糖化血红蛋白与大动脉粥样硬化性缺血性卒中患者预后的关系研究

目的探讨急性缺血性卒中患者入院时糖化血红蛋白与不良心脑血管预后及神经功能预后的关系。方法入选2010年5月至2011年8月首都医科大学附属北京天坛医院脑血管病中心急性缺血性卒中住院患者373例,所有患者均为TOAST分型大动脉粥样硬化型。记录患者的基线资料,按照入院时患者糖化血红蛋白≥7%或7%进行分组并随访。终点事件包括卒中复发、心脑血管事件和心脑血管死亡、随访一年的神经功能恢复情况[改良Rankin量表(modified Rankin Scale,m RS)]。结果共300例患者资料纳入分析,高糖化血红蛋白组83例,低糖化血红蛋白组217例。随访(18.9±5.0)个月。高糖化血红蛋白组糖尿病发病率、1年的m RS评分、心脑血管事件均显著高于低糖化血红蛋白组(P0.01),Kaplan-Meier生存分析显示高糖化血红蛋白组患者无心脑血管事件的生存明显低于低糖化血红蛋白组(P0.001)。Cox回归发现糖化血红蛋白(HR 1.252,95%CI 1.061~1.477,P=0.008)和既往卒中史(HR 2.630,95%CI 1.365~4.970,P=0.004)是卒中患者心脑血管预后不良的预测因素。Logistic回归分析显示缺血性卒中患者随访一年时神经功能恢复不良的独立危险因素有高龄(OR 1.069,95%CI 1.037~1.101,P0.001)、既往有卒中史(OR 4.087,95%CI 2.051~8.144,P0.001)、高糖化血红蛋白(OR 1.208,95%CI 1.002~1.455,P=0.047)和入院美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分(OR 1.320,95%CI 1.217~1.431,P0.001)。结论入院时糖化血红蛋白升高是大动脉粥样硬化性急性缺血性卒中患者一年不良心脑血管预后和不良功能预后的预测因素。     

IL-6和动脉粥样硬化性缺血性卒中的关系研究进展

缺血性卒中是一种病因复杂的综合征,其中动脉粥样硬化是主要病因之一。流行病学、分子生物学证据表明IL-6促进动脉粥样硬化斑块的形成和生长,影响缺血性卒中的发生、发展及预后。新近的临床研究进一步证实干预IL-6通路有望成为缺血性卒中治疗的新靶点。本综述从分子生物学、流行病学和新近开展的临床研究阐述IL-6在缺血性卒中发生、预后中的作用,以及作为潜在治疗靶点的可能性。     

白蛋白尿与缺血性卒中关系的研究进展

缺血性卒中是世界范围内病残率最高的疾病之一。颈部或颅底大动脉粥样硬化是缺血性 卒中的首要病因。既往研究提示，微量白蛋白尿不仅是全身血管内皮功能紊乱的重要标志，还可能是 动脉粥样硬化发生的早期标志。近年来研究发现，白蛋白尿与缺血性卒中的发生、发展及预后均存 在密切联系。本文旨在对白蛋白尿与缺血性卒中关系的研究进展进行综述。     

颅内动脉狭窄致初发或复发缺血性卒中比较研究

目的分析和比较颅内动脉狭窄患者初发或复发缺血性卒中的临床特点。探讨颅内动脉狭窄程度与危险因素的关系。方法横断面研究,连续收集81例颅内动脉狭窄致缺血性卒中患者,复发缺血性卒中占41.98%,比较初发组和复发组的临床及影像学特点。结果初发组糖化血红蛋白(5.61±2.02)%,复发组(6.73±1.43)%,P<0.05;初发组糖尿病比例23.40%,复发组50%,P<0.05。颅内动脉狭窄程度与危险因素总数(高血压、糖尿病、高脂血症、卒中病史、心房纤颤、家族史和吸烟史)低度相关,r=0.245,P=0.028。Logistic回归示白细胞计数(大于7.03×109/L)是中重度颅内动脉狭窄的保护因素(OR=0.123,P=0.028,95%可信区间0.019~0.797)。结论颅内动脉狭窄致复发缺血性卒中组患者糖化血红蛋白和糖尿病比例更高。白细胞计数是中重度颅内动脉狭窄的保护因素。     

