Inherited metabolic disorders and cerebral infarction

The association of genetic factors and cerebral infarction (CI) has long been established. A positive family history alone is a recognized risk factor for CI and vascular events in general. However, there are certain inherited conditions that further increase the risk of stroke. These conditions are generally metabolic and mitochondrial genetic defects that have variable modes of inheritance. This article reviews major inherited metabolic disorders that predispose an individual to CI. Ten main conditions will be discussed: Fabry's disease, cerebrotendinous xanthomatosis, tangier disease, familial hypercholesterolemia, homocystinuria, methylmalonic acidemia, glutaric aciduria type I, propionic acidemia, ornithine transcarbamylase deficiency and mitochondrial encephalopathy, lactic acidosis and stroke-like phenomenon.     

Perfusion imaging in the diagnosis of acute cerebral infarction]

There is no doubt that CT and MRI play a major role in the diagnosis and selection of optimal therapeutic strategies in cases of acute cerebral infarction. However, it is true that there is a wide variation in the scanning protocols as well as data analysis procedures; these differences in imaging studies could translate into a lack of control over therapeutic strategies, thereby undermining the quality of clinical practice. It is obvious that standardization of imaging procedures is mandatory; however, so far, no such project has been conducted either at home or abroad. With this background, a couple of multi-institutional working groups dedicated to the standardization and development of practical guideline for imaging procedures in the setting of acute cerebral stroke, are now in operation in Japan.     

A prospective trial of hemodilution therapy in acute cerebral infarction]

Ninety two 50-year-old-or-more patients with acute (less than 72 hours) cerebral infarction involved middle cerebral artery region and hematocrit of 40% or more were prospectively randomised to either hemodilution group (by rapid venesection, venous infusion of autologous plasma and 500 ml dextran 40) or standard therapy group. Effects of hemodilution on acute cerebral infarction were evaluated by clinically neurological deficit scores, hemorheological parameters and size of infarction. The results of our clinical trial are: 1. Clinical efficacy of hemodiluted patients is significantly superior to that of standard treatment patients. Effective rates are 63.04% and 41.30% respectively (P less than 0.05). 2. At 48th hour after hemodilution there are profound decreases in hematocrit, blood viscosity at high shear rate and blood viscosity at low shear rate. These changes last more than four weeks. Whereas in standard group, hemorheological parameters do not evidently change. 3. Sizes of cerebral infarction do not distinctly change in both groups between at entry and at the fourth weekend after treatment.     

尤瑞克林治疗老年急性脑梗死

目的 评价尤瑞克林治疗老年急性脑梗死(ACI)的有效性和安全性.方法 采取随机的方法,选择82例老年ACI患者,随机分为对照组与治疗组,对照组给予常规治疗,治疗组在常规治疗的基础上加用尤瑞克林静脉滴注,于治疗前后进行美国国立卫生研究院卒中量表(NIHSS)评分及日常生活评定量表-Barthel指数(BI)评定.结果 两组患者用药前后的NIHSS评分、BI的差异有统计学意义(P＜0.05).治疗组较对照组改善比较明显(P＜0.05),且治疗组不良反应无明显增加.结论尤瑞克林治疗老年ACI值得进一步研究.     

Treatment of right hemispheric cerebral infarction by hemicraniectomy

An anecdotal series of nine patients (three men and six women with an average age of 57 years) presented with progressive neurologic deterioration while on medical therapy for large right hemispheric cerebral infarction. Clinical signs of uncal herniation (anisocoria or fixed and dilated pupils, and/or left hemiplegia with right decerebrate posturing) were present in seven of these nine patients. Computerized tomography of the head confirmed mass effect from cerebral edema. It was the clinical judgment of the treating neurologists and neurosurgeons that each of these nine patients would perish unless surgical decompression of the infarcted brain was performed. Accordingly, each was treated with right hemicraniectomy and dural augmentation. Six patients demonstrated neurologic improvement on the first postoperative day. One patient, with a postoperative diagnosis of lung cancer, died 1 month after surgery. The remaining eight patients are currently living with their families with a follow-up period ranging from 5 to 25 months. Patient outcome as evaluated by the Barthel Index indicates that three individuals are functioning with minimal assistance and that the remaining six patients are functionally dependent. After rehabilitative therapy, four patients returned for elective cranioplasty. These results suggest that hemicraniectomy can be an effective lifesaving procedure for malignant cerebral edema after large hemispheric infarction.     

