卒中后认知障碍

卒中后认知障碍包括卒中后非痴呆认知障碍和卒中后痴呆,是卒中后由血管因素、神经变性或混合因素导致的认知功能障碍.卒中后认知障碍的慨念虽未被普遍接受,但值得进一步探讨.文章介绍了卒中后认知障碍的流行病学、危险因素、发病机制、临床表现和防治措施.     

缺血性卒中后认知功能障碍的患病率和危险因素

目的 明确卒中后认知功能障碍(PSCI)的患病率和危险因素.方法 526例缺血性卒中患者被分为无认知障碍、认知障碍非痴呆(CIND)和血管性痴呆(VaD),根据影像学表现,患者分为皮质下缺血性血管病、皮质型缺血性血管病和其他类型,登记患者人口学、血管危险凶素和卒中病情等.结果 PSCI患病率36.7%.与无认知障碍相比,PSCI患者年龄大、女性比例高、教育程度低、彳T侧瘫痪多、抑郁评分高,但血管危险因素无差别.与无认知障碍者相比,VaD者经济水平低、配偶照料少、失语多、尿失禁多、皮质型缺血性血管病多;CIND者则有较多的皮质下缺血性血管病.VaD者较CIND者皮质型缺血性血管病多、抑郁评分低.高龄、女性、低社会经济水平、失语、皮质下缺血性血管病、皮质型缺血性血管病和抑郁评分高为PSCI的独立危险因素.结论 PSCI常见于缺血性卒中患者,与人口学因素、卒中类型及抑郁有关.     

脑梗死存活率影响因素的前瞻性研究

目的研究脑梗死后痴呆对存活率的影响。方法对619例急性脑梗死患者进行人文因素、血管因素、卒中特征资料收集和神经心理检查。在入院及卒中后3个月按美国精神病学会DSM-Ⅳ标准对卒中患者进行痴呆诊断,随访2年,分析痴呆患者的存活率及死亡相关预测因素。结果 卒中后3个月共有146例(23.6％)患者被诊断为痴呆,其中39例为卒中前痴呆,107例为卒中相关痴呆。随访(19.4±8.3)个月,卒中后痴呆患者存活率为49.3％,随访(21.3±9.1)个月,卒中相关性痴呆存活率为53.7％,非痴呆患者存活率为92.0％。多因素分析显示,卒中后痴呆与死亡明显相关,脑梗死后痴呆病死率的独立危险因素是年龄、心房颤动、卒中史、日常生活能力评分、卒中后痴呆和卒中相关痴呆。结论痴呆降低卒中患者存活率,并可作为卒中后存活的一个预测因素。     

美国国立神经疾病和卒中研究所-加拿大卒中网血管性认知障碍统一标准

背景和目的：1／3的个体会罹患卒中和（或）痴呆,而且,除卒中或痴呆外,2倍于此数的人会出现认知障碍。常用的卒中量表并不能评价认知功能,而痴呆的诊断标准则集中在认知障碍的晚期阶段,且在很大程度上偏向Alzheimer病（AD）的诊断。尚缺乏普遍公认的标准用于识别和描述存在认知障碍的个体,尤其是在早期阶段,而且特别是与血管因素有关的认知障碍或血管性认知障碍。方法：美国国立神经疾病和卒中研究所（MINDS）与加拿大卒中网（CSN）召集临床诊断、流行病学、神经心理学、脑影像学、神经病理学、试验模型、生物标记物、遗传学和临床试验方面的研究人员,为血管性认知障碍的描述和研究推荐一些最低限度的常用的临床和研究标准。结果：将这些讨论的结果发表于此。结论：一个统一标准的制定代表着使用、确认和改进过程中的第一步。使用相同的标准将有助于在认知障碍的早期阶段识别患者,使不同的研究具有可比性,并且通过整合知识来加速研究进展的步伐。     

钙通道阻滞剂在认知障碍防治中的应用

认知障碍是一个具有重要医学和社会意义的问题,血管危险因素是其重要的病因。大量临床试验和汇总分析表明,钙通道阻滞剂不仅能治疗各种痴呆,还能预防急性缺血性卒中、高血压、蛛网膜下腔出血和脑外伤患者认知障碍的发生。     

钙通道阻滞剂在认知障碍防治中的应用

认知障碍是一个具有重要医学和社会意义的问题，血管危险因素是其重要的病因。大量临床试验和汇总分析表明，钙通道阻滞剂不仅能治疗各种痴呆，还能预防急性缺血性卒中、高血压、蛛网膜下腔出血和脑外伤患者认知障碍的发生。     

缺血性卒中后认知障碍

缺血性卒中可导致不同程度的认知障碍,其发病率很高.认知障碍的早期诊断能提供最佳干预和治疗时机,并延缓疾病进展,因此越来越受到关注.文章对缺血性卒中后认知障碍的病因、发病机制、危险因素、诊断和防治方面的进展做了综述.     

