缺血性卒中患者脑微出血的相关因素分析

目的 探讨缺血性卒中患者发牛脑微出血(CMBs)的相关因素. 方法 对85例急性缺血性卒中患者进行磁共振检查,其中包括梯度回波T2加权成像(GE-T2~*WI),并对患者的临床资料和影像学特点进行分析. 结果 26例(30.6%)患者中共检出CMBs 124个,每位患者的CMBs数目在1～16个之间.CMBs在基底节丘脑区和皮质一皮质下区分布较多,在幕下区较少见.发生在脑十的CMBs可有相关症状及体征.CMBs数目与年龄、腔隙性梗死数目及白质疏松程度评分有相关性(r=0.243,P=0.025;r=337,P=0.002;r=0.438,P=0.000).CMBs在GE-T2~*WI上显影良好,部分CMBs可在自旋叫波(SE)T2WI及DWI序列上显影. 结论 CMBs是脑微小血管病变标志,主要预测因素有高龄、多发腔隙性梗塞和白质疏松.     

Serum cystatin C and cerebral microbleeds in patients with acute cerebral stroke

Recent studies have shown that kidney dysfunction is associated with cerebral microbleeds (CMB). Cystatin C is a more useful measurement than creatinine-based estimating equations for evaluating kidney function. The purpose of this study was to clarify the relationship between cystatin C levels and CMB in patients with acute cerebral stroke. This cross-sectional study included a total of 485 patients with acute ischemic stroke and 129 patients with cerebral hemorrhage. The serum levels of cystatin C were significantly higher in acute cerebral stroke patients with CMB than in those without (p < 0.001). Multivariate logistic regression analyses showed that for each single standard deviation increase of cystatin C levels, there was a significant increase in the presence of CMB after adjusting for age and sex, and after additional adjustment for cardiovascular risk factors, silent lacunar infarction, and white matter hyperintensity in patients with acute stroke. The odds ratio (95% confidence interval) in patients with acute cerebral infarction and cerebral hemorrhage were 2.92 (1.81–6.93) and 2.98 (1.76–6.97), respectively. The present study suggests that elevated levels of cystatin C are associated with the presence of CMB in acute stroke patients, independent of conventional risk factors.     

Nucleosomes in serum of patients with early cerebral stroke

BACKGROUND: Nucleosomes are cell death products that are elevated in serum of patients with diseases that are associated with massive cell destruction. We investigated the kinetics of circulating nucleosomes after cerebral stroke and their correlation with the clinical status. METHODS: In total, we analyzed nucleosomes by ELISA in sera of 63 patients with early stroke daily during the first week after onset. For correlation with the clinical pathology, patients were grouped into those with medium to slight functional impairment (Barthel Index BI >or=50) and those with severe functional impairment (BI<50). RESULTS: Patients with BI >or=50 showed a continuous increase in nucleosomes until day 5 (median: 523 arbitrary units, AU) followed by a slow decline. In contrast, patients with BI<50 showed a steeper initial increase reaching a maximum already on day 3 (869 AU). Both, days after stroke (p < 0.001) and BI (p < 0.001), had a significant influence on nucleosome concentrations, respectively. Consistently, patients with BI<50 had a significantly larger area under the curve (AUC/day) of nucleosome values during the first week after stroke (800 AU) than patients with BI >or=50 (497 AU; p=0.031). Concerning the infarction volume, nucleosomes showed significant correlations for the concentrations on day 3 (r=0.43; p=0.001) and for the area under the curve (r=0.34; p=0.016). CONCLUSION: Even if nucleosomes are nonspecific cell death markers, their release into serum after cerebral stroke correlates with the gross functional status as well as with the infarction volume and can be considered as biochemical correlative to the severity of stroke.     

