缺血性卒中患者脑内微出血特点及危险因素的研究

目的 探讨脑内微出血在缺血性卒中患者中的发生率及在脑内各区域的分布情况,观察缺血性卒中亚型之间微出血发生率的差异,初步分析其相关因素及其与腔隙性脑梗死、脑白质病变等微小血管病变程度之间的关系。方法 连续入选261例心源性栓塞型、大动脉粥样硬化型及小动脉闭塞型3个亚型的缺血性卒中患者。记录患者一般临床资料及实验室检查结果,应用头颅磁共振梯度回波T2*加权成像（gradient-echoT2*-weighted,GRE-T2*）观察脑内微出血的数目及部位,同时观察腔隙性脑梗死数目和部位以及脑白质病变程度。结果 80例患者（30.70%）存在脑内微出血,数目为1～109个。微出血最常见于皮质-皮质下区（46.09%）,其次位于基底节区（27.80%）。各亚型中小动脉闭塞型患者脑内微出血的发生率最高（53.30%）。高血压、腔隙性脑梗死数目及脑白质改变程度为缺血性卒中患者脑内微出血发生的独立危险因素,比值比（odds ratio,OR）分别为4.364、1.190和1.310;脑内微出血的分级与腔隙性梗死分级（r =0.519,P <0.001）及白质改变程度（r =0.437,P <0.001）显著相关。结论 微出血在缺血性卒中患者特别是小动脉闭塞患者中发生率较高,微出血与腔隙性脑梗死数目及脑白质改变明显相关。     

衰老相关的脑小血管病诊疗现状和亟待解决的问题

脑小血管病(cerebral small vessel disease,CSVD)是指脑小动脉、分支小动脉、毛细血管和小静脉病变,导致临床表现为多种症状的一种综合征,如情绪异常、排尿异常、步态异常、腔隙性脑梗死、脑出血、认知功能障碍和痴呆、帕金森综合征等。MRI表现为脑白质损伤也称脑白质高信号(T2WI和FLAIR)、腔隙性梗死、扩大的血管周围间隙、脑微出血及脑萎缩。     

脑微出血对认知功能的影响及其发病机制研究进展

认知功能是人脑的高级功能,随着社会的老龄化,认知功能障碍和痴呆患者日益增多.流行病学研究显示,皮质下小血管病变是引起认知功能损害和痴呆的危险因素[1].通常,MRI上显示的白质高信号及腔隙性脑梗死被认为是常见的脑小血管病变标志.关于脑白质病变及腔隙性脑梗死与认知功能的研究颇多,但目前,在个体患者中脑白质病变及腔隙性脑梗死的临床意义仍难与患者的认知功能表现建立联系[1].     

脑内微出血的研究进展

MRI能显示脑内一些无症状的微小或轻微病变。既往只能依靠病理才能诊断的脑白质疏松(leukoaraiosis)和腔隙性脑梗死(lacunar cerebral infarction)等微小血管病变，临床上利用MRI T2加权相的脑白质高信号改变已能作出诊断。但多数研究集中在脑微小血管病变所致的缺血性损害，对通过严重破坏的小血管壁发生的脑内微出血(intracerebral     

血脑屏障与脑小血管病

脑小血管病是指主要累及直径400μm以下的脑微小动脉血管病,临床表现为无症状性脑梗死,各种腔隙综合征和血管性认知功能障碍,影像学表现为腔隙性脑梗死灶,脑白质缺血性损害,微出血及血管间隙扩大的多种病因性疾病。血脑屏障渗透性的改变与脑小血管病之间有着重要的关系,即血管内皮及相关结构功能障碍导致血脑屏障渗透性增加,造成血液成分漏出到血管周围组织和脑实质内,继发相应的病理生理改变,导致脑小血管病相关的影像学和病理变化。     

脑皮质下小血管病变与脑萎缩的相关性分析

目的探讨脑皮质下小血管病变与脑萎缩的相关性。方法通过10例临床确诊为脑萎缩的病人的调查,收集其临床基本资料及头颅磁共振成像(magnetic resonance imaging,MRI)的结果及图像,评判其脑皮质下小血管的病变情况。结果所有病例颅脑MRI均发现显著的弥漫性脑白质病变(white matter lesions,WML)和多发的脑腔隙性梗死灶(lacunarinfarcts,LI)。结论颅脑MRI提示,脑皮质下小血管病变与脑萎缩共存,提供了其与脑萎缩可能有关的临床依据。     

