青年缺血性卒中病因分型特点及相关危险因素分析

目的探讨青年缺血性卒中患者的病因分型构成特点和相关危险因素。方法回顾性分析北京市海淀医院神经内科2010年1月~2014年6月连续登记的120例青年首发缺血性卒中患者,同时选取同期住院的中老年缺血性卒中患者136例作为对照,收集所有研究对象的临床资料,根据中国缺血性卒中亚型(China Ischemic Stroke Subclassification,CISS)明确所有研究对象的病因分型及其危险因素,比较两组患者的病因分型特点及相关危险因素特点。结果青年缺血性卒中组男性82例(68.3%),女性38例(31.7%);中老年组男性76例(55.9%),女性60例(44.1%)。两组性别相比差异具有显著性(χ2=4.183,P=0.041)。CISS分型青年组依次为大动脉粥样硬化(large artery atherosclerosis,LAA)25.8%,原因不明(stroke of other undetermined etiology,SUE)22.5%,穿支动脉闭塞(perforating branch artery occlusion,PAO)20.8%,心源性(cardioembolism,CE)19.2%,其他病因(stroke of other etiology,SOE)11.7%。中老年组依次为LAA 40.5%,PAO 33.8%,CE 21.3%,SOE 2.9%,SUE 1.5%。青年缺血性卒中和中老年缺血性卒中两组间病因分型除CE差异无显著性外,LAA、PAO、SOE、SUE两组比较均差异具有显著性(P0.05)。其中青年组SOE、SUE病因分型比例明显高于中老年组,差异有显著性(P0.05)。青年组排前5位的危险因素分别是吸烟48.3%,高血压44.2%,高脂血症40.8%,饮酒36.7%,卒中家族史23.3%。而中老年组分别是高血压57.4%,糖尿病47.1%,高脂血症43.4%,颈动脉粥样硬化37.5%,吸烟35.3%。两组间相关危险因素比较,青年组吸烟、饮酒、卒中家族史明显高于中老年组,两组比较差异有显著性(P0.05)。结论青年缺血性卒中病因分型构成特点和相关危险因素与中老年患者分布不同。早期明确病因分型和发现危险因素有利于青年缺血性卒中的防治。     

穿支动脉性脑梗死早期神经功能恶化的研究

<正>国际上缺血性卒中分型中急性脑卒中Org 10172治疗实验(Trial of Org 10172 in Acute Treatment,TOAST)分型是目前应用最广泛的病因学分型。根据缺血性卒中(ischemic stroke,IS)的病因分型各型大致分为以下几类:大动脉粥样硬化(large-artery athero-sclerosis,LAA)、心源性栓塞(cardioembolism,CE)、小动脉闭塞(small-artery occlusion lacunar,SAA)、其他病因(stroke of other determined etiology,     

基于中国缺血性卒中亚型分型的轻型缺血性卒中与致残性缺血性卒中的危险因素及病因学分析

目的研究轻型缺血性卒中与致残性缺血性卒中危险因素及病因学分型的差异。方法采用中国缺血性卒中亚型(CISS)分型对133例轻型缺血性卒中患者(轻型卒中组)及155例致残性缺血性卒中患者(致残性卒中组)进行病因分型,比较其危险因素及病因学分布上的差异。结果轻型卒中组与致残性卒中组患者糖尿病、高血压、高同型半胱氨酸血症、吸烟史、高脂血症、心房纤颤(房颤)、高尿酸血症比率差异无统计学意义(均P 0. 05)。轻型卒中组大动脉粥样硬化性脑梗死(LAA)比率最高(45. 1%),穿支动脉闭塞性脑梗死(PAD)次之(42. 1%),其次依次为不明原因性缺血性卒中(UE)(7. 52%)、心源性脑栓塞(CS)(4. 51%)和其他病因型缺血性卒中(OE)(0. 75%);致残性卒中组LAA比率最高(65. 16%),PAD次之(16. 13%),其次依次为CS(9. 68%)、UE(8. 39%)和OE(0. 65%)。两组间CISS分型比较差异有统计学意义(χ~2=25. 02,P 0. 0001)。结论轻型缺血性卒中与致残性缺血性卒中的常见危险因素无显著差异。轻型缺血性卒中与致残性缺血性卒中的最常见病因均为LAA、其次为PAD。轻型缺血性卒中的UE比率高于致残性缺血性卒中,而CS的比率低于致残性缺血性卒中。     

