三种不同病因缺血性脑卒中急性期血压与预后的关系

目的 探讨三种不同病因类型的缺血性脑卒中急性期血压与预后的关系.方法 以温州脑卒中登记库为基础,前瞻性连续登记2007年4月至2008年4月温州医学院附属第一医院从发病到入院时间小于48 h并被诊断为脑梗死的患者.采用Logistic多因素逐步回归法分析不同病因型脑梗死患者影响预后的因素.结果 各病因型入院血压和急性期平均血压与预后均呈U型关系.动脉粥样硬化型、心源性栓塞型和其他病因型入院时血压在150/95 mm Hg(1 mm Hg=0.133 kPa)左右,7 d内平均血压140/90 mm Hg时预后最佳;小动脉病变型以入院时血压在130/95 mm Hg左右,7 d内平均血压140/90 mm Hg时预后最佳.在动脉粥样硬化型缺血性脑卒中患者中,入院24 h内收缩压下降幅度大于20 mm Hg使3个月的死亡和残疾风险增加4.44倍(OR 4.44,95%CI 1.70～11.59,P=0.002);入院24 h内舒张压下降幅度大于10 mm Hg使3个月的死亡和残疾风险增加3.70倍(OR 3.70,95%CI 1.54～8.90,P=0.00).心源性脑栓塞患者中,入院24 h内收缩压下降幅度大于20 mm Hg(OR 7.98,95%CI 1.34～47.66,P=0.026)和舒张压下降幅度大于10 mm Hg(OR6.68,95%CI 1.55～28.79,P=0.01)均为3个月死亡和残疾的独立危险因素.结论 入院时各亚型组的血压与3个月病死和残疾率均呈U型关系,血压过高或过低患者预后均较差.对于动脉粥样硬化型患者和心源性栓塞患者,入院24 h内血压下降幅度过大为其3个月预后不良的独立危险因素.     

重症缺血性脑卒中预后相关影响因素分析

目的探讨影响重症缺血性脑卒中(sIS)短期预后的相关因素。方法回顾性分析143例缺血性脑卒中(IS)住院患者的一般资料和实验室检查,包括既往史、血常规、血生化、凝血象等指标,头颅CT或MRI影像资料,发病后的并发症。根据美国国立卫生研究院卒中量表(NIHSS)评分变化进行病情严重程度分类及预后判断。结果 143例IS患者中sIS者82例(57.3%),轻症缺血性脑卒中(mIS)61例(42.7%)。82例sIS患者中,预后不良的发生率为73.2%(60/82)。sIS预后改善与预后不良组间入院收缩压、低密度脂蛋白(LDL-C)、随机血糖(Glu)比较差异有统计学意义(P<0.05);多因素Logistic回归分析显示,LDL-C水平升高是sIS早期不良预后的独立危险因素(OR=1.68,95%CI:1.05～2.69),入院时收缩压相对升高对sIS的预后具有保护作用(OR=0.97,95%CI:0.05～1.00)。mIS 30d预后不良组与sIS 30d预后不良组间房颤、卒中相关肺炎(SAP)、血白细胞数升高比较有统计学差异(P<0.05);多因素Logistic回归分析显示,房颤(OR=5.04,95%CI:1.31～9.63)、SAP(OR=3.23,95%CI:1.12～9.36)是IS早期不良预后的独立危险因素。结论房颤、LDL-C水平升高、SAP是IS早期预后不良的独立危险因素。     

