急性缺血性卒中的影像学新进展

缺血性卒中是一种致死和致残率很高的常见病，近年来随着螺旋CT扫描技术和MR平面回波技术的发展，CT灌注成像和MR灌注、弥散加权成像技术可超早期显示脑缺血时的血流灌注情况，为超早期诊断提供了可靠的影像学信息。     

急性缺血性卒中血管内治疗研究进展

血管内治疗已成为急性缺血性卒中有效的治疗方法,在临床工作中对急性缺血性卒中患者的管理包括多种因素,且急性缺血性卒中的理想治疗方法仍然存在争议.该文综合现有最佳证据的最新建议,为卒中患者的血管内治疗决策与管理提供指导.     

平卧位能改善急性缺血性卒中患者的脑血流速度

蛛网膜下腔出血(SAH)的发病年龄较小，转归通常不良。约70％的SAH患者死亡或生活依赖。其中1／3要归咎于迟发性脑缺血(delayed cerebral ischemia，DCI)。超过半数的SAH患者存在低镁血症。后者可能与转归不良有关。动物实验证实，硫酸镁能逆转大鼠实验性SAH的血管痉挛和缩小梗死体积。     

急性缺血性卒中血管再通治疗的研究进展

美国心脏联合会研究数据显示,在美国每年有79．5万人首次或再次发生卒中事件,给社会及家庭带来了巨大的负担。而其中缺血性卒中最为常见,约占全部卒中亚型的60％-87％[1-3]。因此,如何有效地预防和治疗缺血性卒中已成为目前广泛关注的热点。有研究显示,中枢神经细胞对缺血的耐受性极差,在供氧不足的情况下,平均每分钟就有190万个神经细胞永久丧失功能[4]。患者恢复脑灌注时间每拖延30min,其神经功能恢复概率就下降10％[5]。因此,尽早恢复缺血脑组织的灌注即血管再通,是治疗缺血性卒中的关键。目前血管再通主要采取溶栓药物治疗和血管内机械取栓治疗两种手段,笔者就两种治疗的研究进展综述如下。     

急性缺血性卒中的磁共振成像研究进展

早期诊断和早期溶栓治疗能使缺血性卒中患者获得更好的预后.在该领域中,现代磁共振成像技术的发展所带来的益处备受关注,且直接指导了急性缺血性卒中的治疗.文章对目前临床上较为常用的磁共振弥散加权成像、灌注加权成像、磁共振波谱分析等新技术做了简要介绍.     

急性缺血性卒中转归的血清生物标志物

血清生物标志物在预测急性缺血性卒中的严重程度、早期神经功能恶化和转归方面具有重要作用.了解这些血清生物标志物的种类、作用机制以及与急性缺血性脑损伤的相关性,有助于急性缺血性卒中患者的早期转归预测并指导治疗.     

瘦素对缺血性卒中影响的研究进展

正瘦素对处于缺血、缺氧状态下的神经细胞具有保护作用,可有效减少缺血、缺氧引起的神经细胞死亡,减少梗死体积~([1-3])。对于瘦素神经保护作用的研究尚处于基础阶段,瘦素作为卒中风险预测因子的临床应用仍存在一定争议。作为目前国内外的研究热点,了解瘦素的神经保护作用及机制对防治缺血性脑血管疾病具有重要的基础和临床意义,现对其神经保护机制及临床研究的最新进展综述如下。1瘦素的神经保护作用瘦素是一种由肥胖基因编码,主要由脂肪细胞     

缺血性卒中DNA甲基化调控的研究进展

正神经可塑性作为贯穿于整个卒中后神经功能康复过程的基础[1],其发生机制目前并不十分清楚,但康复过程存在多种调控神经发育基因的改变。现代分子生物学研究显示,细胞中信息的表达受两种因素控制:一种是遗传调控,另一种是表观遗传调控。表观遗传学机制主要包括DNA甲基化/去甲基化,组蛋白修饰和非编码RNA(如microRNA),调控不同细胞类型的特异性基因表达及其转录程     