ASCO与改良TOAST病因分型对缺血性卒中病因诊断的比较

目的 评价ASCO与改良TOAST分型方法对卒中亚型分型的准确性.方法 425例首发急性脑梗死患者分别经ASCO与改良TOAST病因分型方法进行卒中病因诊断,比较两种分型方法对卒中病因诊断的准确性.结果 与改良TOAST分型相比,ASCO 1级证据未明显降低不明病因卒中的诊断比例(15.5％比16.2％,x2=0.09,P=0.795),动脉粥样硬化性卒中的发病率60.2％,与改良TOAST分型相近(57.9％,x2=2.68,P=0.132),小动脉病变、心源性卒中的诊断比例略低于改良TOAST分型(13.4％比14.8％,x2=1.30,P=0.238;8.5％比8.7％,X2=0.00,P=1.000).2种分型方法对动脉粥样硬化性卒中和小动脉病变的诊断均具有很好的一致性(κ值均大于0.81),对心源性卒中的诊断具有较好的一致性(κ值0.61～0.80).结论 ASCO分型、改良TOAST分型方法对各卒中亚型的诊断均存在一致性,ASCO分型的设计特点能更充分地利用临床信息,弥补改良TOAST分型对多病因卒中患者病因诊断的不足.     

200例老年女性脑梗死的临床特点

目的分析老年女性脑梗死的临床特点。方法回顾性分析在昆明市延安医院神经内科住院的老年女性首发急性脑梗死患者(年龄≥60岁)200例的临床资料,经影像学及其他病因学检查确诊。依据新版治疗急性卒中试验(NEW.TOAST)分型标准,确定患者病因分型。治疗后3个月,根据改良Rankin评分法(MRS)判断预后。结果收集老年女性脑梗死病因呈多样化,根据TOAST分型构成,大动脉粥样硬化型卒中60例(30.0%),小动脉闭塞型卒中83例(41.5%),心源性脑栓塞型55例(27.5%),其他原因型卒中2例(1.0%),原因不明缺血性卒中0例。危险因素的暴露率最高为血脂异常134例(67.0%),其次为高血压122例(61.0%),心脏病72例(36.0%),糖尿病70例(35.0%),吸烟、饮酒39例(19.5%),高同型半胱氨酸38例(19.0%)。NEW.TOAST分型各组预后较差的是大动脉粥样硬化型,预后较好的是小动脉闭塞型。结论老年女性脑梗死的病因分型以小动脉闭塞型卒中所占比例最高,危险因素中血脂异常和高血压的暴露率高,小动脉闭塞型预后较好。     

缺血性脑卒中TOAST病因分型危险因素及短期预后分析

目的分析缺血性脑卒中各TOAST亚型的危险因素及短期预后。方法连续收集急性缺血性脑卒中患者300例,按照TOAST分型标准进行病因分型。采用美国国立卫生院神经功能评分标准(NIHSS)对所有患者入院当天、3 d、7 d、14 d、出院当天进行神经功能评分。治疗期间筛查并记录各亚型患者的危险因素。对比分析各亚型患者治疗期间神经功能改善情况,并采用logistic回归模型对各TOAST亚型患者的危险因素进行分析。结果TOAST分型情况:心源性脑栓塞(CE)40例;大动脉粥样硬化性卒中(LAA)47例;小动脉卒中(SAA)143例;其他原因引发的缺血性卒中(SOE)5例;原因不明的缺血性卒中(SUE)65例。与大动脉粥样硬化性卒中相关的危险因素为高血压和高血脂(P<0.05);与小动脉卒中(SAA)相关的危险因素仅为高血压(P<0.05)。心源性栓塞患者神经功能缺损最严重,恢复较慢,预后最差;小动脉卒中患者神经功能缺损最轻,恢复最快,预后最好;其他类型卒中介于两者之间。结论 TOAST作为一种病因分型方法可以有效地为缺血性脑卒中的预后估计及危险因素预防提供帮助。     