神经元特异性烯醇酶与急性脑梗死

目的：探讨急性脑梗死患者血清神经元特异性烯醇酶（NSE）的变化及其临床意义。方法：采集69例脑梗死患者起病3天内的血标本,用酶联免疫分析法测定血清NSE含量（其中35例2周时复测）。结果脑梗死3天内血清NSE明显高于对照组及2周时（P＜0．001）,血清NSE含量与梗死灶大小,神经功能缺损程度明显正相关（P＜0．001）,与意义障碍明显负相关（P＜0．001）,临床疗效赵差血清NSE含量越高（P＜0．001）。结论：脑梗死早期血清NSE明显升高,血清NSE含量与临床表现关系密切。     

糖尿病和脑梗死后高血糖对急性脑梗死的影响

目的探讨糖尿病和脑梗死后高血糖对急性脑梗死的影响。方法将147例脑梗死患者分为糖尿病组、脑梗死后高血糖组（高血糖组）和对照组,对3组患者的临床资料进行统计学分析。结果糖尿病组、高血糖组的斯堪的纳维亚卒中量表评分低于对照组,糖尿病组与高血糖组合并后的并发症的发生率及病死率高于对照组（P〈0.05）。结论急性脑血管病可引起血糖升高,高血糖又可进一步加重脑损伤,积极控制脑梗死患者的高血糖对阻断恶性循环有重要意义。     

Treatment of massive cerebral infarction

Stroke is the third leading cause of death in the United States, with a person dying every 3 minutes of a stroke. Massive ischemic stroke accounts for 10% to 20% of ischemic strokes, has traditionally been associated with a high mortality and morbidity, and requires a unique management strategy. Recent advances in management, fueled by an increased understanding of the pathophysiology, may help decrease mortality and improve outcomes. Rapid access to reperfusion therapies remains the most critical element of stroke care and the cornerstone of therapy. This article focuses on newer therapies, including osmotic therapy, hypothermia, maintained normothermia, strict glycemic control, induced hypertension, and hemicraniectomy, all of which show promise for reducing mortality and improving functional outcome. These interventions have become integrated into neurologic intensive care units around the world. They are complicated, require a high level of expertise, and carry a significant learning curve. In order for these new management techniques to be effective, an expedited, aggressive, meticulous, and potentially prolonged medical management approach is needed. To accomplish this there is a growing need for focused specialists in the areas of neurointensive care and stroke.     

Brain CT scan for acute cerebral infarction: early signs of ischemia]

Computed tomography (CT) is widely used for early evaluation of acute strokes. Most importantly, CT excludes acute hemorrhage or other diseases mimicking ischemia. Therefore, CT is the main imaging examination in patients with brain ischemia and when antithrombotic agents are being considered. During the first hours after acute ischemic stroke, the CT does not usually show much in the first 24 hours. However, early abnormal findings on CT scan have been described such as the hyperdense middle cerebral artery sign (HMCAS), and reduced contrast attenuation of the cerebral parenchyma. HMCAS reflects arterial occlusion. Early parenchymal abnormalities, the attenuation of lentiform nucleus (ALN), loss of the insular ribbon (LIR) or hemispheric sulcus effacement (HSE) occur less frequently and they are positive criteria for cerebral in progress. Early parenchymal abnormalities might also predict subsequent infarct extension and hemorrhagic transformation. Therapeutic trials of ischemia in MCA territory involved decision making when the CT may not show obvious ischemic changes. Finally, initial CT findings may also help to predict response to therapy.     

急性脑梗死与高血浆同型半胱氨酸血症关系探讨

目的探讨急性脑梗死与血浆同型半胱氨酸(Hcy)水平的关系。方法测定86例急性脑梗死病人的血浆Hcy的浓度,并与92例对照者进行比较。结果急性脑梗死组血浆Hcy水平为(17.06±6.61)μmol.L-1,明显高于对照组水平(10.68±5.62)μmol.L-1(t=6.952,P<0.001)。结论高血浆同型半胱氨酸是脑梗死危险因素。     

重症脑梗死脑血流动力学的动态观察

目的:动态观察重症脑梗死脑血流动力学变化的特征和规律。方法:对42例急性重症脑梗死患者进行连续7天的TCD检测,20例正常人TCD检测数据作为正常组。结果:急性重症脑梗死患者脑血流速度减慢。血管阻力参数值(Pl、Rl)增大,病程的3～5天各指标变化达高峰。结论:根据脑血流动力学的特征性改变,表明重症脑梗死在病程早期就有不同程度的缺血性脑水肿发生,进展迅速,多在病程的3—5天达高峰:TCD用于床旁连续监测,可通过动态观察TCD参数变化,评价颅内压变化、判断预后。     