腔隙性脑梗塞患者脑内微出血的发生、分布及其意义

目的 探讨脑内微出血在腔隙性梗塞病人中的发生率及在脑内各区域的分布情况,以及与其他微小血管病变包括脑白质改变和腔隙性梗塞之间的关系。方法 连续入选腔隙性脑梗塞病人82例。记录一般临床资料、实验室检查及神经精神功能评分包括入院时的美国国立卫生研究院卒中评分(NIHSS)和发病三个月时的Barthel生活指数(BI)和简易精神状态量表(MMSE)。所有病人均进行头颅MR检查观察脑内微出血的数目及部位,脑白质改变的程度和腔隙性脑梗塞的数目及部位。数据处理均采用SPSS软件进行。结果 22例患者(27％)存在脑内微出血,数目由1～42个,分布于脑内不同部位包括皮层-皮层下、丘脑基底节区、小脑和脑干。微出血的数目与腔隙性梗塞的数目以及脑白质改变的程度显著相关(r=0.297,0.552;P=0.007,<0.001)。3个月时微出血组病人的MMSE和BI有低于无微出血组病人的趋势(22.56 vs 24.53,16.71 vs 19.11),但无统计学差异(P=0.162,0.052)。结论 脑内微出血在腔隙性脑梗塞中发生率较高,且与脑白质改变的严重程度以及腔隙性梗塞的数目相关。提示脑内微出血是另外一种微小血管病损的标志,可能代表着更为严重的小血管壁的损害,更为直接地提示出血倾向,在腔隙性脑梗塞的治疗及预防过程中应予以相应的重视。     

脑小血管病与步态障碍相关性研究进展

脑小血管病的影像改变包括脑白质高信号、腔隙性脑梗死、血管周围间隙、脑微出血、脑 萎缩等。步态障碍是脑小血管病的重要临床特征,进一步导致跌倒风险增加。脑小血管病破坏脊髓 运动系统和皮层、基底节纤维联系的完整性,同时存在视空间和执行功能障碍、抑郁状态等多种认 知或精神心理障碍,均与步态异常显著相关。在步态障碍的上述产生机制中,侧脑室周围、额叶深部 白质疏松与运动协调和认知损伤相关;腔隙性脑梗死常见于运动-认知风险人群;血管周围间隙、一 定数量的脑微出血、脑萎缩或脑灌注异常等均会导致认知损伤相关步态障碍。本文根据近期研究进 展,以不同的临床或影像特征为基础,对脑小血管病导致步态障碍的发病机制进行详细综述。     

编者按

正脑小血管病(cerebral small vessel disease,CSVD)中80%左右与老年相关,为衰老性疾病,其中腔隙性脑梗死分别占卒中的25%～30%、老年性痴呆的45%。危险因素主要为高血压、糖尿病、吸烟、睡眠呼吸暂停综合征、慢性肾脏病、皮层下卒中相关的分支动脉粥样硬化性疾病、高脂血症等。其MRI表现主要为:腔隙性脑梗死、脑白质高信号、脑微出血、扩大的血管周围间隙及脑萎缩。诊断结合病史、临床表现和MRI。治疗主要控制危险因素,对腔隙性脑梗死建议长期使用一种抗血小板     

脑小血管病的结构影像学研究

正脑小血管病主要是各种病因累及脑小动脉、微动脉、毛细血管和小静脉,从而引起急性脑卒中、认知障碍、精神行为异常及步态障碍等一系列临床症状的疾病。磁共振上主要表现包括近期皮质下小梗死、腔隙性脑梗死、脑白质高信号、血管周围间隙扩大、脑微出血及脑萎缩。本文对脑小血管病在影像学方面的研究进展进行综述。一、脑小血管病脑小血管病(cerebral small vessel disease,CSVD)由脑血管损伤的各种原因引起的脑血管疾病导致一系列疾病的临床、影像成像和病理变化,包括脑动脉、小动脉、毛细血管     

Virchow-Robin spaces relate to cerebral small vessel disease severity

BACKGROUND AND PURPOSE: Virchow-Robin spaces (VRs) are perivascular spaces surrounding the deep perforating brain arteries. VRs dilatation is pathologic, and it could be a manifestation of cerebral small vessel disease. In the present study we assessed the relation between VRs and silent ischemic lesions in a cohort of patients with cerebral small vessel disease. METHODS: We divided dilated VRs on MRI (1.5 Tesla) into three semi-quantitative categories in 165 first ever lacunar stroke patients. We counted asymptomatic lacunar infarcts and graded white matter lesions, and compared the prevalence of vascular risk factors in different categories of VRs. We also determined independent predictors of silent ischemic lesions. RESULTS: VRs at basal ganglia level related to age, hypertension, asymptomatic lacunar infarcts, and white matter lesions. VRs at basal ganglia level predicted silent ischemic lesions (odds ratio 10.58 per higher VRs category; 95 %- confidence interval 3.40 - 32.92). CONCLUSION: Dilated VRs in the basal ganglia relate to the severity of cerebral small vessel disease and might be a manifestation of the same small vessel abnormality that causes silent ischemic lesions. This adds a role for VRs as a potential marker for small vessel disease.     

