高同型半胱氨酸血症与青年卒中

近年来青年卒中(18～44岁)的发病率有逐年升高的趋势,其中缺血性卒中占较大比例(约占60%～80%)。引发青年卒中的原因很多,高血压病、吸烟、饮酒、高脂血症及糖尿病等这些传统的危险因素已被大家所熟知,而高同型半胱氨酸血症(hyperhomocysteinemia,HHcy)作为卒中新的独立危险因素越来越受到重视。现结合文献,对HHcy的形成、代谢、干预及其与卒中的相关性综述如下:     

Infectious Causes of Stroke

Stroke is one of the primary causes of mortality and morbidity worldwide. It can be ischemic or hemorrhagic, and the former can be due to an in-situ thrombus or a distant embolus. Despite being a rare cause, stroke can also be caused in the setting of infection. Bacterial agents are the most common cause of stroke, among other infectious agents. Until the antibiotic era, rheumatic heart disease was a predisposing risk factor of infective endocarditis. VZV is the most common cause of strokes in pediatric and adult populations. Cryptococcus and Candida spp are the most common yeasts involved in CNS infections, especially in immunocompromised patients. In COVID-19 patients, ischemic strokes are more common than hemorrhagic strokes. In this review, we will discuss the most common infectious agents, with particular emphasis on COVID-19.     

卒中的遗传因素

大量的临床及流行病学研究显示,卒中具有明显的家族聚集趋势。不论缺血性卒中、出血性卒中,还是脑血管畸形,越来越多的证据证明遗传因素与环境因素一样,在发病过程中发挥着重要作用。然而,在临床实践中,当一位患者因急性卒中就诊于神经科急诊时,我们的注意力更多集中于急性期的溶栓再通治疗,     

Fabry病与青年卒中

Fabry病是一种X染色体性连锁隐性遗传性疾病。由于染色体Xq22上的基因突变或缺失,引起其编码蛋白产物α-半乳糖苷酶部分或全部缺乏,使该蛋白的代谢底物三聚己糖神经酰胺（globotriao sylceramide,Gb3）不能分解,继而在肾、心、血管壁和神经系统等组织细胞中进行性病理性堆积,从而引起多系统脏器的损害。该病在青－中年时期即可出现多系统损害的临床表现,中枢神经系统的主要表现为短暂性脑缺血发作和缺血性卒中,因此对于不明原因的青年卒中要充分考虑到Fabry’s病的可能性。近年来一种全新的特殊治疗方法——酶替代疗法显示了较好的临床疗效,但强调在疾病早期就应开始治疗而不是等到器官损害之后。尽早诊断并提供适当的治疗方法可最大限度的改善预后和提高生活质量。     

青年型卒中——卒中患者中不可忽视的人群

<正>每年全世界有将近200万青年人发生卒中事件,青年缺血性卒中对家庭、社会和经济造成巨大的负担。与老年人卒中发病率逐年下降相反,流行病学资料表明,青年型卒中的发病率上升显著~([1])。这一现象提示对于青年型卒中危险因素(如高血压、高血脂、糖尿病、吸烟、肥胖等)的发现与干预至关重要,其中包括对于传统危险因素的控制以及发现新的卒中危险     

青年卒中幕后黑手不好找？ASCOD病因表型来帮忙

<正>Stroke Vascular Neurology(SVN)近期发表的文章Phenotypic ASCOD characterisations of ischaemic stroke in the young at an urban tertiary care centre,由来自美国圣路易斯华盛顿大学神经内科Angela Liu教授执笔,联合美国加州大学圣地亚哥分校、美国宾夕法尼亚州天普大学路易斯卡茨医学院以及美国佛蒙特大学医学     

