aCL in those patients who experience unexplained recurrent cerebral ischemic events.     

Transient ischemic attack: A neurologic emergency

Classically, a transient ischemic attack (TIA) has been defined as an acute episode of neurologic symptoms lasting less than 24 hours attributed to focal ischemia in a vascular distribution of the brain or retina. Stroke and TIA share similar risk factors, evaluation, and secondary prevention. However, evaluation of patients with TIA has traditionally lacked the same urgency that has been directed to acute stroke, probably because patients with TIA are at baseline neurologically when the diagnosis is made. Recently, several studies have found a high risk of stroke shortly after TIA. Furthermore, recent evidence suggests that early recovery from ischemia actually is associated with greater instability. Identifying patients with the highest risk of recurrent ischemic events for urgent evaluation and intervention is key in secondary stroke prevention. This article reviews the current literature on new concepts about TIA, subsequent risk of stroke, and guidelines on evaluation and treatment.     

非心源性缺血性卒中及短暂性脑缺血发作患者的抗血小板治疗

在脑血管病患者中,约80%为缺血性卒中患者,多伴有多种危险因素,是卒中复发的高危人群。在非心源性缺血性卒中/短暂性脑缺血发作（transient ischemic attack,TIA）的二级预防中,抗血小板治疗的疗效已被大量临床研究证实,并被各国的指南所推荐。本文结合新近发表的指南以及经典的临床试验,对非心源性缺血性卒中/TIA的抗血小板治疗模式做一综述。     

White matter changes in stroke patients. Relationship with stroke subtype and outcome.

White matter changes (WMC), detected by imaging techniques, are frequent in stroke patients. The aim of the study was to determine how WMC relate to stroke subtypes and to stroke outcome. We made a systematic Medline search for articles appearing with two of the following key words: either 'WMC or white matter lesions or leukoencephalopathy or leukoaraiosis' and 'stroke or cerebral infarct or cerebral hemorrhage or cerebrovascular disease or transient ischemic attack (TIA)'. WMC, as defined radiologically, are present in up to 44% of patients with stroke or TIA and in 50% of patients with vascular dementia. WMC are more frequent in patients with lacunar infarcts, deep intracerebral hemorrhages, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy and cerebral amyloid angiopathy. After an acute ischemic stroke, WMC are associated with a higher risk of death or dependency, recurrent stroke of any type, cerebral bleeding under anticoagulation, myocardial infarction, and poststroke dementia. WMC in stroke patients are often associated with small-vessel disease and lead to a higher risk of death, and poor cardiac and neurological outcome. However, several questions remain open and need further investigations.     

Rheumatoid arthritis significantly increased recurrence risk after ischemic stroke/transient ischemic attack

The effect of RA on recurrent stroke is unknown. Therefore, we examined effects of rheumatoid arthritis (RA) on risk of stroke recurrence and investigated the interaction between RA and traditional cardiovascular risk factors on recurrence risk after ischemic stroke (IS) or transient ischemic attack (TIA). Of 3190 patients with IS or TIA recruited in this cohort study, 638 were comorbid with RA and 2552 without RA. Stroke recurrence, RA, lifestyle, lipid variables and other comorbidities were identified through linkage between a nationwide stroke database in Taiwan and the National Health Insurance claims database. Cox proportional hazard models with competing risk adjustment were used to evaluate the relationship between RA and recurrent stroke. Patients with RA showed a significantly increased risk of recurrent stroke, particular in recurrent IS/TIA. The increased risk of recurrent IS/TIA in RA patients may through the changes of triglycerides (TG)/high-density lipoprotein cholesterol (HDL-C) ratio. A positive additive interaction was observed between RA and current smoking on the risk of recurrent IS/TIA. Significantly increased risks for recurrent IS/TIA were observed among RA patients who smoked?>?40 years or those who smoked?>?20 cigarettes/day. This study provides the first evidence that RA significantly increased recurrence IS/TIA risk. The changes of TG/HDL-C ratio may play some roles in the recurrence IS/TIA risk in RA patients. In addition, our results suggest that smoking increases the risk of recurrent IS/TIA in RA patients and reinforces the need for aggressive smoking cessation efforts in RA patients.