不同TOAST亚型脑卒中患者动脉硬化负担分级比较

目的按照TOAST分型标准对急性脑梗死患者进行病因学分型,并评价各类型患者的动脉硬化负担分级。方法选取2014-01—2016-05我院收治的急性脑梗死患者160例,并对其临床资料进行回顾性分析;按照TOAST标准进行病因分型,并根据动脉硬化负担分级对各亚型卒中患者进行分级评价,比较各亚型卒中患者的动脉硬化负担分级。结果 TOAST分型结果:心源性栓塞型(CE)24例(15.38%),大动脉粥样硬化型(LAA)54例(34.62%),小动脉闭塞型(SAO)28例(17.59%),其他明确病因型(ODC)20例(12.82%)及不明原因型(UND)30例(19.23%);动脉硬化负担分级结果:心源性栓塞型患者、大动脉粥样硬化型患者与小动脉闭塞型患者的动脉硬化负担分级程度高于其他明确病因型与不明原因型,差异有统计学意义(P0.05)。结论心源性栓塞型、大动脉粥样硬化型与小动脉闭塞型患者的病因均与血管性因素有关,通过动脉硬化负担分级有利于血管性脑卒中患者的病因诊断。     

卵圆孔未闭与缺血性卒中的关系

正随着缺血性卒中分型理论在国内的普及[1-2],人们越来越重视针对卒中病因的筛查和研究。病因不同,缺血性卒中二级预防的策略就可能不同,如心源性卒中侧重于抗凝治疗,而大动脉粥样硬化性卒中则强调抗血小板聚集。近年,所谓隐源性卒中的病因研究,在国内逐渐受到重视。本文将简要介绍隐源性卒中研究中所涉及的相关问题,重点阐述卵圆孔未闭(patent foramen ovale,PFO)在缺血性卒中发病中的     

缺血性卒中的分型─从原始TOAST到ASCO分型

卒中分型是针对各种不同类型缺血性卒中诊断与治疗的基础,对于卒中的基础研究与临床应用也是不可或缺的工具。目前最为广泛使用的分型系统就是急性卒中Orgl10172治疗试验（trialof org10172 in acute stroke treatment,TOAST）分型。随着医学影像技术的进步与流行病学研究的发展,为了更精确的卒中分型,学者陆续提出修订TOAST的版本,因而有基于停止卒中研究（stop strokestudy,SSS）提出的SSS-TOAST与韩国改良-TOAST的产生。而新发展出的ASCO分型系统,在决定最可能卒中分型的同时,也同时保留了其他较不可能病因的信息,因此可能对于卒中复发的预防与研究是很好的工具。迄今仍没有一个十全十美的缺血性卒中分型系统,本研究探讨各个卒中分型系统的特性,分析其在诊断卒中时的优缺点。以此为基础,希望未来能发展出适合中国人的缺血性卒中分型系统。     

急性缺血性卒中患者病因分析

目的依据改良TOAST分型方法作为标准,探讨河北省中南部地区急性缺血性卒中的病因学特征。方法收集2002年1月至2007年6月入住我院神经内科的急性缺血性脑卒中患者作为研究对象,依据改良的TOAST病因分型法作为诊断标准,结合头颅DWI和/或TCD微栓子监测结果确定动脉粥样硬化性血栓(AT)的诊断及病因分型。结果本研究共纳入1164例急性缺血性卒中患者,所有患者M-TOAST亚型构成比例分别为:动脉粥样硬化性血栓71.48%,小动脉病变21.39%,心源性栓塞3.09%,其它病因明确0.86%,不明病因者3.18%。结论河北省中南部地区急性缺血性卒中的病因分型以AT为主。     

Classifying Ischemic Stroke,from TOAST to CISS

SUMMARY Ischemic stroke classification is critical in conducting basic research and clinical practice. A precise analysis of stroke subtypes requires the integration of clinical features, findings from diagnostic tests, and knowledge about potential etiologic factors by competent diagnostic investigators. We performed a literature review of the published stroke classification systems and examined each for its benefits and limitations in the evaluation of the stroke etiology. Two major approaches to etiologic classifications of ischemic stroke are currently being used: the causative and phenotypic subtyping. The most widely used causative system is the Trial of Org 10172 in acute stroke treatment (TOAST) classification. With the advances in modern diagnostic technology, new stroke subclassification systems, such as the causative classification system (CCS) and Chinese ischemic stroke subclassification (CISS) system, have been developed to enhance the accuracy of TOAST. The A‐S‐C‐O ( A therosclerosis, S mall‐vessel disease, C ardiac source, O ther cause) phenotypic classification system makes efforts to identify the most likely etiology but not neglecting the possibility of other potential multiple causes. We conclude that the ideal stroke classification system needs to be valid, easy to use, evidence‐based, and incorporate new information as it emerges.     