卒中后抑郁的危险因素和机制

抑郁症是卒中后常见的一种并发症,常与残疾、认知障碍和病死率增高相关.文章就卒中后抑郁的流行病学、危险因素、预测因素和病理生理学机制进行了综述.     

谷红注射液治疗脑梗死后认知障碍186例疗效分析

卒中后认知障碍即血管性认知障碍（vasular cognitive impairment，VCI），目前认为是由于脑血管危险因素（高血压、心脏病、糖尿病、和高脂血症等）引起的明显的脑梗死、脑出血或不明显的脑血管病（如白质疏松和慢性脑缺血）引起的从轻度认知障碍到痴呆的综合征。脑梗死后认知障碍的发生率高达20％～30％，脑血液循环改善剂既用于防治衰老也用与改善记忆力，已被广泛应用于临床，我科2004年12月-2006年5月采用谷红注射液治疗梗死后认知障碍186例，取得满意疗效，现报道如下。     

卒中后痴呆

卒中是老年人死亡的主要原因,卒中后发生痴呆的风险增高。卒中后痴呆涵盖了卒中后的各种痴呆类型,是老年人致残的重要原因,其患病率在卒中后3个月至4年内为31·4%~21·5%,其发病率随卒中后时间的延长而增高。卒中和痴呆有许多共同的危险因素。卒中可以是痴呆的直接原因,也可能促进了变性性疾病的发展而引起痴呆。     

Acupuncture-related therapies for the poststroke cognitive impairment patients: A protocol for systematic review and network meta-analysis

Background:To compare and rank the clinical effects of different acupuncture and acupuncture-related therapies on patients with poststroke cognitive impairment.Methods:We evaluated the direct and indirect evidence from relevant studies using network meta-analysis. Eight databases were examined in order to find randomized controlled trials of acupuncture-related therapies for individuals with poststroke cognitive impairment. After 2 researchers independently scanned the literature, extracted the data, and assessed the risk of bias in the included studies, the data were analyzed using RevMan5.4, Stata15.0, and WinBUGS1.4.3 software.Results:We assess the benefits and drawbacks of various acupuncture-related therapies, rank the efficacy of various acupuncture-related therapies in the treatment of poststroke cognitive impairment, and describe the best acupuncture intervention approaches or combinations based on the available data.Conclusion:This study will contribute to the existence of data on the safety and efficacy of acupuncture-related therapies in the treatment of poststroke cognitive impairment, and it may aid clinical guideline makers in selecting the best acupuncture treatment for poststroke cognitive impairment.Registration Number:INPLASY2021120117.     

Elevated serum alkaline phosphatase as a predictor of cognitive impairment in patients with acute ischaemic stroke: A retrospective cohort study

BackgroundIn the present study, we assessed the relationship between serum alkaline phosphatase (ALP) levels and cognitive function changes in acute ischaemic stroke patients.MethodsWe retrospectively collected the demographic data and clinical information from the medical records of patients after the onset of ischaemic stroke. We used the Chinese version of the Mini-Mental State Examination to assess cognitive function. Mixed linear and logistic regression models adjusted for several factors were used to explore the relationship between ALP and cognitive impairment.ResultsA total of 1019 patients were included in the analysis, including 523 poststroke patients with cognitive impairment (PSCI) and 496 patients with non-PSCI. The incidence of poststroke cognitive impairment was 51.3 %. The serum ALP level in the PSCI group was significantly higher than that in the non-PSCI group (86.5 ± 18.9 U/L vs 68.6 ± 15.5 U/L, P < 0.001). The mixed linear model fully adjusted for all variables indicated that the ALP level was positively associated with cognitive impairment (based on the Mini-mental State Examination score) decline, with changes from -0.54 to -0.16 per unit increase in ALP. The logistic regression revealed that the odds of cognitive impairment increased by 42 % when the ALP concentration increased by one U/L (odds ratio (OR) = 1.42, 95 %CI: 1.17−3.09, P = 0.012). The spline regression model further confirmed the dose-response relationships between ALP levels and three-month cognitive impairment (P for nonlinear trend = 0.012).ConclusionThe present study revealed that relatively high serum ALP levels at baseline might be an independent risk factor for cognitive impairment in patients with acute ischaemic stroke.     

Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes

OBJECTIVES: To identify factors that were associated with cognitive impairment 3 months after stroke, and to examine the associations of cognitive impairment with stroke outcomes up to 4 years after stroke. DESIGN: Observational study. SETTING: Population-based stroke register. PARTICIPANTS: Six hundred forty-five subjects with first-ever stroke, identified from the register. MEASUREMENTS: Subjects were assessed for cognition using the Mini-Mental State Examination (MMSE) 3 months after stroke. Cognitively impaired subjects (MMSE <24, n = 248 (38%)) were compared with cognitively intact subjects (MMSE 24-30, n = 397) in terms of demographic details, stroke risk factors, laterality of stroke, and initial poststroke impairments. Outcome data collected at 1, 3, and 4 years poststroke included disability assessed by the Barthel Index (BI) and the Frenchay Activity Index, case fatality, and institutionalization. RESULTS: Two hundred forty-eight (38%) of 645 subjects were cognitively impaired 3 months after stroke. Using multivariate analyses, cognitive impairment was associated with age of 75 and older (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.5-4.2), ethnicity (Caribbean/African (OR = 1.9, 95% CI = 1.2-3.2) and Asian (OR = 3.4, 95% CI = 1.1-10.2), lower socioeconomic class (OR = 2.1, 95% CI = 1.3-3.3), left hemispheric lesion (OR = 1.6, 95% CI = 1.01-2.4), visual field defect (OR = 2.0, 95% CI = 1.2-3.2), and urinary incontinence (OR = 4.8, 95% CI = 3.1-7.3). Using multivariate analyses, cognitive impairment was associated with death or disability (BI <15) at 4 years after stroke (OR = 2.2, 95% CI = 1.1-4.5). In univariate analyses, it was also associated with higher institutionalization 4 years after stroke (P =.001). CONCLUSIONS: Cognitive impairment is common 3 months after stroke and is independently associated with older age, ethnicity, lower social class, left hemispheric stroke, visual field defect, and urinary incontinence. It is associated with poor long-term outcomes, including survival and disability, up to 4 years after stroke. Because physical and cognitive impairments after stroke have independent prognostic implications, measures that evaluate both functions should be used in future studies of stroke outcome and in care of stroke patients.     

50岁以上患者卒中后认知功能损害及生活质量的研究

目的 探讨54岁以上患者的卒中后认知功能损害及其对患者生活质量的影响。方法运用中文版简易智能量表（MMSE）、神经功能缺损量表（NFDS）和诺丁汉健康问卷（NHP）对318例卒中患者进行现状调查。结果①318例卒中患者中,93例有卒中后认知障碍,发生率为29．2％。②认知功能损害组93例,年龄为54～86岁,平均（66±3）岁。〈60岁患者中认知功能损害有21例,占22．6％（21／93）;≥60岁患者中有72例,占77．4％（72／93）,两者比较差异有统计学意义,u=2．32,P〈0．05。即≥60岁卒中后认知障碍患者的发生率高于〈60岁患者的发生率。③本组女性患者58例,发生率为50．4％（58／115）,男性患者35例,发生率为17．2％（35／203）,两者比较差异有统计学意义,X^2=39．085,P〈0．001,即女性发病率高于男性。④本组患者中241例有不同程度的神经功能缺损,其中93例出现认知功能损害表现,发生率为38．6％（93／241）,认知功能损害患者神经功能缺损评分（12．0±2．8）;无认知功能损害患者148例的神经功能缺损评分为（8．4±2．1）,两者比较差异有统计学意义,t=10．68,P〈0．001,即卒中后有认知功能障碍患者的NHP和NFDS评分高。⑤采用NI-IP问卷测定结果表明,认知功能损害组的老年人精力、情绪反应、社交隔离、躯体活动、嗜好、社会交往、与亲属关系均低于对照组（P〈0．01）。结论50岁以上卒中后认知功能障碍发生率较高,对患者的神经功能及生活质量有明显的影响。     

Association between mild vascular cognitive impairment and impaired activities of daily living in older stroke survivors without dementia