TIA及轻型卒中远期复发卒中及死亡的队列研究

目的既往的研究对短暂性脑缺血发作(TIA)及轻型缺血性卒中的远期预后关注较少。我们将对影响此类患者的远期预后的危险因素进行探讨。方法我们筛选了自2004年²005年间连续住院的TIA及轻型卒中患者。出院后定期对其进行门诊或电话随访其发生缺血性卒中及死亡事件,截止至2012年6月30日。结果共278位TIA及轻型卒中患者入组。其中,53人(19.6%)发生了卒中,67人(24.1%)死亡。多因素非条件Cox回归分析,结果显示:缺血性心脏病史、缺血性卒中病史是TIA/轻型卒中患者远期复发卒中的独立危险因素;而高龄、男性、糖尿病史及新鲜卒中病灶增加TIA/轻型卒中患者远期死亡风险的独立危险因素。结论缺血性心脏病及既往卒中病史是TIA/轻型卒中患者远期(>5 y)发生卒中的独立危险因素。除高龄和男性两个因素外,急性病灶及糖尿病史是TIA/轻型卒中患者远期发生死亡的独立危险因素。     

缺血性卒中急性期血糖水平对卒中病情和预后的影响

目的 探讨急性缺血性卒中患者血糖水平变化与临床病情严重程度以及预后的关系。方法 按入院次日清晨血糖水平,将196例急性缺血性卒中患者分成血糖升高组49例,血糖正常组147例,观察血糖与梗死部位、病灶大小、病情程度以及预后的关系。结果 高血糖的发生与急性缺血性卒中患者病灶部位、临床病情严重程度以及梗死病灶的大小有关,高血糖多见于大脑中线部位梗死及临床症状严重的缺血性卒中患者。血糖升高组患者预后明显差于血糖正常组。结论 高血糖可能加剧急性缺血性卒中患者神经系统损伤,血糖水平的高低可作为判断病情轻重和预后的重要参数。     

颅内动脉粥样硬化性狭窄与缺血性卒中

卒中已成为中国居民死亡的第一大病因,随着人口老龄化、经济水平的提高和生活方式的改变,缺血性卒中,包括短暂性脑缺血发作的发病率逐年上升。颅内动脉粥样硬化性狭窄(ICAS)是导致缺血性卒中最常见的原因之一。早期诊断 ICAS 并控制其发展能减少缺血性卒中的发生和复发,现针对 ICAS 的流行病学、危险因素、诊断、治疗及预后作一综述。     

神经肌电图联合体感诱发电位在糖尿病神经系统并发症评估中的应用

目的 :探讨神经肌电图(electromyography,EMG)联合体感诱发电位(somatosensory evoked potential,SEP)在糖尿病神经系统并发症评估中的应用价值。方法 :将135例符合病例选择标准的糖尿病患者分别按糖尿病病程(1年、1～10年、10年)、有无糖尿病周围神经病(diabetic perilpheral neuropathy,DPN)、是否伴发缺血性卒中以及脑卒中部位进行分组。回顾性分析和比较各组患者的年龄、糖化血红蛋白水平、神经传导速度(nerve conduction velocity,NCV)、SEP、DPN和缺血性卒中情况。结果 :135例糖尿病患者中,50例(37.0%)明确诊断为DPN,伴发缺血性卒中32例(23.7%),EMG发现NCV异常56例(41.5%)、F波异常16例(11.9%),SEP异常27例(20.0%)。糖尿病病程1～10年和10年组患者的NCV异常率、DPN比例及缺血性卒中比例均显著高于糖尿病病程1年组(P0.05)。有DPN症状及体征患者的NCV异常率(P0.01)、F波异常率(P0.01)和SEP异常率(P0.01)均显著高于无DPN症状及体征患者。伴发缺血性卒中的糖尿病患者与未伴发缺血性卒中的糖尿病患者相比,前者的年龄较大(P0.01)、病程较长(P=0.01)、SEP异常率较高(P=0.02)。Spearman相关分析结果显示,NCV异常(r=0.26,P0.01)和缺血性卒中(r=0.22,P0.01)与病程呈正相关;DPN与病程(r=0.21,P0.05)、年龄(r=0.19,P0.05)、糖化血红蛋白水平(r=0.24,P0.01)、NCV异常(r=0.75,P0.01)和F波异常(r=0.22,P0.01)均呈正相关;NCV异常(r=0.28,P0.01)和F波异常(r=0.30,P0.01)均与糖化血红蛋白水平呈正相关;SEP异常与F波异常(r=0.62,P0.01)、缺血性卒中(r=0.20,P0.05)和住院(7～14 d)前后美国国立卫生研究院卒中量表评分差值呈正相关(r=0.43,P0.05)。结论 :EMG是筛查和诊断DPN的重要方法,EMG联合SEP可以筛查早期DPN,有助于提高亚临床DPN的检出率,并且对糖尿病伴发中枢系统损害及预后的评估具有一定的应用价值。     