青年缺血性卒中的中国缺血性卒中亚型及危险因素分析

目的 分析青年缺血性卒中的病因分型以及危险因素,以期对青年缺血性卒中的防治有所帮助。 方法 回顾性分析2011年1～12月于我院脑病中心住院的共52例青年缺血性卒中患者（青年卒中组） 的临床资料,随机抽取同期住院的中老年缺血性卒中患者50例作为中老年卒中组,进行中国缺血性 卒中亚型（Chinese ischemic stroke subclassification,CISS）病因分型以及危险因素分析。 结果 ①青年卒中组男性46例（88.46%）,女性6例（11.54%）,与中老年卒中组差异存在显著 性（χ2=5.573,P =0.018）。②青年卒中组CISS分型分布依次为大动脉粥样硬化型（large artery atherosclerosis,LAA）46.15%,穿支动脉疾病型（penetrating artery disease,PAD）36.54%,病因不确定 型（undetermined etiology,UE）11.54%,心源性卒中型（cardiogenic stroke,CS）5.77%,无一例其他病因 型（other etiology,OE）。其分布与中老年卒中组差异无显著性。③青年卒中组患者危险因素暴露率依 次为吸烟、高血压、血脂异常、饮酒、糖尿病、卒中家族史;具有3个以上的危险因素者超过半数,该 数量与中老年卒中组相比差异存在显著性（χ2=7.186,P =0.007）,同型半胱氨酸（homocysteine,Hcy） 水平较中老年卒中组增高（t =1.250,P =0.038）,叶酸水平较中老年卒中组下降（t =2.106,P =0.007）; 吸烟（χ2=7.993,P =0.005）、饮酒（χ2=17.005,P =0.000）的暴露率较中老年卒中组升高;LAA亚组 Hcy水平高于PAD亚组（t =2.046,P =0.004）。 结论 青年缺血性卒中患者在性别分布、危险因素、卒中病因分型方面具有一定特点,Hcy水平可能 与缺血性卒中的发生年龄以及病因分型有关。青年缺血性卒中患者危险因素较中老年患者多,控制并 减少危险因素,尤其是纠正高Hcy,对青年缺血性卒中的预防十分重要。     

Obesity and the Risk of Cryptogenic Ischemic Stroke in Young Adults

ObjectivesWe examined the association between obesity and early-onset cryptogenic ischemic stroke (CIS) and whether fat distribution or sex altered this association.Materials and MethodsThis prospective, multi-center, case-control study included 345 patients, aged 18-49 years, with first-ever, acute CIS. The control group included 345 age- and sex-matched stroke-free individuals. We measured height, weight, waist circumference, and hip circumference. Obesity metrics analyzed included body mass index (BMI), waist-to-hip ratio (WHR), waist-to-stature ratio (WSR), and a body shape index (ABSI). Models were adjusted for age, level of education, vascular risk factors, and migraine with aura.ResultsAfter adjusting for demographics, vascular risk factors, and migraine with aura, the highest tertile of WHR was associated with CIS (OR for highest versus lowest WHR tertile 2.81, 95%CI 1.43-5.51; P=0.003). In sex-specific analyses, WHR tertiles were not associated with CIS. However, using WHO WHR cutoff values (>0.85 for women, >0.90 for men), abdominally obese women were at increased risk of CIS (OR 2.09, 95%CI 1.02-4.27; P=0.045). After adjusting for confounders, WC, BMI, WSR, or ABSI were not associated with CIS.ConclusionsAbdominal obesity measured with WHR was an independent risk factor for CIS in young adults after rigorous adjustment for concomitant risk factors.     

青年卒中遗传学研究进展

青年卒中的发病率呈上升趋势,发现临床前生物标志物将获益巨大。除了罕见的卒中相关单基因疾病,许多遗传易感性研究表明青年卒中是多基因遗传病。近20年来,全基因组关联分析、验证研究和meta分析研究方法被应用于青年卒中的遗传学研究。本篇综述阐述了青年卒中的遗传学证据以及相关的单基因突变和候选基因变异,为疾病诊治提供参考。     

Volume of Plasma Expansion and Functional Outcomes in Stroke

Background

Plasma expansion in acute ischemic stroke has potential to improve cerebral perfusion, but the long-term effects on functional outcome are mixed in prior trials. The goal of this study was to evaluate how the magnitude of plasma expansion affects neurological recovery in acute stroke.

