基层医院卒中单元对初次脑梗死后生存质量的影响

目的 探讨基层医院卒中单元对初次轻-中度大脑中动脉梗死后近期生存质量的影响.方法 以收住我科卒中单元的55例患者为观察组(卒中单元组),收住我科普通病房及市三院老年科的61例患者为对照组(普通病房组),观察2组患者治疗前后4 周和12周的美国国立卫生研究院卒中量表(NIHSS)评分、Barthel指数(BI)评分、脑卒中专门化生存质量量表中译本(SS-QOL)评分,比较2组治疗前后的神经功能缺损评分、日常生活指数和生存质量评分. 结果 2组治疗后4周及12周的NIHSS评分比较差异无统计学意义,而BI差异均有统计学意义.4周时 SS-QOL中除精力、家庭角色、个性、上肢功能、工作/劳动等5个领域评分差异无统计学意义外,其他领域评分差异均有统计学意义,12周时 SS-QOL各项指标差异均有统计学意义. 结论基层医院卒中单元能改善初次轻-中度大脑中动脉梗死患者近期生存质量.     

在二级医院建立延伸卒中单元模式病房的疗效分析

目的 通过在二级医院建立延伸卒中单元模式病房,探讨脑血管病新的管理模式及疗效评定.方法 将398例住院卒中患者,随机分入卒中单元病房和普通病房,通过对急性期病死率、并发症发生率、Barthel指数(BI)、NIHSS、出院时医疗满意度评分观察,评估近期疗效.通过观察卒中后两年内的复发率、病死率、NIHSS、BI、Hamiltom量表及评估远期疗效.结果 卒中单元组急性期病死率、并发症发生率低,患者满意度高,NIHSS、BI相比较,两组间有显著性差异(P＜0.05).卒中后两年内的复发率、病死率卒中单元组低于对照组.结论 延伸卒中单元的建立提高了脑血管病患者的近期及远期疗效.     

急性脑卒中合并感染患者在卒中单元和普通病房治疗的临床转归分析

目的分析收住卒中单元和神经内科普通病房急性脑卒中合并感染病例的治疗与转归。方法回顾性分析急性脑卒中后合并感染(肺部/尿路感染)患者165例,其中卒中单元组67例,普通病房组98例。分析两组感染特点及病原体检查结果。评价两组患者的转归:1主要转归为90 d病死率;2次要转归为第21天NIHSS评分和90d改良Rank(m RS)评分。比较两组患者的营养不良发生率、住院天数和药占比。结果两组患者均以合并肺部感染为主,感染病原体均以革兰阴性杆菌为主。卒中单元组90 d病死率明显低于普通病房组(P=0.009);第21天NIHSS评分和90 d m RS评分均显著优于普通病房组(均P=0.000)。卒中单元组营养不良发生率显著低于普通病房组(P=0.000)。卒中单元组住院天数和药占比均低于普通病房组,差异有显著统计学意义(P=0.000)。结论相对于普通病房,卒中单元在减少住院天数和药品费用的前提下,能降低脑卒中住院患者的病死率,提高患者神经功能恢复。     

急性脑卒中患者血清白蛋白水平与近期预后的关系

目的 探讨急性脑卒中患者血清白蛋白(Alb)水平与近期预后的关系.方法 对242例急性脑卒中患者入院时和住院期间每2周检测血清Alb 1次,比较低Alb组(Alb<35 g/L)和正常Alb组(Alb≥35 g/L)脑卒中并发症的发生率、死亡率以及好转率.结果 242例患者中入院时低Alb 38例(15.7%),住院期间出现低Alb 105例(46.5%).与入院时正常Alb组比较,入院时低Alb组的死亡率、卒中后并发症的发生率明显增高,出院时病情好转率明显下降(P<0.05～0.01);与病程中正常Alb组比较,住院期间低Alb组的死亡率、并发症的发生率明显升高,出院时病情好转率明显降低(P<0.05～0.01).入院时Alb水平与死亡率呈负相关,与美国国立卫生研究院卒中量表(NIHSS)评分差值正相关(r=-0.297,r=0.282;均P<0.01).住院期间Alb水平与肺部感染发生率、死亡率呈负相关(r=-0.545,r=-0.336),与NIHSS评分差值呈正相关(r=0.274;均P<0.01).Logistic回归分析显示,排除年龄、病情因素后,急性脑卒中患者入院时及住院期间血清Alb水平对近期预后影响显著. 结论血清Alb水平是影响急性脑卒中患者近期预后的因素.     