卒中单元对急性脑卒中患者近期预后的影响

目的 探讨卒中单元对急性脑卒中患者近期预后的影响.方法 196例急性脑卒中患者(脑出血59例,脑梗死137例)随机分为卒中单元组(101例)和普通病房组(95例),并进行相应的治疗.比较两组治疗后与治疗前美国国立卫生研究院卒中量表(NIHSS)评分、Barthel指数(BI)的差值及疗效,以及并发症的发生率.结果 与治疗前比较,卒中单元组治疗后NIHSS评分降低(12.6± 5.5)分,普通病房组降低(8.9 ±4.1)分;卒中单元组BI升高24.3±14.8,普通病房组升高15.1±10.6;两组间差异有统计学意义(均P<0.05).卒中单元组基本痊愈率、总有效率、并发症发生率及病死率(27.7%、97.0%、10.9%及2.0%)与普通病房组(15.8%、88.4%、23.2%及8.4%)比较差异均有统计学意义(均P<0.05).结论 卒中单元能明显改善急性脑卒中患者的近期预后.     

缺血性脑卒中合并脑微出血的危险因素

目的研究缺血性脑卒中患者脑微出血的临床、影像学及血清生物学的危险因素,以及不同部位微出血与危险因素之间的关系。方法回顾性分析纳入153例缺血性脑卒中患者,应用磁敏感成像(susceptibility weighted imaging,SWI)技术检测脑微出血,计数并记录其部位。颅脑MRI的脑白质病变的严重程度采用Fazekas评分进行评估。应用Logistic回归分析法研究缺血性脑卒中合并脑微出血的危险因素,并研究危险因素与不同部位脑微出血数量的关系。结果 59例(38.6%)患者存在CMBs。皮层-皮层下CMBs出现率为34.0%,深部CMBs为24.8%,幕下CMBs为27.5%。多因素Logistic回归显示,男性、高血压病及中重度深部脑白质病变是伴有CMBs的有显著统计学意义的相关因素(P0.05)。校正年龄及性别后,偏相关分析显示,高血压病仅与深部CMBs的数量仍然显著相关(r=0.174,P=0.032)。中重度深部脑白质病变与皮层-皮层下CMBs及深部CMBs数量存在显著相关(r=0.285,P0.001,r=0.258,P=0.001)。结论男性、高血压病及中重度深部白质病变为脑微出血的危险因素;高血压病主要与与脑深部微出血的数量相关,而中重度深部脑白质病变与脑皮层-皮层下及深部微出血数量相关。     

Catalase-like activity in cerebrospinal fluid in patients with cerebral stroke]

Catalase-like activity was determined in the cerebrospinal fluid of 16 patients with cerebral haemorrhage, 24 cases od encephalomalacia due to thrombosis, and 10 controls. It was demonstrated that catalase-like activity in the cerebrospinal fluid of patients with cerebral stroke is significantly raised in relation to the activity observed in controls. This rise is patricularly evident in the first 24 hours after the onset. The rise was statistically significant only in the group of encephalomalacia.     

老年脑卒中患者的护理风险管理

护理质量是护理管理的永恒话题,护理风险管理是对护理工作中存在或潜在的风险事件及预防方法的识别、评价,并寻求处置对策和科学管理[1],是确保护理质量的核心决策[2].     

Doppler examination and cerebral arterial stricture in patients with ischemic stroke