高尿酸血症对急性缺血性脑卒中的双重影响

高尿酸血症作为新的脑血管病危险因素可能与缺血性脑卒中的发生风险增加、不良预后及死亡有关。除此之外,血尿酸作为抗氧化剂尚具有清除自由基、抗氧化作用。卒中急性期血尿酸水平的增高可能发挥了其神经元保护作用,改善了卒中预后、减少卒中复发。     

急性缺血性脑卒中患者认知损害的危险因素分析

目的探讨急性缺血性脑卒中患者出现认知损害的危险因素,为预防脑卒中后认知损害提供依据。方法回顾性分析2015年1月至2018年9月住院的103例急性缺血性脑卒中患者的临床资料,所有入组病例均在入院第2天空腹采集肘静脉血测定血脂、同型半胱氨酸、空腹血糖及糖化血红蛋白。参照2019年美国糖尿病学会发布的"糖尿病医学诊疗标准"制定血糖控制标准(空腹血糖4.4~7.2mmol·L-1,糖化血红蛋白<6.5%)。发病第10~14天(病情稳定排除谵妄等情况)进行北京版蒙特利尔认知评估(MoCA)量表测评,将MoCA评分<26分为认知损害组(64例)和MoCA≥26分为无认知损害组(39例),通过统计学分析探讨急性缺血性脑卒中出现认知损害的危险因素。结果与无认知损害组比较,认知损害患者年龄偏大(P=0.013)、美国国立卫生研究院卒中量表(NIHSS)评分较高(P=0.016);认知损害组空腹血糖、糖化血红蛋白水平高于无认知损害组,且血糖控制达标情况较无认知损害组差(分别P=0.001,P=0.045,P=0.006,P=0.001)。结论高龄、NIHSS评分高、空腹血糖升高及血糖水平控制达标差是急性缺血性脑卒中患者出现认知损害的危险因素之一,血糖作为可控因素,严格控制血糖可能有助于预防急性缺血性脑卒中后认知损害的发生。     

缺血性脑卒中患者糖化血红蛋白与血浆致动脉粥样硬化指数的相关性研究

目的探讨缺血性脑卒中患者糖化血红蛋白(Hb A1c)与血浆致动脉粥样硬化指数(AIP)的关系。方法选择2017年1月至2017年6月河北省保定市第一中心医院神经内科收治的缺血性脑卒中患者117例,选择同期在本院体检健康者48例为对照组,采用高压液相方法检测两组研究对象血中Hb A1c水平,并计算AIP(等于甘油三酯与高密度脂蛋白胆固醇比值的对数)。结果缺血性脑卒中组吸烟史(55. 6%vs. 35. 7%,P=0. 027)、高血压病史(76. 9%vs.42. 8%,P=0. 000)、甘油三脂(1. 58±0. 96 vs. 1. 19±0. 87,P=0. 028)、基线收缩压(151. 62±21. 55 vs. 134. 12±16. 97,P=0. 000)、基线舒张压(91. 58±14. 16 vs. 82. 00±12. 71,P=0. 000)、Hb A1 c (6. 8±1. 8 vs. 5. 5±0. 6,P=0. 001)、AIP (0. 05±0. 26 vs.-0. 06±0. 24,P=0. 015)均高于对照组,差异有统计学意义(P 0. 05)。缺血性脑卒中组HbA1c与AIP呈正相关(r=0. 276,P=0. 003)。结论缺血性脑卒中患者Hb A1c与AIP正相关,因此定期检测HbA1 c和AIP,积极控制血糖和血脂,对于预防缺血性脑卒中会起到一定的作用。     

Impact of Elevated Hemoglobin A1c Levels on Functional Outcome in Patients with Acute Ischemic Stroke