Advances in the Diagnosis of Etiologic Subtypes of Ischemic Stroke

A fundamental goal of etiologic stroke classification is to generate subgroups with discrete phenotypic, therapeutic, and prognostic features. Accurate stroke classification requires integration of multiple aspects of diagnostic stroke evaluation in a standardized manner. Diagnostic test findings can be simply organized into major etiologic groups to create a phenotypic subtype, or they can be reduced to a single causative subtype through a decision-making process. It is essential for a classification system to provide consistent results across different raters in different clinical settings. Comparability of subtype assignments is the key to valid communication of research results across the field. This article highlights important theoretical aspects of etiologic stroke classification and reviews major etiologic classification systems that have benefited from recent advances in etiologic stroke evaluation.     

既往卒中病史对缺血性脑血管病患者卒中结局的影响研究

目的 探讨中国人群中首发和复发缺血性脑血管病患者的临床特征和卒中结局差异。 方法 本研究基于全国多中心前瞻性中国国家卒中登记研究Ⅲ（the third China national stroke regi stry,CNSR-Ⅲ）,连续纳入2015年8月-2018年3月急性缺血性卒中或TIA患者,收集人口学信息、血 管危险因素、既往用药史及病因分型系统（causative classification system,CCS）等临床资料,记录随 访3个月和1年时卒中结局。卒中结局包括卒中复发（缺血性卒中或出血性卒中）、联合血管事件（卒中、 心肌梗死及血管性死亡事件）、脑血管病源性死亡及不良功能结局（mRS＞2分）。依据患者既往是否 有卒中病史分为有卒中病史组和无卒中病史组,比较两组的临床特征及卒中结局差异,并分析卒中病 史与卒中结局间的关系。 结果 最终纳入15 166例患者,平均年龄62.2±11.3岁,其中女性4802例（31.7%）;有卒中病史患者 3355例,无卒中病史患者11 811例。有卒中病史组患者年龄,冠心病、高血压、脂代谢紊乱、糖尿病、心 房颤动比例,既往用药史比例、入院NIHSS评分、住院期间降糖和降压治疗比例均高于无卒中病史组, 目前吸烟和重度饮酒比例、入院时LDL-C水平及住院期间抗血小板治疗比例低于无卒中病史组,差 异均有统计学意义。两组CCS分型的分布差异有统计学意义,其中有卒中病史组大动脉粥样硬化型和 心源性栓塞型卒中比例高于无卒中病史组。多因素分析结果显示,卒中病史是随访3个月不良功能结 局（校正OR 1.25,95%CI 1.09～1.44,P =0.002）,随访1年卒中复发（校正HR 1.44,95%CI 1.25～1.67, P＜0.001）、联合血管事件（校正HR 1.43,95%CI 1.24～1.64,P＜0.001）、脑血管病源性死亡（校正 HR 1.42,95%CI 1.12～1.80,P =0.004）、不良功能结局（校正OR 1.63,95%CI 1.42～1.88,P＜0.001）的 危险因素。 结论 有无卒中病史的缺血性卒中患者的临床特征及随访结局差异较大,尽管患者进行卒中二级 预防治疗,卒中病史仍然是患者1年卒中复发、联合血管事件、脑血管病源性死亡及不良功能结局的 危险因素。     

Burden of stroke in Malaysia

Stroke is one of the top five leading causes of death and one of the top 10 causes for hospitalization in Malaysia. Stroke is also in the top five diseases with the greatest burden of disease, based on disability-adjusted life years. However, prospective studies on stroke in Malaysia are limited. To date, neither the prevalence of stroke nor its incidence nationally has been recorded. Hypertension is the major risk factor for stroke. The mean age of stroke patients in Malaysia is between 54.5 and 62.6 years. Traditional medicine is commonly practiced. With the increasing number of stroke cases annually, more government and nongovernment organizations should be involved in primary and secondary prevention strategies.     

Antiplatelet Agents for Stroke Prevention

Stroke is one of the leading causes of disability and death. Ischemic stroke is a syndrome with heterogeneous mechanisms and multiple etiologies, rather than a singularly defined disease. Approximately one third of ischemic strokes are preceded by another cerebrovascular ischemic event. Stroke survivors are at high risk of vascular events (i.e., cerebrovascular and cardiovascular events), particularly during the first several months after the ischemic event. The use of antiplatelet agents remains the fundamental component of secondary stroke prevention. Based on the available data, antiplatelet agents should be used for patients with noncardioembolic stroke. The use of combination therapy (aspirin plus clopidogrel) has not been proven to be effective or safe to use for prevention of early stroke recurrence or in long-term treatment. There is no convincing evidence that any of the available antiplatelet agents are superior for a given stroke subtype. Currently, the uses of aspirin, clopidogrel, or aspirin combined with extended release dipyridamole are all valid alternatives after an ischemic stroke or transient ischemic attack. However, to maximize the effects of these agents, the treatment should be initiated as early as possible and be continued on a lifelong basis.     