急性缺血性卒中静脉溶栓后缺血性早期神经功能恶化的研究进展

静脉溶栓是指南推荐的治疗急性缺血性卒中的有效方式,很多患者静脉溶栓后虽然神经功能获得改善,但溶栓后24 h内症状再次恶化,称为早期神经功能恶化(END)。目前指南推荐溶栓24 h后除外颅内出血后给予抗血小板聚集药物治疗,因此,静脉溶栓后缺血性END是临床中非常棘手的问题。作者根据近年的研究情况,从静脉溶栓后缺血性END的定义、发生率、危险因素、发生机制以及预防和治疗措施等方面进行阐述,以期为广大临床医师和研究者在静脉溶栓后缺血性END的预防、诊治及研究方向等方面提供参考。     

Outcome of first-ever acute ischemic stroke in the elderly

Our purpose was to evaluate the outcome of patients aged 70 years or older with a first-ever acute ischemic stroke and to identify the factors which determine poor outcome. Data from 115 patients, non-disabled prior to stroke, consecutively admitted to a medical department of a teaching hospital over a 30-month period, were prospectively collected at stroke onset and 6-month follow-up. Clinical and brain imaging findings and functional status were recorded. Predictors of unfavorable outcome at 6 months, defined as a modified Rankin Scale score >2, were analyzed by multiple logistic regression. The mean age of this cohort was 78.6 years (SD, 5.7) and 66.1% were women, 73.9% had hypertension, 25.2% diabetes, 36.0% atrial fibrillation (AF), 33.9% heart failure (HF), 15.8% previous transient ischemic attack (TIA), 47.8% a Charlson comorbidity index (CCI) score >1 and 52.2% a baseline National Institute of Health stroke scale (NIHSS) score ≥6. At 6 months, 54 patients (47%) had unfavorable outcome and the independent predictors of poor outcome were the initial systolic blood pressure and the NIHSS score on admission. In conclusion, near 50% of these old patients were dependent or dead 6 months after stroke onset and the main predictor of poor outcome was the neurological severity of stroke.     

缺血性卒中患者血清生物标志物的应用现状

缺血性卒中具有高发病率、高致残率及高病死率的特点,血清中神经元特异性烯醇化酶、S-100β蛋白、细胞间黏附分子1、C反应蛋白、纤维蛋白原、D-二聚体及血清铁蛋白等生物标志物对缺血性卒中的辅助诊断、出血转化风险预测及预后判断等方面有重要的应用价值.该文对以上血清生物标志物在缺血性卒中中的应用作一综述.     

圆形分布法在缺血性中风事件昼夜分布中的应用

目的探讨缺血性中风发病时间的昼夜分布规律。方法采用圆形分布对２６３例缺血性中风患者的发病时间进行统计分析。结果缺血性中风发病的高峰时点平均为８∶２１,标准差（ｓ）为４小时零３分,９５％的缺血性中风发病时段为０∶２５～１６∶１７。结论圆形分布对于昼时性资料是否具有集中趋势提供良好的统计分析,缺血性中风的发病时间存在昼夜２４ｈ的分布差异。     

单唾液酸神经节苷脂治疗老年急性缺血性脑卒中的临床研究

目的通过对单唾液酸神经节苷脂（ＧＭ１）治疗组与常规治疗组病人神经功能缺损程度的评定，阐明ＧＭ１在老年缺血性脑卒中患者急性期应用对局灶性脑缺血的损害有一定保护作用。方法采用Ｆｒｉｔｈｚ－Ｗｅｎｎｅｒ（ＦＷ）及ＢａｒｔｈｅｌＩｎｄｅｘ（ＢＩ）评分法，对病人进行神经学及日常生活能力和意识水平评分。结果ＧＭ１治疗组病人治疗后ＦＷ及ＢＩ评分均高于对照组（Ｐ＜０．０１）。结论ＧＭ１在缺血性脑卒中急性期使用提高了治愈率，降低了病人神经功能的缺损程度。     

Association between serum matrix metalloproteinase-9 and poor prognosis in acute ischemic stroke patients: The role of dyslipidemia