Cerebral small vessel disease: a review of clinical, radiological, and histopathological phenotypes

Cerebral small vessel disease is difficult to directly visualize in vivo. Therefore, we rely on radiological phenotypes as surrogate markers of disease. The principal phenotypes of clinical interest are small, deep brain infarcts, cerebral white matter lesions, deep brain haemorrhages, and cerebral microbleeds. The causes or mechanisms underlying these phenotypes are understood in varying degrees of detail. This review aims to summarize recent knowledge regarding these phenotypes and place it in context with classical clinicopathological observations to provide mechanistic, clinical, and therapeutic insights into small vessel disease.     

Cerebral small vessel disease and C-reactive protein: results of a cross-sectional study in community-based Japanese elderly

BACKGROUND AND PURPOSE: Inflammatory processes are involved in the pathogenesis of atherosclerosis. Inflammation has been known as a risk factor for coronary heart disease, whereas inflammation as a risk for cerebrovascular disease is less well established. Whether inflammatory processes, excluded from their involvement in large-vessel disease, are implicated in the pathogenesis of cerebral small vessel disease remains unclear. We assessed whether higher C-reactive protein (CRP) levels were associated with an increased number of lacunar infarcts or severity of white matter lesions. METHODS AND RESULTS: In a community-based group of Japanese elderly (n=689), CRP concentrations were measured using a highly sensitive assay. All participants underwent magnetic resonance imaging (MRI), and cerebral small vessel disease-related lesions (lacunar infarcts and white matter hyperintensity) were subsequently evaluated. Furthermore, carotid atherosclerosis was also assessed with ultrasonography. As the grades of white matter hyperintensity and the numbers of lacunes were considered small vessel disease-related lesions, we evaluated the relationships between CRP levels and small vessel disease-related brain lesions. Interestingly, the median CRP concentration of our participants was remarkably lower, being approximately one third or one quarter of the value of Western populations. Subjects with higher CRP levels tended to have more small vessel disease-related lesions; however, these associations were not seen after adjustment for cardiovascular risk factors and carotid atherosclerosis. CONCLUSIONS: The relationship between CRP levels and small vessel disease-related lesions was not apparent in the community-based Japanese elderly. The impact of inflammation in the pathogenesis of small vessel disease-related brain lesions seems to be weak among the Japanese elderly.     

症状性小动脉硬化脑小血管病患者脑微出血的危险因素分析

目的 应用头颅MRI的SWI序列检测症状性小动脉硬化脑小血管病(cerebral small vessel disease,CSVD)患者脑微出血(cerebral microbleeds,CMBs)灶,分析不同部位CMBs的临床特征差异及CMBs的危险因素。方法 回顾性纳入2017年3月—2018年10月就诊于新疆昌吉州中医院神经内科的小动脉硬化的CSVD患者。根据有无微出血分为CMBs组与无CMBs组。应用二元logistic回归分析CMBs的独立危险因素;判断CMBs数量分级与独立危险因素的相关性。根据CMBs的位置分为脑叶区亚组、深部区亚组、幕下区亚组。比较脑叶区CMBs与非脑叶区CMBs、深部CMBs与非深部CMBs、幕下区CMBs与非幕下区CMBs亚组之间的临床特征差异。结果 共纳入144例CSVD患者,CMBs组42例(29.2%),无CMBs组102例(70.8%),其中脑叶区18例,深部白质区23例,幕下区9例。二元logistic回归分析显示,低载脂蛋白b水平(OR 0.308,95%CI 0.099～0.957,P=0.042)及高空腹血糖值(OR 1.128,9...     

脑淀粉样血管病的影像学标志物及临床相关性研究进展

脑淀粉样血管病（cerebral amyloid angiopathy,CAA）是一种多见于老年人群中的脑小血管病, 不同于高血压导致的脑小血管病易累及脑深部区域,CAA多累及皮层及软脑膜小血管。多发脑叶微出 血是CAA患者常见的影像学表现,研究认为其与症状性脑叶出血及进行性认知功能下降相关。随着 近年来对脑小血管病影像学表现的深入研究,发现皮层蛛网膜下腔出血与皮层表面含铁血黄素沉 积是CAA相对特异的影像学表现,并且与短暂性局灶性神经系统症状发作相关。此外,脑白质高信号、 小梗死灶等脑小血管病影像学标志均在CAA患者中出现,提示除外临床较关注的出血性改变,CAA患 者的缺血性损伤也是导致临床症状的重要因素。     