中西医结合卒中单元的疗效和卫生经济学评价

目的探讨中西医结合卒中单元治疗急性缺血性脑卒中的临床疗效和卫生经济学价值。方法随机选取符合入选标准的260例急性缺血性脑卒中(风痰瘀阻症)患者,分为实验组(中西医结合卒中单元组)和对照组(常规治疗组),两组均为130例。采用美国国立卫生院卒中量表(NIHSS)评分、Barthe1指数(BI)、改良的Rankin量表(mRS)为疗效观察指标;住院时间、住院费用、药品费用、检查和治疗费用为卫生经济学指标。比较NIHSS评分每减少1分、BI评分每增加5分、mRS评分每减少1分,患者每人每天所花费的住院费用。结果①与对照组比较,实验组治疗后14 d时NIHSS、BI、mRS改善程度明显优于对照组(P0.05)。实验组14 d后NIHSS评分下降主要在构音和运动功能方面优于对照组(P0.001);实验组BI评分提高主要在用厕、吃饭、移动、行走、穿衣、上楼、洗浴方面优于对照组(P0.01),实验组mRS(0~2)分的患者近期残障功能的改善优于对照组(P0.01)。②住院期间,两组患者的住院费用和检查费用差异无统计学意义(P0.05);实验组的平均住院时间和药品费用明显低于对照组(P0.01),治疗费用高于对照组(P0.001)。③NIHSS评分每减少1分,BI评分每增加5分,MRS评分每减少1分,实验组所需费用均较对照组少。结论中西医结合卒中单元治疗急性缺血性脑卒中更具有社会效益和经济效益。     

脑卒中后吞咽障碍196例临床分析

目的探讨吞咽障碍与脑卒中患者预后的相关性,旨在提高对卒中后吞咽障碍的重视。方法选择住院的397例急性脑卒中患者为研究对象,入院后48h内完成标准吞咽评估(standardized swallowing assessment,SSA)。观察急性卒中后吞咽障碍发生率、误吸发生率、1个月内获得性肺炎发生率。按SSA分为吞咽障碍组和无吞咽障碍组。6个月后完成改良Rankin量表(mRS)评分、Barthel指数(BI)评分、NIHSS评分。比较2组预后情况。结果 397例卒中患者中196例吞有咽障碍(49.37%),其中误吸112例,6个月后45例仍存吞咽障碍,8例仍需胃管饮食。无吞咽障碍组BI评分、NIHSS评分分别高于、低于吞咽障碍组(P<0.05),预后良好率高于吞咽障碍组(P<0.05)。结论卒中后吞咽障碍发生率较高,吞咽障碍影响脑卒中患者预后。     

慢性阻塞性肺病对急性脑梗死患者预后的影响

目的探讨慢性阻塞性肺病对急性脑梗死患者预后的影响。方法采用美国国立卫生研究院卒中量表(NIHSS)和Barthel指数(BI)对慢性阻塞性肺病合并急性脑梗死(COPD组)患者发病不同阶段(入院时、治疗第14和28天)神经功能缺损程度和日常生活活动能力进行评分,与单纯急性脑梗死(对照组)患者进行比较,评价其预后。结果治疗前两组一般情况、NIHSS和BI评分差异均无统计学意义(P0.05)。治疗第14天时,COPD组患者NIHSS评分升高[(9.47±3.43)分]、BI评分降低[(33.83±15.68)分],但与对照组[NIHSS评分:(8.37±3.50)分,BI评分:(37.83±17.25)分]比较差异无统计学意义(P=0.224,0.351)。治疗第28天时,COPD组患者NIHSS评分[(6.93±2.59)分]高于、BI评分[(54.00±15.45)分]低于对照组[NIHSS评分:(5.43±2.13)分,BI评分:(65.67±16.33)分],差异具有统计学意义(P=0.017,0.006)。结论慢性阻塞性肺病合并急性脑梗死患者发病后预后不良可能与病程中始终存在的系统性炎症和氧化应激有关。     

急性/康复联合卒中单元对急性脑梗死患者日常生活活动能力的影响

目的 探讨急性/康复联合卒中单元对急性脑梗死患者日常生活活动能力的影响。方法 185例急性脑梗死患者,随机分入急性/康复联合卒中单元和普通病房。分别在入院和出院时进行Barthel指数（Barthel index,BI）、Fugl-Meyer运动功能评定（Fugl-Meyer assessment,FMA）和美国国立卫生研究院卒中量表（U.S. National Institutes of Health Stroke Scale,NIHSS）评价,BI在随访至6个月时第3次评价,并应用SPSS 13.0进行结果分析。结果 治疗后,卒中单元组在出院时和6个月随访时的BI改善值均高于普通病房组（20±18 vs 12±16,Ｐ＜0.01;44±20 vs 26±17,Ｐ＜0.01）。6个月时,卒中单元组生活基本自理的比例显著高于普通病房组（73.63% vs 53.19%,Ｐ=0.003）,而重度障碍率则低于普通病房组（12.09% vs 21.28%,Ｐ=0.044）。两组出院时运动功能和神经功能均有改善,但改善值卒中单元组更大（Ｐ＜0.01）。结论 与普通病房相比,急性/康复联合卒中单元能提高患者的日常生活活动能力,降低致残率,提高生活质量,提高运动功能,减少神经功能缺损。     