Background and aimsWhether the prognostic value of matrix metalloproteinase-9 (MMP-9) is modified by patients' dyslipidemia status is unknown. The aim of present study was to evaluate the prognostic effect of MMP-9 among ischemic stroke patients stratified by dyslipidemia status.Methods and resultsMMP-9 levels were measured for 2977 acute ischemic stroke patients from 26 participating hospitals across China, and data of clinical outcomes within one year after ischemic stroke was collected. The primary outcome was a composite outcome of major disability and death at one year after stroke onset, and secondary outcomes were major disability, death, vascular events and recurrent stroke. The association between MMP-9 and primary outcome was appreciably modified by dyslipidemia status (P_interaction = 0.048). After multivariate adjustment, increased MMP-9 level was associated with increased risk of primary outcome at one year after ischemic stroke in the patients with dyslipidemia (odds ratio, 1.34; 95% confidence interval, 1.06–1.79), but not in those without dyslipidemia (odds ratio, 1.23; 95% confidence interval, 0.90–1.68). Increased MMP-9 was also significantly associated with major disability, death and vascular events in the patients with dyslipidemia but not in those without dyslipidemia (P for interaction < 0.05 for all).ConclusionIncreased MMP-9 was associated with poor prognosis within one-year after stroke only in patients with dyslipidemia, suggesting that the prognostic value of MMP-9 be modified by dyslipidemia status of ischemic stroke patients. Further prospective study from other populations and randomized clinical trials are needed to verify our findings and clarify the potential mechanisms.     

急性缺血性卒中患者的血压管理

急性缺血性卒中患者在发病最初24 h内一般会出现血压增高,且血压水平与患者预后相关.在缺血性卒中急性期的血压管理中,无论是试图升压或是降压治疗都存在争议.文章综述了缺血性卒中急性期血压变化以及血压管理与卒中预后的关系.     

急性缺血性卒中静脉溶栓决策的影响因素

目的探讨静脉注射阿替普酶溶栓治疗在急性缺血性卒中临床实践中应用的影响因素。方法回顾性连续纳入2011年4月至2014年4月首都医科大学宣武医院神经内科收治的急性缺血性卒中患者1 068例,均为发病12 h内。其中资料不全(7例)、存在绝对禁忌证(465例)者被排除,最终有596例无绝对禁忌证的静脉溶栓候选者被纳入研究。以有无进行静脉溶栓治疗为终点事件,根据是否采用阿替普酶静脉溶栓治疗将静脉溶栓候选者分为治疗组(133例)和对照组(463例)。比较两组年龄、性别、发病至入院时间(OTD)、发病日期、多模式影像检查和卒中美国国立卫生研究院卒中量表(NIHSS)评分等的差异,分析年龄、性别、OTD和基线NIHSS评分对静脉溶栓决策的影响。静脉溶栓的绝对禁忌证包括OTD超过6 h、卒中模拟病、影像学证据提示的出血性卒中、未获得患者及家属知情同意等。结果小卒中及症状快速恢复卒中(MRIS)是静脉溶栓候选者中最常见的相对禁忌证[47.5%(283/596)],其次为发病至评估结束时间超过4.5 h[34.7%(207/596)]。治疗组NIHSS评分高于对照组,OTD低于对照组,MRIS比例低于对照组,多模式CT检查比例高于对照组,组间差异均有统计学意义[NIHSS评分:9.0(5.5,12.0)分比2.0(1.0,5.0)分;OTD:120(74,170)min比210(120,285)min;MRIS:12.0%(16/133)比61.1%(283/463);多模式CT检查:33.1%(44/133)比21.8%(101/463),均P0.01];两组间年龄、性别及工作日发病的差异均无统计学意义(均P0.05)。以有无静脉溶栓治疗为终点指标的Logistic回归分析结果显示,年龄及OTD与静脉溶栓治疗决策呈负相关(OR=0.97,95%CI:0.95~0.99,P0.05;OR=0.99,95%CI:0.98~0.99,P0.01),基线NIHSS评分及多模式CT检查与静脉溶栓治疗决策呈正相关(OR=1.24,95%CI:1.17~1.31,P0.01;OR=17.55,95%CI:4.28~71.88,P0.01)。结论 MRIS及发病至评估结束时间延误是急性缺血性卒中排除溶栓治疗的最主要原因,多模式CT影像和较重的基线卒中程度是促进静脉溶栓临床决策的正性影响因素。     