入院时中性粒细胞与淋巴细胞比值和血糖水平对急性脑出血患者短期预后不良的预测价值

目的分析急性脑出血患者短期预后不良的相关危险因素,并探讨入院时中性粒细胞与淋巴细胞比值(neutrophil-to-lymphocyte ratio,NLR)和入院即刻血糖水平(admission blood glucose,ABG)对短期预后不良的预测价值。方法收集2017-01-2018-05期间作者医院收治的急性脑出血患者226例,根据3个月时改良Rankin评分量表(modified Rankin scale,mRS)评分分为预后良好(mRS≤2分)组124例,预后不良(mRS2分)102例,单因素分析两组患者入院时的临床、影像学及实验室资料,采用二分类Logistic回归分析探讨影响急性脑出血患者短期预后不良的危险因素,采用受试者工作特征(receiver operating characteristic,ROC)曲线评价NLR和ABG对短期预后不良的预测价值。结果 (1)与预后良好组相比,预后不良组患者糖尿病病史、饮酒史比例以及年龄、美国国立卫生研究院卒中量表(National Institute of Health stroke scale,NIHSS)评分均升高,血肿体积大,出血破入脑室比例高,白细胞计数(ABC)、中性粒细胞计数(ANC)、NLR及ABG升高,淋巴细胞计数(ALC)低(均P0.05)。(2)二分类Logistic回归分析显示患者年龄(OR=1.051,95%CI:1.013～1.090,P0.01)、血肿体积(OR=1.055,95%CI:1.003～1.110,P0.05)、NLR(OR=1.389,95%CI:1.124～1.716,P0.01)、ABG(OR=1.308,95%CI:1.074～1.593,P0.05)及NIHSS评分(OR=1.151,95%CI:1.065～1.243,P0.01)升高为急性脑出血患者短期预后不良的独立危险因素。(3)ROC曲线分析表明,NLR和ABG的ROC曲线下面积分别为0.767(95%CI:0.705～0.829,P0.01)、0.678(95%CI:0.609～0.747,P0.05)。结论入院时年龄、血肿体积、NIHSS评分、NLR及ABG升高是急性脑出血患者短期预后不良的独立危险因素,NLR和ABG对急性脑出血患者短期预后不良有一定的预测价值。     

近期单发皮质下梗死患者预后不良危险因素分析

研究背景脑白质高信号为脑小血管病的影像学标志物,常与近期单发皮质下梗死并存。本研究旨在筛查近期单发皮质下梗死患者预后不良相关危险因素。方法纳入2018年6月至2019年12月四川大学华西医院收治的432例近期单发皮质下梗死患者,头部MRI评估脑白质高信号(包括脑室旁白质高信号和脑深部白质高信号)。单因素和多因素Logistic回归分析筛查近期单发皮质下梗死预后不良相关危险因素,分层分析评估该危险因素在不同人群中的稳定性。结果 432例患者根据Fazekas评分分为轻度脑白质高信号组(评分0～3,277例)和重度脑白质高信号组(评分4～6,155例)。Logistic回归分析显示,年龄较大(OR=1.060,95%CI:1.028～1.093;P=0.000)、发病至入院时间较长(OR=1.005,95%CI:1.002～1.008;P=0.001)、入院时NIHSS评分较高(OR=1.109,95%CI:1.047～1.175;P=0.000)、梗死灶直径较大(OR=1.077,95%CI:1.028～1.129;P=0.002)和重度脑白质高信号(OR=2.229,95%CI:1.082～4.591;P=0.030)是近期单发皮质下梗死患者预后不良的危险因素;进一步分层分析显示,在女性(OR=2.460,95%CI:1.120～5.360;P=0.024)、年龄 50岁(OR=1.890,95%CI:1.120～3.180;P=0.017)和高血压(OR=3.150,95%CI:1.230～8.100;P=0.017)患者中,重度脑白质高信号(Fazekas评分4～6)作为近期单发皮质下梗死预后不良的危险因素是稳定的。结论重度脑白质高信号(Fazekas评分为4～6)是近期单发皮质下梗死患者发病3个月时预后不良的危险因素,且在女性、年龄 50岁和高血压人群中具有稳定性。     