Methods

This was a secondary analysis of data from the Albumin in Acute Stroke Part 2 trial investigating the relationship between the magnitude of overall intravenous volume infusion (crystalloid and colloid) to clinical outcome. The data were inclusive of 841 patients with a mean age of 64 years and a median National Institutes of Health Stroke Scale (NIHSS) of 11. In a multivariable-adjusted logistic regression model, this analysis tested the volume of plasma expansion over the first 48 h of hospitalization as a predictor of favorable outcome, defined as either a modified Rankin Scale score of 0 or 1 or a NIHSS score of 0 or 1 at 90 days. This model included all study patients, irrespective of albumin or isotonic saline treatment.

Results

Patients that received higher volumes of plasma expansion more frequently had large vessel ischemic stroke and higher NIHSS scores. The multivariable-adjusted model revealed that there was decreased odds of a favorable outcome for every 250 ml additional volume plasma expansion over the first 48 h (OR 0.91, 95 % CI, 0.88–0.94).

Conclusions

The present study demonstrates an association between greater volume of plasma expansion and worse neurological recovery.

     

脑微出血与卒中相关性研究进展

脑微出血是脑小血管病的重要影像学表现之一,目前检出率随着影像学技术的进步而显著提升。研究显示脑微出血可能与缺血性卒中和脑出血风险增加相关,对未来卒中发生、发展具有一定预测价值,有助于指导卒中高危人群筛查及防治。脑微出血是否增加抗栓治疗后出血转化风险,以及相应风险是否与抗栓治疗获益相抵,目前仍有争议,是亟待解决的临床难题。临床工作中应综合评估抗栓治疗的预防获益及出血风险,以制订合理的治疗策略。     

高同型半胱氨酸血症及其相关因素与青年脑梗死的关系

目的探讨同型半胱氨酸(homocysteine,Hcy)及其相关因素与青年脑梗死的关系。方法比较40例青年脑梗死患者(初发年龄<=45岁),30例神经系统非血管性疾病(NVD)患者和30例健康人血浆Hcy水平。分析年龄、性别、体重指数、肝肾功能、吸烟、嗜酒、血清VitBl2、叶酸水平的影响。结果脑梗死组血浆Hcy水平(21.4±18.8umol/L)分别与神经系统非血管疾病组(10.2±5.0umol/L)和健康对照组(12.9±8.6umol/L)比较差异均有显著性(P<0.01)。叶酸、VitB12与Hcy呈负相关,二者的降低与青年脑梗死关系密切(P<0.01)。血肌苷增高和吸烟与Hcy增高有关(P<0.05)。男性Hcy显著高于女性(P<0.05)。结论Hcy和青年脑梗死密切相关,与叶酸、VitBl2呈负相关,与肌苷呈正相关。男性、吸烟也与Hcy增高有关。     

青年卒中的危险因素及病因学调查分析

目的 调查青年卒中患者各危险因素及影像学检查情况,探讨青年卒中住院患者的危险因素及病因学特点。方法 回顾性收集首都医科大学附属北京安贞医院神经内科2002年1月至2010年12月期间连续登记住院的青年卒中（18～44岁）患者的病历资料入组274例,并分层随机抽取同期住院的中老年卒中（45岁及以上）患者入组300例,分析其众多危险因素及病因学构成特点。结果 ①青年卒中组中,缺血性卒中229例（83.58%）,男性211例（77.01%）;年龄在40～44岁的患者160例（58.39%）;②青年卒中组,合并高血压179例（65.33%）、吸烟162例（59.12%）、饮酒123例（44.89%）、高同型半胱氨酸血症100例（39.84%）、肥胖86例（31.39%）,与中老年卒中组对比,差异有显著性（P＜0.05）;合并高脂血症156例（56.93%）,两组间差异无显著性（P＞0.05）;③缺血性卒中经TOAST（Trial of Org 10 172 in Acute Stroke Treatment）病因学分型,青年组大动脉粥样硬化性卒中100例（44.25%）和小动脉闭塞性卒中66例（29.20%）,与中老年组对比,差异有显著性（P＜0.05）;④青年组颅内外血管情况优于中老年组,主要动脉无异常的患者比率（26.55%）高于中老年组（15.79%）,轻、中度和重度狭窄率（46.02%和7.96%）低于中老年组（50.20%和17.81%）,两组间差异有显著性（P＜0.05）。结论 ①青年卒中以缺血性卒中、男性为主,其中40～44岁的患者占1/2以上;②青年卒中主要的危险因素依次是高血压、吸烟、高脂血症、饮酒、高同型半胱氨酸血症、肥胖,其中高血压、吸烟、高脂血症、高同型半胱氨酸血症的百分率随年份的增长有逐渐增高趋势;③青年缺血性卒中主要的病因是大动脉粥样硬化性卒中、小动脉闭塞性卒中,其他病因多样化;④青年卒中患者的颅内外血管情况优于中老年卒中患者。     