脑梗死合并代谢综合征的并发症及预后分析

目的 总结脑梗死的合并代谢综合征(metabolic syndrome,MS)患者的临床特征.方法 对593例脑梗死患者的临床资料进行相关分析.结果 脑梗死合并MS的发生率为55.99%,脑梗死合并MS与单纯脑梗死患者比较,心、肺、肾等并发症的发生率明显增高.脑梗死患者合并MS的发生率随患者脑梗死病程的延长和发病年龄的增加而呈上升趋势.结论 代谢综合征与脑梗死关系密切,发生MS后直接影响到患者的预后,而脑梗死病程越长,发病年龄越大,MS的发生率越高.     

老年急性脑梗死合并代谢综合征患者的认知损伤表现分析

目的：分析老年急性脑梗死合并代谢综合征（metabolic syndrome ,MS）患者的认知损伤表现,为减少老年急性脑梗死患者的认知损伤提供方案。方法回顾性分析我院2008-02-2013-02收治的急性脑梗死患者153例,其中急性脑梗死合并代谢综合征77例为A组,急性脑梗死患者76例为B组,比较2组认知损伤程度。结果 B组蒙特利尔认知评估量表（MoCA）评分（24.65±4.62）明显高于A组的倡18.58±5.59）,差异有统计学意义（P＜0.05）。主要差异体现在记忆能力、语言流.性、注意力和计算力、定向能力、抽象思维能力方面。结论老年急性脑梗死合并代谢综合征患者的认知功能损伤较单纯急性脑梗死患者损伤严重,治疗中控制好血糖、血压及血脂、体质量等,有助于改善患者认知功能。     

Antithrombotic therapy in cerebral infarction]

Antithrombotic therapy for the acute stage of cerebral infarction consists of thrombolysis, anticoagulant therapy and antiplatelet therapy, and their indications depend on the clinicopathological type of lesion, time after onset, and severity of illness. Tissue plasminogen activator has been approved in the United States for use in cerebral infarction within 3 hours after onset. The usefulness of heparin as anticoagulant therapy at the acute stage of cerebral infarction was not proved by the International Stroke Trial due to hemorrhagic complication. A selective thrombin inhibitor (argatroban) is used in Japan for atherothrombotic cerebral infarction within 48 hours after onset. A selective thromboxane A2 synthetase inhibitor (sodium ozagrel) had been approved for cerebral thrombosis within 5 days after onset. Aspirin (160-300 mg/day) is effective, but slightly, in the acute stage of cerebral infarction by the International Stroke Trial and Chinese Acute Stroke Trial. To prevent recurrence of stroke in the chronic stage of cerebral infarction, antiplatelet therapy (with aspirin or ticlopidine) is used for atherothrombotic cerebral infarction, and anticoagulant therapy with warfarin for cardioembolic cerebral infarction.     

急性脑梗塞所致颅内高压的特点和治疗

急性脑梗塞后病灶区域脑细胞坏死、肿胀等重度脑水肿引起颅内高压从而导致脑疝是神经内科脑梗塞最严重的并发症,常导致患者死亡。甘露醇脱水治疗颅内高压是临床上最常用方法。但是目前在临床上对颅内高压的诊治仍有许多误区,滥用甘露醇仍时有发生,因此正确认识急性脑梗塞所致颅     

CT脑灌注成像指导下的急性前循环脑梗死溶栓治疗

目的 探讨以CT脑灌注成像(CTP)指导下的急性前循环脑梗死溶栓治疗的优越性.方法 通过对比分析5例急性前循环脑梗死者"时间窗"、"缺血半暗带"、和溶栓干预疗效之间的相关关系,阐析以CTP结果指导下的急性前循环脑梗死溶栓治疗的优越性.结果 对急性前循环脑梗死患者进行CTP检查,如显示有缺血半暗带,即使超过溶栓时间窗,仍可进行溶栓治疗(本组有2例效果较好);对在溶栓时间窗内的患者,如CTP显示已有脑梗死形成,对该类患者进行溶栓治疗疗效欠佳(本组有3例).结论 以时间窗为指导的溶栓干预模式存在固有的局限性,对急性前循环脑梗死患者应行CTP检查,根据缺血半暗带来判断是否溶栓治疗,是一种较为理想的模式.