Background: The association between hemoglobin A1c (HbA1c) and clinical outcomes of acute ischemic stroke is uncertain. We aimed to evaluate the association between initial hemoglobin A1c level and clinical outcome after acute ischemic stroke.Methods: A total of 408 patients with first-ever acute ischemic stroke were included in this study. We divided the patients into three groups according to HbA1c level: low HbA1c level (HbA1c <5.7%), moderate HbA1c level (HbA1c 5.7-6.4%), and high HbA1c level (HbA1c ≥6.5%). Poor neurological outcomes were defined as modified Rankin Scale (mRS) score of 2-6 at 3 months after stroke. The relation between HbA1c value and clinical outcomes were evaluated by using multivariate logistic regression analyses.Results: Moderate HbA1c level was present in 126 (30.9%) patients and high HbA1c level in 129 (31.6%) patients. After adjustment for potential confounding variables, both patients in the high HbA1c level group (adjusted odds ratio [OR]: 2.387; 95% confidence interval [CI], 1.201-4.745; P?=?.013) and moderate HbA1c level group (adjusted OR: 1.797; 95% CI, 1.005-3.214; P?=?.048) had a significantly higher poor neurological outcomes than the group in the low HbA1c level. When separately analyzed according to with or without diabetes, the HbA1c level as continuous variable was also associated with poor functional outcome at 3 months in the diabetic patients (adjusted OR: 1.482, 95% CI, 1.013-2.167, P?=?.042), nor in nondiabetic group.Conclusions: Higher HbA1c on admission was an independent predictor of adverse functional outcome in ischemic stroke patients. Based on this point, tight glycemic control must be necessary for high-risk diabetic patients.     

Association of hemoglobin glycation index with outcomes of acute ischemic stroke in type 2 diabetic patients

Objective This study aimed to investigate the association between the hemoglobin glycation index (HGI) and the prognosis of diabetic patients with ischemic stroke.

Methods Data were derived from the Abnormal Glucose Regulation in Patients with Acute Stroke across China (ACROSS-China) registry. Diabetic patients with ischemic stroke were included. HGI was calculated by subtracting the predicted HbA1c based on fasting plasma glucose from the observed HbA1c, and then classified into three groups by the tertiles: low HGI (Results A total of 976 diabetic patients were included. Low HGI was associated with an increased risk of stroke recurrence and poor outcome (adj.hazard ratio 1.53, 95% confidence intervals (CIs) 1.11–2.12, p = 0.01; and adj.odds ratio 1.64, 95% CI 1.13–2.38, p = 0.01, respectively), and high HGI was associated with an increased risk of poor outcome (adj.odds ratio 1.54, 95% CI 1.06–2.24, p = 0.02), compared with moderate HGI. We found a U-shaped association between HGI and the prognosis.

Conclusion Both low HGI and high HGI was associated with an increased risk of poor prognosis in diabetic patients with ischemic stroke, compared with moderate HGI.     

脑微出血与不同亚型缺血性脑卒中的关系及预后分析

目的探讨脑微出血(CMBs)与不同亚型缺血性脑卒中的关系及预后。方法收集2014年3月~2016年5月期间就诊我院,并确诊为缺血性脑卒中的患者116例,根据中国缺血性脑卒中亚型(CISS)标准分为5种亚型,即大动脉粥样硬化型卒中(LAA)、心源性卒中(CS)、其他病因型(OE)、穿支动脉疾病型(PAD)和病因不确定型(UE)。每个亚型分为CMBs组和非CMBs组,比较各组血清相关指标,采用Logistic回归分析每种亚型伴CMBs的影响因素,采用NIHSS评分评价每种亚型伴CMBs的预后情况。结果 PAD组同型半胱氨酸(Hcy)水平(23.32±2.79)μmol/L,明显高于LAA(20.64±3.11)μmol/L、CS(20.7±2.63)μmol/L、OE(18.92±2.91)μmol/L和UE(17.63±3.06)μmol/L,差异具有统计学意义(P0.05)。OE组和LAA组糖化血红蛋白(Hb A1)水平(7.60±0.25和7.11±0.32)明显高于CS组(5.03±0.11)、PAD组(5.10±0.11)和UE组(4.99±0.12),差异具有统计学意义(P0.05);而OE和LAA两组间、CS、PAD和UE三组间Hb A1水平差异不明显(P0.05)。长期饮酒是CS和PAD伴CMBs的独立危险因素;Hcy是每种亚型伴CMBs的独立危险因素;Hb A1是PAD、LAA伴CMBs的独立危险因素。结论 Hcy、Hb A1和长期饮酒是缺血性脑卒中伴CMBs的独立危险因素。不同亚型缺血性脑卒中伴CMBs的预后差异不明显。     