Higher ambulatory blood pressure relates to enlarged Virchow-Robin spaces in first-ever lacunar stroke patients

Enlarged Virchow-Robin spaces (EVRS) are considered to be a sign of cerebral small vessel disease. Hypertension is an important risk factor for cerebral small vessel disease, whereas ambulatory blood pressure (BP) is the strongest predictor of hypertension-related brain damage. However, the association between ambulatory BP levels and EVRS has never been investigated. The aim of this study was to determine the association between ambulatory BP levels and EVRS. In 143 first-ever lacunar stroke patients, we performed 24-h ambulatory BP monitoring after the acute stroke phase. On brain MRI we counted EVRS in the basal ganglia and the centrum semiovale. We graded the number of EVRS at each level into a three-category severity scale. We assessed the association between BP levels and EVRS by ordinal regression analysis. After adjusting for age, sex, extensive white matter lesions, and asymptomatic lacunar infarcts, higher day systolic (OR 1.21; 95 % CI 1.00–1.46 per 10 mmHg), day diastolic (1.18; 95 % CI 1.02–1.37 per 5 mmHg) and 24-h diastolic (OR 1.18; 95 % CI 1.01–1.37 per 5 mmHg) ambulatory BP levels were associated with EVRS at the basal ganglia level. No relation was found between ambulatory BP levels and EVRS in the centrum semiovale. Higher day ambulatory BP levels are associated with EVRS in the basal ganglia. This association was independent of the presence of extensive white matter lesions and asymptomatic lacunar infarcts. Our results imply that basal ganglia EVRS should be regarded as a separate manifestation of BP-related brain damage.     

Cerebral lacunae: still under debate]

During the last fifteen years, a new interest has been shown in cerebral lacunes due to the development of brain imagery using Magnetic Resonance Imaging (MRI). The concept of lacunar infarction as defined par Fisher (lacunar hypothesis) can no longer be accepted. Clinical data showed that the so-called lacunar clinical syndromes were far from being specific and could be observed in corticosubcortical infarcts. Epidemiological data pointed out that hypertensive disease was not found in many cases of lacunar infarction. Pathological studies suggest that there are two types of lacunar infarction. Lacunar infarcts resulting in clinical stroke syndromes (type 1 a lacunae) seem to be mainly due to obstruction of the trunk of a perforating artery by atherosclerosis. Silent lacunar infarcts (type 1 b lacunae) result from obstruction of small ramifications of the perforating arteries by a non specific microangiopathy related to age, atherosclerosis, cardiovascular disease as well as to hypertensive disease. Silent lacunar infarcts and dilatation of perivascular spaces (type 3 lacunae) are associated with the white matter hyperintensities shown by MRI in elderly subjects. Lacunar infarcts and diffuse white matter hyperintensities are related to small vessel changes and ischaemic damages resulting from (a) arteriolar occlusion and or (b) loss of autoregulation associated with variations in systemic blood pressure. Both lesions constitute a high risk to develop Vascular Cognitive Impairment (Hachinski) and are frequently associated with Alzheimer's disease. Cases of giant or expanding type 3 lacunae have been reported in the last ten years but the physiopathology of such lacunes and their relationship with clinical symptoms remain a puzzle.     

The role of small vessel disease in development of Alzheimer's disease

Classically Alzheimer's disease and vascular dementia have been considered as two different entities, with their own clinical criteria, but relatively recent epidemiological and clinicopathological studies suggest an overlap between them sharing not only most of the risk factors and some clinical aspects but also pathophysiological mechanisms. Cerebrovascular lesions, especially small vessel disease (lacunar infarcts, white matter hyperintensities and microbleeds), may magnify the effects of mild Alzheimer's disease pathology and promote the progression of cognitive decline and may also be a precursor of neuronal damage and dementia. "Vascular hypothesis" of Alzheimer's disease would open a window for new approaches and treatments.     

脑小血管病磁共振影像研究概况

脑小血管病（cerebral small vessel disease,cSVD）是血管性痴呆最常见的病因,且约占 卒中病因的1/5。目前对cSVD的认识主要是通过磁共振成像（magnetic resonance imaging,MRI）进 行,cSVD在MRI上的表现包括腔隙性梗死（lacunar infarction,LI）与腔隙灶、白质高信号（white matter hyperintensities,WMH）、血管周围间隙扩张（dilated Virchow-Robin space,dVRS）、脑微出血（cerebral microbleeds,CMBs）及脑萎缩。本文综述上述cSVD磁共振影像学表现定义、分级及推荐序列等的研究 概况。