Depression and Anxiety after Stroke in Young Adult Filipinos

Background and ObjectivesYoung adult patients may suffer from poststroke depression (PSD) and anxiety. Few studies have evaluated these important psychiatric conditions that may lead to adverse outcomes in young adults. We aimed to determine the prevalence of PSD and anxiety as well as to identify their predictors in a population of young Filipino adults (18-49 years old).MethodsWe performed a cross-sectional epidemiologic study in the largest tertiary hospital in the Philippines. The study involved the administration of a structured survey tool and review of medical records. The Hospital Anxiety and Depression Score – Pilipino version (HADS-P) was used to screen for anxiety and depression. Multivariable logistic regression analysis was performed to determine significant socio-economic and clinical risk factors of PSD and anxiety.Results114 young adult stroke patients were included. The prevalence of depression was 20.2% while that of anxiety was 34.2%. Significant predictors of PSD were the presence of anxiety (OR 1.84; CI 1.05-3.22), lower mRS scores (mRS 3-5 OR 5.52; 95% CI 1.09-8.03) and diabetes (OR 2.09; 95% CI 1.67-6.26). Meanwhile, significant predictors of poststroke anxiety included depression (OR 7.5; 95% CI 5.02-21.94) and dependency (Barthel Index scores 95-100; OR 0.94; 95% CI 0.89-0.99). Relationship status, educational attainment, stroke subtype and location were not found to be significant predictors of PSD and anxiety.ConclusionA significant proportion of young adults suffered from depression and anxiety after stroke. Clinicians should be aware of these psychiatric conditions that influence outcomes and quality of life of young adults with stroke.     

Impact of Infection on Stroke Morbidity and Outcomes

Each year, millions of persons worldwide are disabled by stroke. The burden of stroke is expected to increase as a consequence of growth in our elderly population. Outcome is dependent upon limitation of secondary medical processes in the acute setting that lead to deterioration and increased long-term disability. The prevalence of infection after stroke is greater that seen in other medical conditions with similar acuity and its impact upon morbidity and mortality is substantial. Physical impairment and immune modulation are chief determinants in rate of infection after stroke. Each of these factors has been a target for therapeutic intervention. Current best practices for acute stroke management implement strategies for prevention, prompt identification, and treatment of infection. Novel therapies are currently being explored which have the opportunity to greatly minimize infectious complications following stroke. Fever commonly accompanies infection and independently influences stroke outcome. Targeted temperature management provides an additional chance to improve stroke recovery.     

青年卒中的研究现状和展望

卒中是当今世界范围内严重威胁人类生命和健康的疾病,2008年全国第三次死因回顾抽样调查显示卒中已高居国内死亡原因首位。回顾传统观念,卒中一直以来被认为是中老年人群的常见病和多发病;由于时代、环境以及疾病谱等因素的变化,卒中的发病有日益年轻化的趋势。随着对青年卒中研究的深入,逐渐揭示了一些青年卒中的特殊性,本文就青年卒中的研究现状和未来发展趋势做一综合探讨。