血清前清蛋白对急诊初发缺血性脑卒中患者生存状况影响的研究

目的分析血清前清蛋白(PA)对急诊初发缺血性脑卒中患者生存状况的影响。方法选取2013-01-2014-01在我院急诊初发的急性脑梗死患者80例,入院后均按照脑卒中单元的标准指南进行相应的治疗,出院前通过改良Rankin量表(mRS)评分,将患者分为预后良好组(mRS评分0~2分,54例)和预后不良组(mRS评分3~6分,26例)。分别比较2组患者的一般资料、血清PA的差异,采用多因素Logistic回归分析影响患者预后不良的因素。结果 2组比较,患者的起病年龄、冠心病、2型糖尿病、完全前循环梗死(TACI)等级别的患病率明显增高,血清PA水平明显下降,差异有统计学意义(P0.05);多因素Logistic回归分析显示:高龄(OR=1.027,P=0.010)、2型糖尿病(OR=2.384,P=0.004)、冠心病(OR=2.305,P=0.021)和TACI(OR=17.578,P0.001)是急性脑梗死患者预后不良的危险因素,而急性期血清PA水平升高(OR=0.993,P0.001)有利于提高急性脑梗死患者的恢复和生活质量。结论血清PA水平升高对急诊初发缺血性脑卒中患者生存状况有着积极的作用。     

急性缺血性脑卒中静脉溶栓预后的影响因素分析

目的研究急性缺血性脑卒中静脉溶栓预后的影响因素。方法选择96例接受静脉溶栓治疗的急性缺血性脑卒中患者,观察年龄、性别、体质量、高血压史、糖尿病史、吸烟史、溶栓前收缩压、溶栓前血糖、起病-溶栓时间、溶栓前NIHSS评分等指标与预后的关系。结果预后不良组与预后良好组年龄、性别、体质量、高血压史、吸烟史无显著差异(P0.05)。与预后良好组比较,预后不良组糖尿病史比例更高,溶栓前收缩压更高,溶栓前血糖更高,起病-溶栓时间更长,溶栓前NIHSS评分更高(P0.05)。Logistic回归分析示,糖尿病史(OR=4,P=0.032)、溶栓前收缩压(OR=11,P=0.001)、溶栓前血糖(OR=10,P=0.028)、起病-溶栓时间(OR=1.01,P=0.013)、溶栓前NIHSS评分(OR=1.28,P=0.001)与溶栓预后不良显著相关。结论糖尿病史、溶栓前收缩压、溶栓前血糖、起病-溶栓时间、溶栓前NIHSS评分与预后不良密切相关,是预后不良的独立危险因素。     

神经外科重型颅脑创伤急性期血压变异性对患者近期预后的影响研究

目的探讨神经外科重型颅脑创伤(TBI)急性期血压变异性对患者近期预后的影响。方法选取110例重型TBI患者作为研究对象,根据格拉斯哥预后(GOS)评分分为预后良好组(n=53)和预后不良组(n=57),对两组患者术后3d内的血压变异性进行对比分析。结果预后良好组的平均年龄明显低于预后不良组,GCS评分、APACHEⅡ评分均明显高于预后不良组,P0.05。预后良好组入院24h的收缩压标准差、舒张压标准差、收缩压变异系数均显著低于预后不良组,入院72h的收缩压标准差、舒张压标准差、收缩压变异系数、舒张压变异系数均显著低于预后不良组,P0.05。APACHEⅡ评分是患者预后的保护因素,TBI程度、72h SD(SBP)是患者预后的危险因素。结论急性期血压变异性与重型TBI患者的预后密切相关,其影响患者预后的独立危险因素。     