Prediction of infarct topography using the Oxfordshire Community Stroke Project classification of stroke subtypes.

Background: The Oxfordshire Community Stroke Project clinical classification of ischemic stroke syndromes has been shown to be predictive of important clinical outcomes. In this study, we examined the correlation between this classification system and infarct topography on computed tomography (CT) of the brain. Method: A cohort of consecutive cases of acute ischemic stroke admitted to an acute stroke service during the 3-year period ending December 31, 1996 were identified from a prospective stroke registry. Brain scans were reviewed by a single neuroradiologist without knowledge of the clinical features. Results: There were 418 patients with acute ischemic stroke who met the study admission criteria. Forty patients were excluded, 20 (5%) did not have a CT scan during the admission, and 20 scans were not available for review. In 239 of 378 patients (63%), the brain scan revealed the lesion responsible for the clinical syndrome. In patients with positive scans, the positive predictive values of the clinical subtypes were: 86% (95% confidence interval, 78-94) for the total anterior territory stroke syndrome, 96% (92-100) for the partial anterior territory stroke syndrome, 99% (97-100) for the lacunar stroke syndrome, and 100% for the posterior circulation stroke syndrome. Conclusion: The Oxfordshire Community Stroke Project classification of ischemic stroke syndromes usefully predicts infarct topography on CT scan.     

Current Status of Antiplatelet Agents to Prevent Stroke

Stroke is one of the leading causes of disability; most are due to atherothrombotic mechanisms. About one third of ischemic strokes are preceded by other stroke or transient ischemic attacks. Stroke survivors are at high risk for vascular events (i.e., cerebrovascular and cardiovascular). Prevention of recurrent stroke and other major vascular events can be accomplished by control of risk factors. Nonetheless, the use of antiplatelet agents remains the fundamental component of secondary stroke prevention strategy in patients with noncardioembolic disease. Currently, the uses of aspirin, clopidogrel, or aspirin plus extended-release dipyridamole are valid alternatives for stroke or transient ischemic attack patients. To maximize the beneficial effects of these agents, the treatment should be initiated as early as possible and continue on a lifelong basis.     

Incidence and etiology of ischemic stroke in Persian young adults

BACKGROUND: Stroke in young adults causes morbidity in this socioeconomically active age group. The etiologic frequency of ischemic stroke in young adults differs around the world. METHODS: The study population consisted of 314,000 'young adult' residents in Southern Khorasan province in Iran. All patients with stroke are routinely admitted to the Valie Asr tertiary care hospital. Data on patients demographics, clinical presentation and investigations of consecutive patients aged 15-45 years with ischemic stroke are registered in Southern Khorasan stroke data bank for the period March 2000 to March 2005. All patients underwent a standard battery of diagnostic investigations by a stroke neurologist. The etiologic classification of stroke in the patients was made based on the trial of ORG 10172 in acute stroke treatment (TOAST) criteria. RESULTS: One hundred and twenty-four patients (60 female, 64 male) were prospectively investigated during a 5-year period. The incidence of ischemic stroke in young adults was eight cases per 100,000 people per year. Cardioembolic mechanism comprised 54% of stroke etiology in young adults. Rheumatic valvular disease was present in 32% of the patients and caused 2.5 preventable stroke cases per 100,000 'young adults' per year. CONCLUSION: Rheumatic valvular disease is the most common cause and a preventable etiology of stroke in Persian young adults.     

Stroke in Latin America

Stroke is one of the leading causes of mortality in Latin America, with variable incidence and prevalence throughout the continent reflecting regional socioeconomic differences. In Latin America, uncontrolled hypertension is one of the major causes of stroke, but other modifiable risk factors also play a role, such as heavy alcohol consumption and smoking. Intracerebral hemorrhage and lacunar stroke are more frequent in Latin America than in North America and Europe. There are multiple causes of stroke that are endemic to Latin America, including neurocysticercosis, Chagas' disease, sickle cell anemia, malaria, hemorrhagic fever, and snake bites.