营养支持对急性卒中患者血清氨基酸谱和神经功能的影响

目的 探讨不同营养支持因素对急性卒中患者产生的血清氨基酸谱变化及其对神经功能的影响.方法 采用随机数字表法将60例急性卒中伴吞咽困难的患者分为肠内营养组(30例)和对照组(30例),分别检测入院后48 h内、入院后(7±1)d及入院后(14±1)d时患者血清氨基酸谱、血红蛋白、总蛋白、白蛋白、前白蛋白、免疫球蛋白、补体、神经功能缺损评分(NIHSS)及Barthel日常生活能力指数评分(BI)、感染率.随访发生急性卒中后的1、3个月患者的NIHSS及BI评分.结果 肠内组患者入院(7±1)d及(14±1)d的血清氨基酸谱、血红蛋白、总蛋白、白蛋白、前白蛋白、免疫球蛋白、补体、神经功能缺损评分均优于对照组,感染率低于对照组;随访1、3个月,NIHSS评分肠内组(9.0±1.4,7.9±1.3)优于对照组(11.1 ±1.5,10.6±1.4),差异有统计学意义(F=46.042,P＜0.05),而BI评分肠内组(50.1±1.8,52.0±2.4)与对照组(49.0±2.1,51.3±2.8)间差异无统计学意义(F=2.707,P＞0.05).结论 对急性卒中伴吞咽障碍患者早期给予肠内营养支持可改善机体的血清氨基酸水平,从而改善机体的营养状况,减少感染并发症,促进近期神经功能恢复,改善预后.     

颅脑CT血管成像对判断急性脑梗死患者预后的价值

目的 探讨颅脑CT血管成像(CTA)对判断急性脑梗死(ACI)患者预后的价值.方法 对70例发病≤6 h ACI患者进行颅脑CTA检查,并评价患者入院时、出院时美国国立卫生研究院卒中量表 (NIHSS) 评分和改良的Ranking量表(mRS)评分.结果 CTA检查显示血管正常32例,大血管闭塞38例.血管闭塞组患者出院时NIHSS评分和mRS评分均高于无血管闭塞组,差异有统计学意义 (P<0.01,P<0.001);两组出院时NIHSS评分、mRS评分均比入院时明显降低(均P<0.001).无血管闭塞组患者预后良好25例(78.1%),血管闭塞组预后良好17例(44.7%),两组差异有统计学意义(P<0.01).入院时NIHSS评分及CTA显示的血管状况与临床预后呈负相关(r=-0.25,P<0.05;r=-0.73,P<0.001),入院时NIHSS评分(OR 0.09, 95%CI: 0.07～0.12, P<0.01)和血管是否闭塞(OR 0.12, 95%CI: 0.01～0.24, P<0.05)与预后有关,是ACI预后的独立预测因素.无血管闭塞组患者进行溶栓或未溶栓治疗的预后良好比率(分别为66.7%、75.0%)差异无统计学意义(P>0.05).血管闭塞组溶栓治疗患者预后良好比率(58.8%)明显高于未溶栓治疗患者(31.8%)(P<0.05).结论 血管闭塞的ACI患者预后较差,CTA对判断ACI患者的预后及选择溶栓治疗有意义.     

卒中后高血糖与缺血性脑卒中

20～40％的脑卒中患者,无论其此前是否诊断为糖尿病,均可在卒中发生后出现高血糖,称为卒中后高血糖（post stroke hyperglycemia,PSH）。PSH是脑卒中预后的一个重要预测因子,PSH能预测脑卒中患者的死亡风险及神经功能恢复情况。     

Long-term prevention of ischaemic stroke and stroke recurrence

Stroke is the third most important cause of mortality, but the leading cause of severe handicap, dependency, and loss of social competence. Because of the high recurrence rate, active secondary prevention is mandatory once a stroke has occurred. Secondary prevention of stroke implies the primary prevention of cardiovascular disorders as well. Among the modifiable risk factors hypertension is worst and should be normalized according to recent WHO criteria, also in the elderly. Smoking is another major risk factor and hard to delete. Diabetes mellitus and hyperlipidaemia are also important risk factors and should be treated consequently by diet and medication. Moderate alcohol intake, normalization of body weight and regular physical activity also contribute considerably to prevention of stroke. Whether hyperhomocysteinaemia should be normalized has not yet been clarified. Cardiovascular disorders are an important source of ischemic strokes, particularly atrial fibrillation. Low dose anticoagulation can dramatically reduce stroke risk. Carotid endarterectomy in symptomatic stenoses is the most expensive means of stroke prevention. In less severe stenoses, or ICA occlusions, antiplatelet agents are the treatment of choice. Composite drugs with ASS and other antiplatelet agents seem to be superior to either compound alone. Dissections of the cervical arteries should not be operated on but may be treated by anticoagulation or antiplatelet agents in the acute and subacute phase. The potency of a consequent and comprehensive stroke prevention in preventing disability and death is much greater than any sophisticated acute stroke treatment.     