OBJECTIVES: To determine the relationship between mild vascular cognitive impairment (mVCI) and functional disability in older stroke survivors without dementia. DESIGN: Cohort study. SETTING: Stroke patients from representative hospital-based stroke registers. PARTICIPANTS: Three hundred thirty-nine stroke survivors without dementia, aged 75 and older. MEASUREMENTS: Neuropsychological assessments were completed 3 months poststroke. Activities of daily living (ADLs) were evaluated using the Bristol scale. Operationalized criteria, including cognitive impairment no dementia (CIND), were applied for mVCI. RESULTS: Significant impairments of ADLs were evident in mVCI (CIND vs no CIND; basic care: z=3.2; P=.001, intermediate care: z=3.6; P<.001, complex management: z=4.5; P<.001) but varied according to the profile of cognitive impairments. Patients with attentional or global impairments had more severe functional disability than patients with isolated memory deficits, with an intermediate level of dysfunction in patients with executive impairments. CONCLUSION: The findings emphasize the importance of identifying early cognitive impairments to optimize rehabilitation, care planning, and secondary prevention of dementia in stroke patients.     

Cardiovascular disease risk factors and cognitive impairment

The role of cardiovascular disease risk factors in the occurrence and progression of cognitive impairment has been the subject of a significant number of publications but has not achieved widespread recognition among many physicians and educated laymen. It is apparent that the active treatment of certain of these cardiovascular disease risk factors is accompanied by a reduced risk for cognitive impairment. Patients with hypertension who are treated experience fewer cardiovascular disease events as well as less cognitive impairment than similar untreated patients. Patients who exercise may present with less cognitive impairment, and obesity may increase the risk for cognitive impairment. Lipid abnormalities and genetic markers are associated with an increased risk for cardiovascular disease and cognitive impairment. Autopsy studies have demonstrated a correlation between elevated levels of cholesterol and amyloid deposition in the brain. Research has demonstrated a relation between atherosclerotic obstruction lesions in the circle of Willis and dementia. Diabetes mellitus is associated with an increased risk for cardiovascular disease and cognitive impairment. A number of nonpharmacologic factors have a role in reducing the risk for cognitive impairment. Antioxidants, fatty acids, and micronutrients may have a role, and diets rich in fruits and vegetables and other dietary approaches may improve the outlook for patients considered at risk for cognitive impairment.     

心房颤动和认知功能下降的关系研究

心房颤动（简称房颤）是老年人常见的心律失常,并随着年龄增长发病率及死亡率增高。众多的血管危险因素和血管疾病导致认知功能障碍和痴呆,而年龄亦是认知功能障碍的最主要因素。房颤和认知功能障碍相关的可能机制有：共同危险因素及共患病、缺血性卒中（有症状或无症状）、房颤的促炎状态等。房颤患者窦律的恢复和抗凝治疗有可能降低认知功能障碍的发生。本文将从房颤与认知功能障碍的相关性、可能机制及房颤治疗后认知获益方面进行综述。     

Underrecognition of preexisting cognitive impairment by physicians in older ICU patients

OBJECTIVES: Cognitive impairment increases with age, as do many serious illnesses requiring intensive care. Little is known, however, about physician recognition of preexisting cognitive impairment in the ICU and which patient factors may play a role in physician recognition. DESIGN: Cross-sectional comparative study. SETTING: Urban university teaching hospital. PARTICIPANTS: A total of 165 patients aged > or =65 years who were admitted to the medical ICU. MEASUREMENTS: Two previously validated proxy measures of cognitive impairment, the modified Blessed dementia rating scale and the informant questionnaire on cognitive decline in the elderly. Physician interviews and medical record abstraction were used to evaluate the recognition of cognitive impairment. RESULTS: The prevalence of preexisting cognitive impairment in the ICU was 37%. Attending physicians were unaware of the preexisting cognitive impairment in 53% of cases, and intern physicians were unaware in 59% of cases. The recognition of preexisting cognitive impairment increased as the severity of the cognitive impairment increased. Two independent risk factors were identified that were significantly associated with the increased recognition of preexisting cognitive impairment (ie, impairment in activities of daily living or being admitted to the ICU from a nursing home). If both were present, preexisting cognitive impairment was 13 times more likely to be recognized. CONCLUSIONS: A substantial number of older ICU patients have preexisting cognitive impairment on admission to the ICU, and ICU physicians caring for these patients are unaware of this cognitive impairment in the majority of cases. Future research is needed to identify outcomes related to preexisting cognitive impairment and to improve its recognition.