急性脑梗塞与脑出血相关因素的对比研究

目的:探讨不同危险因素在脑卒中发生的情况及不同危险因素在脑梗死与脑出血间的差异。方法:将收治的卒中患者共408例,其中脑梗死281例,脑出血127例,均预先对各项资料进行编码,输入计算机数据库。所有患者均进行系统的临床和辅助检查,生化指标为集体测定,脑卒中诊断经过MRI或CT确诊。结果:1、高血压、吸烟是脑卒中最重要的危险因素。2、脑出血患者首诊舒张压(P=0．014)、缓解期舒张压(P=0．006)、HDL(P=0．034)、较脑梗塞患者高,其差别有统计学意义;其TC(P=0．047)、吸烟(P=0．007)、心脏病病史(P=0．020)、糖尿病病史(0．000)、卒中家族史(P=0．033)、心脏病家族史(P=0．040)较脑梗塞患者低或少,其差别有统计学差异。3、与脑梗塞相比,吸烟(OR=0. 226,95％CI=0．107—1．623)、糖尿病病史(OR=0．094,95％CI=0．023—2．401)、心脏病病史(OR=0．046,95％CI=0．236-0．905)对脑出血危险较小;高血压病史(OR=1．096,95％CI=0．542-0.895)是脑出血唯一危险因素。结论:高血压、吸烟是脑卒中最重要的危险因素;脑梗塞与脑出血的危险因素并不完全一致。     

非心源性脑梗死患者急性期血压变异与早期神经功能恶化的相关性研究

目的探讨非心源性脑梗死患者急性期24 h血压变异和早期神经功能恶化的关系。方法采用病例对照研究方法连续登记急性非心源性脑梗死患者,收集一般临床资料,连续血压监测并计算24 h血压变异的各参数,按照入院7 d内有无发生脑梗死早期神经功能恶化进行分组比较,建立Logistic回归模型分析24 h血压和血压变异参数与早期神经功能恶化的关系。结果 221例入组患者中59例(26.7%)出现早期神经功能恶化。出现早期神经功能恶化组24 h平均收缩压和收缩压变异系数显著高于未发生组[(145.8±18.2)mm Hg vs.(139.9±20.3)mm Hg;9.0(7.3~11.2)vs.8.4(6.9~10.2)],差异均有统计学意义(P0.05)。多因素校正后,24 h平均收缩压水平和收缩压变异系数增大是发生早期神经功能恶化的独立危险因素(每10 mm Hg 24 h平均收缩压OR=1.285,95%CI(1.059~1.559);收缩压变异系数OR=1.206,95%CI(1.050~1.384))。结论入院后24 h收缩压变异增大是急性非心源性脑梗死7 d内发生早期神经功能恶化的危险因素。     

经颅多普勒超声研究我国南方社区人群椎-基底动脉颅内段狭窄的状况

目的 研究我国南方社区健康人群椎-基底动脉颅内段狭窄的患病情况和危险因素.方法 以居委会为单位随机整群抽取社区成年居民.测量身高、体重、腰围、臀围和血压,记录病史资料.空腹静脉采血检测血糖、甘油三酯、总胆固醇等.经颅多普勒超声(TCD)检测双侧椎动脉颅内段(VA)和基底动脉(BA)狭窄情况.用SPSS 11.0软件包进行数据统计分析.结果 1035名有效研究对象中,58例(5.6%)存在椎-基底动脉颅内段狭窄.其中左、右侧VA狭窄分别为17例和23例,BA狭窄30例.单因素分析提示,糖尿病患者中椎-基底动脉颅内段狭窄的患病率(10.3%)显著高于非糖尿病患者(3.2%,χ2=6.221,P=0.013);狭窄组人群平均收缩压水平[(131.1±25.5)mm Hg,1 mm Hg=0.133 kPa]显著高于非狭窄组[(124.1±21.6)mm Hg,t=2.228,P=0.026].Logistic回归分析证实糖尿病史和收缩压是椎-基底动脉颅内段狭窄的独立危险因素(糖尿病史:OR=3.305,P=0.023;收缩压升高1 mm Hg,OR=1.012,P=0.047).结论 椎-基底动脉颅内段狭窄在我国成年人群中均有较高的发生率.收缩压的升高和糖尿病是椎-基底动脉颅内段狭窄的重要危险因素.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.