With the development of interventional therapy, it is necessary for evaluating cerebral vessels to instruct treatment and determine prognosis of patients with ischemic stroke; however, correlation of distribution of infarction focus and clinical symptoms with degrees of cerebrovasoular stricture is still unclear.OBJECTIVE: To evaluate the characteristics of cerebral arterial stricture of patients with ischemic stroke with transcranial Doppler (TCD) and color duplex flow imaging (CDFI) and compare the correlation between distribution of cerebral infarction focus and clinical types with magnetic resonance imaging (MRI).DESIGN: Contrast observation.SETTING: Department of Neurology, the First Hospital of Jilin University.PARTICIPANTS: A total of 159 patients with ischemic stroke were selected from the Department of Neurology, the First Hospital of Jilin University from January to December 2005, including 106 males and 53 females aged from 27 to 88 years. Bases on diagnostic criteria of cerebrovascular disease established by Rao et al, clinical manifestations of all patients were evaluated with CT or nuclear magnetic resonance. All patients provided the confirmed consent.METHODS: The accepted patients received TCD and CDFI examination at 1 week after onset of ischemic stroke. Among them, 112 patients received cerebrovascular imaging examination simultaneously. MRI was used to check cerebral infarction focus and cerebrovascular stricture ＞ 50% was regarded as the accepted vessels. In addition, DWI-T2 TCD (Germany) was used to check middle cerebral artery, and degrees of middle cerebral artery were classified into mild, moderate and severe stricture based on blood velocity (140 cm/s,180 cm/s). Stroke was classified based on characteristics of infarction focus and clinical symptoms showed with MRI and correlation with degrees of cerebrovascular stricture was analyzed simultaneously.MAIN OUTCOME MEASURES: Correlation between the characteristics of ischemic stroke and clinical symptoms checked with TCD and CDFI.RESULTS: A total of 159 patients with ischemic stroke were involved in the final analysis; in addition, 112 oases received cerebrovascular imaging examination simultaneously. ① MRI results of 159 patients with cerebral artery occlusive disease (CAOD): There were 131 patients (82.3%) with cerebral infarction, 40 (25.2%)with transient ischemic attack and 4 (2.5%) with subclavian steal syndrome (SSS). ② Infarction types with MRI examination: There were 33 patients (20.8%) with solitary cerebral infarction and 98 (61.6%) with multiple-cerebral infarction. ③ Results of TCD, CDFI, MRI angiography, CT angiography and digital subtraction angiography (DSA): Among 112 patients, 181 lesion sites (61 .8%) were located in cranium and 112 lesion sites were located out of cranium; especially, lesion site was mostly observed in stem of middle cerebral artery (31.2%) and watershed of basilar artery (7.2%) in cranium and the beginning site of internal carotid artery (21 .4%) out of cranium. ④ Correlation of vascular stricture checking with TCD, MRI and clinical diagnosis: On one hand, MRI and clinical diagnosis demonstrated that 68 patients had a watershed infarction; meanwhile,TCD examination indicated that there were 3 patients with mild vascular stricture, 24 with moderate vascular stricture and 36 with severe vascular stricture. On the other hand, among 68 patients with non-watershed infarction, there were 27 patient with mild vascular stricture, 26 with moderate vascular stricture and 15 with severe vascular stricture. There were significant differences (x2 =26.854, P =0.001 ). Clinical diagnosis indicated that 40 patients had transient ischemic attack and TCD examination demonstrated that there were 8 patient with mild vascular stricture, 12 with moderate vascular stricture and 20 with severe vascular stricture. There were significant differences as compared with 68 patients with watershed infarction (x2 =21.258, P =0.001). ⑤Correlation of vascular stricture checking with CDFI, MRI and clinical diagnosis: On one hand, among patients who were determined as watershed infarction with MRI and clinical diagnosis, CDFI examination indicated that there were 32 patients with mild vascular stricture at neck, 25 with moderate vascular stricture and 6 with severe vascular stricture. On the other hand, among patients with non-watershed infarction, there were 48 patient with mild vascular stricture, 18 with moderate vascular stricture and 2 with severe vascular stricture.There were significant differences (x2 =6.018, P =0.019). Among patients with transient ischemic attack checking with clinical diagnosis, there were 23 patient with mild vascular stricture, 9 with moderate vascular stricture and 8 with severe vascular stricture. There were no significant differences as compared with patients with non-watershed infarction (x2 =0.597, P=0.440).CONCLUSION: ① TCD and CDFI are effective marks to determine cerebral arterial stricture and hemodynamical changes. ② Infarction and transient ischemic attack at watershed are generally clinical phenotypes of CAOD patients and infarction at watershed is correlated with degrees of cerebrovascular stricture.③ TCD, MRI and clinical analysis of stroke types are significant for instructing treatment and evaluate prognosis.     