From stroke unit care to stroke care unit

In some stroke units continuous monitoring of blood pressure, electrocardiogram, body temperature, and oxygen saturation has become an integral part of the management of acute stroke. In addition, regular measurements of blood glucose are performed. Stroke units equipped with such monitoring facilities should be named 'stroke care units' by analogy with coronary care units. The goal of a stroke care unit is early detection and rapid correction of extracranial factors which may aggravate cerebral damage in ischemic brain, including hypoxia, hyperglycemia, hypotension, cardiac arrhythmias, and elevated body temperature.     

Depression in stroke patients 7 years following stroke

OBJECTIVE: To study the frequency of depression in stroke patients many years following stroke, most previous studies having concentrated on the first few years. METHOD: Participants of a previous study of post-stroke depression (99 stroke patients and 28 control subjects) were re-examined 7 years later. Depression was diagnosed using research diagnostic criteria. The test battery comprised the Mini Mental State Examination, the Raven Matrices A+B and Word Pair Learning. Subjective experience of changes in memory, concentration, mood, irritability and fatigue during the 7-year period was also examined. RESULTS: Twenty per cent of the stroke patients fulfilled the criteria for major or minor depression compared with 11% of the control subjects. No differences in cognitive function were found between depressed and non-depressed stroke patients. The stroke patients reported experiencing more lability of mood and irritability during the 7-year period following stroke than the control subjects. Depressed stroke patients experienced more impairment of concentration and memory function than non-depressed stroke patients. CONCLUSION: Affective symptoms are common among stroke patients 7 years following stroke.     

Awareness of stroke risk in chagasic stroke patients

BACKGROUND: Reduction in stroke risk may depend on the general population's knowledge of stroke. In South America, chagasic myocardiopathy is independently associated with ischemic stroke. OBJECTIVE: The aim of this study was to evaluate awareness of Chagas' disease (CD) as a stroke risk factor and to determine the frequency of stroke patients that are diagnosed as having CD after stroke. METHODS: Eighty CD stroke patients and 140 non-chagasic stroke patients (53.2% males; mean age 60 years), consecutively admitted to the hospital during 2005 were interviewed with a questionnaire. Demographic variables included age, sex, ethnicity, education, previous history of stroke, vascular risk factors, social background information and several questions regarding awareness of CD as a stroke risk factor. A logistic regression model was developed to identify social variables that could predict the risk of CD stroke. RESULTS: The diagnosis of CD was established after stroke in 42.5% of CD stroke patients. Most respondents (95%) were not aware of stroke risk in CD. Chagasic patients had the lowest rate of awareness about stroke risk (2.5 vs 7.1%), although they had the greatest knowledge about the kissing bug vector (83.7 vs 62.1%; p<0.001). The main social variables associated with CD stroke were: having family members with Chagas' disease (p<0.0001; odds ratio 10.1; 95% CI 3.6-16.1) and a past history of living in a mud-brick house during childhood (p<0.001; odds ratio 8.9; 95% CI: 4.1-24.6). CONCLUSION: Awareness about CD as a risk factor of stroke is low. Educational campaigns about risk of stroke in CD patients are encouraged.     

Perioperative stroke

It is increasingly recognized that one can identify a higher risk patient for perioperative stroke. The risk of stroke around the time of operative procedures is fairly substantial and it is recognized that patients initially at risk for vascular events are those most likely to have this risk heightened by invasive procedures. Higher risk patients include those of advanced age and there is a cumulative risk, over time, of coexistent hypertension, atherosclerosis, diabetes mellitus, cardiac disease and clotting disorders. There are a number of possible mechanisms associated with the procedure (e.g., preoperative hypercoagulability, holding of antithrombic therapy at the time of the procedure and cardiac arrhythmia) that can promote a thrombo-embolic event. Examples of these include: direct mechanical trauma to extracranial vessels related to operations on the head and neck; and vascular injury as a consequence of vascular and innovative endovascular procedures affecting the cerebral circulation (e.g., carotid endarterectomy, extracranial or intracranial angioplasty with stenting, and use of the MERCI clot retrieval device), as well as various endovascular methods that have been developed to obliterate cerebral aneurysms and arteriovenous malformations as an alternative to surgical clipping and surgical resection, respectively.