Assessment of neovascularization within carotid plaques in patients with ischemic stroke

AIM: To assess neovascularization within human carotid atherosclerotic soft plaques in patients with ischemic stroke.METHODS: Eighty-one patients with ischemic stroke and 95 patients without stroke who had soft atherosclerotic plaques in the internal carotid artery were studied. The thickest soft plaque in each patient was examined using contrast-enhanced ultrasound. Time-intensity curves were collected from 5 s to 3 min after contrast injection. The neovascularization within the plaques in the internal carotid artery was evaluated using the ACQ software built into the scanner by 2 of the experienced investigators who were blinded to the clinical history of the patients.RESULTS: Ischemic stroke was present in 7 of 33 patients (21%) with grade I plaque, in 14 of 51 patients (28%) with grade II plaque, in 26 of 43 patients (61%) with grade III plaque, and in 34 of 49 patients (69%) with grade IV plaque (P < 0.001 comparing grade IV plaque with grade I plaque and with grade II plaque and P = 0.001 comparing grade III plaque with grade I plaque and with grade II plaque). Analysis of the time intensity curves revealed that patients with ischemic stroke had a significantly higher intensity of enhancement (IE) than those without ischemic stroke (P < 0.01). The wash-in time (WT) of plaque was significantly shorter in stroke patients (P < 0.05). The sensitivity and specificity for IE in the plaque were 82% and 80%, respectively, and for WT were 68% and 74%, respectively. There was no significant difference in the peak intensity or time to peak between the 2 groups.CONCLUSION: This study shows that the higher the grade of plaque enhancement, the higher the risk of ischemic stroke. The data suggest that the presence of neovascularization is a marker for unstable plaque.     

急性缺血性卒中的远程卒中医疗和护士的作用

急性缺血性卒中的有效治疗方法包括在具备多学科治疗小组的专科病房(卒中单元)接受治疗和静脉溶栓治疗.然而,仅有少部分患者能够接受这些治疗.远程卒中医疗可提高现场缺乏卒中专科医生的医院的急性缺血性卒中溶栓率,并且可使乡村地区的卒中医疗保持在高质量水平.文章对急性缺血性卒中的远程卒中医疗和护士的作用进行了综述.     

The association between cerebral atherosclerosis and arterial stiffness in acute ischemic stroke

Objective

Arterial stiffness is associated with cardiovascular risk factors and atherosclerosis. Measurement of pulse wave velocity (PWV) is one of the most representative and noninvasive techniques for assessing arterial stiffness. We investigated the association of cerebral atherosclerosis with brachial-ankle PWV (baPWV) in acute ischemic stroke patients. If present, we sought to determine whether the relationship differed between atherosclerosis in the intracranial artery and atherosclerosis in the extracranial artery.

Methods

We included 801 patients with acute ischemic stroke who had undergone angiographic study and baPWV measurement between January 2007 and May 2010. Patients with cerebral artery atherosclerosis were categorized into those with intracranial atherosclerosis, those with extracranial atherosclerosis and those with both intracranial and extracranial atherosclerosis. We determined factors that were associated with baPWV.

Results

Univariate and multivariate analyses showed that high baPWV was significantly associated with older age, lower body mass index, higher brachial systolic pressure, and diabetes mellitus. Increased baPWV was associated with the presence of atherosclerosis (≥50% stenosis) in the intracranial cerebral artery as well as in both the intracranial and extracranial arteries, but not with atherosclerosis in the extracranial cerebral artery. The burden of intracranial cerebral atherosclerosis, which was assessed based on the number of arteries with atherosclerosis, was also closely associated with baPWV.

Conclusion

Arterial stiffness was associated with the presence and burden of intracranial cerebral atherosclerosis in stroke patients, but was not associated with the extracranial cerebral atherosclerosis. These findings suggest a potential pathophysiological association between increased arterial stiffness and intracranial cerebral atherosclerosis.