Intravenous thrombolysis in stroke patients with hyperdense middle cerebral artery sign

Background and purpose:  We assessed the safety and efficacy of intravenous thrombolysis (IVT) in acute stroke patients with hyperdense middle cerebral artery sign (HMCAS).
Patients and methods:  Data from consecutive patients with acute (within 6 h of symptom onset) ischaemic stroke admitted between January 1999 and November 2007, in whom HMCAS was diagnosed on admission CT scan was retrospectively analysed. Seventy-one patients, admitted within the 3-h window, were treated with IVT, whilst further 42, admitted 3–6 h after symptom onset, were not. At 3-month clinical follow-up, outcome, mortality at 3 months and incidence of symptomatic intracranial haemorrhage were evaluated.
Results:  The two groups were comparable concerning age, stroke risk factors, prior antithrombotic treatment and NIHSS scores on admission. Good outcome (mRS score ≤ 1) was observed in 12/71 (17%) patients who were treated with IVT and in 1/42 (2%) patients who were not ( P  = 0.02). IVT treatment was identified as independent predictor of good outcome ( P  = 0.05). Mortality was 20% in patients treated with IVT and 12% in remaining patients ( P  = 0.3). Symptomatic intracranial haemorrhage occurred in 1 patient of each group (2%).
Conclusions:  These findings suggest that IVT in patients with HMCAS results in significantly better outcome, without significantly influencing mortality.     

Dynamic cerebral autoregulation in stroke patients with a central sympathetic deficit

Gierthmühlen J, Allardt A, Sawade M, Baron R, Wasner G. Dynamic cerebral autoregulation in stroke patients with a central sympathetic deficit.
Acta Neurol Scand: 2011: 123: 332–338.
© 2010 John Wiley & Sons A/S. Objective – To investigate the functional role of the sympathetic innervation on cerebral autoregulation. Materials and methods – Seventeen patients with infarction of the dorsolateral medulla oblongata affecting central sympathetic pathways (Wallenberg′s syndrome) and 21 healthy controls were included in the study. Cerebral blood flow velocity (CBFV) in the medial cerebral artery was investigated using transcranial Doppler ultrasound during decrease in cerebral perfusion pressure induced by leg‐cuff test and tilt table. Results – Upon leg‐cuff test, changes of cerebral blood flow and mean arterial blood pressure as well as autoregulatory index did not differ between patients or controls. No differences were found in changes of CBFV, mean arterial blood pressure and heart rate between patients or controls during the tilt table test. Conclusions – We suggest that the sympathetic nervous system does not have an influence on cerebral autoregulation after decrease in perfusion pressure under normotonous conditions.     

脑卒中患者血浆白细胞介素13水平的动态变化

目的　探讨白细胞介素 13(IL 13)在抑制脑卒中炎性损伤中的作用。方法　用酶联免疫吸附法 (ELISA)测定 5 0例脑梗死患者及 30例脑出血患者发病后 48h内及第 6～ 8天、第 15天血浆IL 13的水平 ,并检测 6 0例对照者的血浆IL 13水平。结果　脑梗死组 3个时相血浆IL 13水平 (ng/L)分别为 37 6± 6 2 ,45 2± 10 1,41 3± 8 3;脑出血组为 36 6± 4 9,45 3± 8 9,38 1± 5 6 ;均较危险因素对照组 (2 8 0± 3 2 )及健康对照组 (2 6 4± 2 7)明显增高。中度 (脑梗死组 :40 7± 5 8,5 1 1± 8 0 ,44 8± 7 2 ;脑出血组 :38 2± 4 1,48 2± 5 8,38 7± 4 1)及重度 (脑梗死组 :42 3± 5 2 ,5 3 3± 7 2 ,47 3± 9 6 ;脑出血组 :38 6± 3 9,5 2 2± 9 2 ,40 6± 7 6 )患者血浆IL 13水平明显增高 ,且第 6～ 8天的水平最高。结论　IL 13可能参与了抑制脑卒中炎性损伤的病理过程 ,并与病情程度呈正相关。     

Mirror pattern of cerebral artery atherosclerosis in patients with ischaemic stroke

Background and purpose:  Although it has been suggested that bilateral symmetry of atherosclerosis can be found in paired arteries, including external carotid arteries and femoral arteries, it has remained unknown in intracranial arteries. We determined whether bilateral symmetry (a mirror pattern) of atherosclerosis presents in the entire cerebral arterial system.
Methods:  Angiographic findings of 795 consecutive patients with ischaemic stroke, after excluding those with cardiac sources of embolism or other causes of stroke, were reviewed retrospectively. The presence (location) and severity (the degree of stenosis) of atherosclerosis were compared between left and right sides at 26 predetermined arteries/segments.
Results:  We found 2230 lesions in predetermined segments/arteries from 669 patients. Amongst 509 patients with atherosclerotic lesions at two or more arteries/segments, mirror patterns were observed in 312 patients (61.3%). The mirror pattern increased steeply as the number of atherosclerotic arteries increased and was most frequently found in the carotid bulb (C1, 26.7%), followed by the middle cerebral artery (M1, 14.1%). The severity of stenosis was also correlated between left and right sides, and the correlation was highest in the C1 ( r  = 0.40, P  < 0.001). Multiple logistic regression analyses revealed that the mirror patterns of atherosclerosis were more obvious in C1 and associated with a past history of ischaemic stroke and the number of stenotic lesions.
Conclusion:  Atherosclerosis in cerebral arteries may develop and progress in a mirror pattern. In patients with cerebral artery atherosclerosis, the occurrence and progression of atherosclerosis in the contralateral cerebral artery should be considered during follow-up examination.     

合并脑微出血急性缺血性脑卒中患者静脉溶栓治疗的风险评估及安全性研究

目的研究脑微出血是否增加急性缺血性脑卒中静脉溶栓治疗脑出血的风险。方法对2015年7月-2016年7月期间天津市环湖医院神经内科四病区发病4.5 h内接受阿替普酶(recombinant tissue plasminogen activator,rtPA)急性缺血性脑卒中患者206例进行回顾性研究:发病4.5 h内接受阿替普酶静脉溶栓治疗的206例患者,溶栓前根据头部MRI检查分为微出血组89例,无微出血组117例;主要观察指标是溶栓后住院期间症状性及非症状性脑出血发生率和3个月良好预后率,次要观察指标是3个月生存率。结果含铁血黄素沉积组症状性脑出血共2例(2.2%),与无含铁血黄素沉积组3例(2.6%)相比,两组间差异无统计学意义(P=0.874)。含铁血黄素沉积组非症状性脑出血共4例(4.5%),与无含铁血黄素沉积组2例(1.7%)相比,两组间差异无统计学意义。3个月神经功能获得良好预后,含铁血黄素组共计41例(46.1%),无含铁血黄素组62例(52.9%),两组间差异无统计学意义(P=0.325)。含铁血黄素沉积组3个月生存率92.1%,无含铁血黄素沉积组为95.7%,两组间差异无统计学意义。结论急性缺血性脑卒中患者合并脑微出血(CMB)与静脉溶栓治疗后出血性转化无显著相关。     

Distribution of artificial cerebral microemboli in stroke patients with patent foramen ovale

OBJECTIVES: Patent foramen ovale (PFO) is considered as an important risk factor for cerebrovascular diseases. Nevertheless, the relationship between the distribution of high-intensity transient signals (HITS), resulting from injection of air mixed with saline and detected by transcranial Doppler (TCD), and clinical cerebrovascular syndromes in these patients has not been investigated. METHODS: Using TCD, we screened 40 patients with stroke or transient ischemic attack (TIA), in whom PFO was proven by transesophageal echocariography (TEE). Of these, 30 patients (75%) with artificially produced HITS either in the middle cerebral artery (MCA) or the basilar artery (BA) were included in the analysis. RESULTS: Nineteen patients had a stroke or TIA in the carotid territory and 11 patients in the vertebro-basilar territory. HITS were found in the MCA in all 30 patients and in 21 of the 30 patients in the BA. Of the latter, ten patients were in the carotid group and 11 patients were in the veretebro-basilar group, p = 0.011. CONCLUSION: There is a significant association between the distribution of artificial HITS and the clinical cerebrovascular syndromes.