血糖和脑梗死患者颈动脉内膜中层厚度的相关性研究

目的 探讨血糖对脑梗死患者颈动脉内膜中层厚度的影响.方法 对172例急性缺血性卒中患者的颈动脉分叉处内膜中层厚度(IMT)和糖尿病史、空腹血糖及糖化血红蛋白(HbA1c)进行相关性分析,同时分析糖尿病患者的血糖水平和颈动脉IMT的相关性.结果 颈动脉IMT增厚组的年龄(P<0.01)、糖尿病比例(P<0.01)、入院时的空腹血糖(P=0.035)及HbAlc(P=0.051)明显增高,其中,年龄(P=0.023)及糖尿病史(P<0.01)和颈动脉IMT的增厚存在独立相关性.在糖尿病患者中,空腹血糖及HbA1c的增高和颈动脉IMT的增厚无显著相关性(P>0.05).结论 急性缺血性卒中患者中,年龄及糖尿病史为颈动脉IMT增厚的独立危险因素.     

Prolonged hyperglycemia in the early subacute period after cerebral infarction: effects on short term prognosis

Although the adverse effect of admission hyperglycemia in cerebral infarction on prognosis is well known, studies generally have not questioned the effect of hyperglycemia in the early subacute period on prognosis after a stroke. Forty-six patients with acute ischemic stroke were seperated into 3 groups: Group 1) Known diabetes or admission blood glucose (ABG) > or = 140 mg/dl and HbA1c > or = 8,0%); Group 2) ABG > or = 140 mg/dl and HbA1c < 8,0%; and Group 3) ABG < 140 mg/dl and HbA1c < 8,0%. Blood glucose was followed-up 4 times a day for 10 days after the stroke and the mean of these measurements was calculated as the mean of glycemic regulation (MGR). Neurological evaluation was done at presentation and on day 10 and 30 with the National Institute of Health (NIH) scale. Oedema, lesion size and presence of hemorrhagic transformation were evaluated using CT. The MGR was significantly higher in group 1 compared to the other two groups (p < 0,001 and p < 0,01) and in group 2 compared to group 3 (p < 0,001). Patients with clinical worsening had a significantly higher MGR (p < 0,05). Patients with marked cerebral edema had a significantly higher MGR (p < 0,01) compared to patients with lesser edema. No correlation was found between MGR and lesion size or hemorrhagic transformation. Our results show that hyperglycemia in the early subacute period after cerebral infarction is associated with more pronounced cerebral edema and has an adverse effect on short term prognosis. We suggest that studies investigating the effect of insulin infusion on stroke prognosis should also consider infusions for a longer period than 24 hours.     

A pilot study of the effects of non-invasive mechanical ventilation on the prognosis of ischemic cerebrovascular events in patients with obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for ischemic cerebrovascular diseases, and results in worse prognosis and higher mortality. We aimed to investigate the effects of early treatment of OSAS on the prognosis of ischemic stroke. We prospectively evaluated patients with acute supratentorial ischemic stroke and OSAS on admission (acute stage), at second week (subacute stage) and at second month (chronic stage); 11 (73.3%) out of 15 patients put on the non-invasive mechanical ventilation treatment within 48 h of stroke constituted the treatment group, and 13 patients constituted the control group. Patients with OSAS treatment showed significantly better prognosis and better functioning in activities of daily living in both subacute and chronic stages. The rate of shrinkage of the ischemic lesion was higher in the treatment group, though not significant. The early and effective treatment of OSAS provides a better clinical prognosis in ischemic stroke. The beneficial effects on radiological parameters need to be further studied.     

Does glycated hemoglobin have clinical significance in ischemic stroke patients?

Objectives

It has been suggested that patients with an elevated hemoglobin A1c (HbA1c) level have an increased risk of cardiovascular disease regardless of the presence of diabetes. However, an association between HbA1c and stroke has not yet been determined. In this study, our purpose was to examine whether HbA1c was independently associated with various types of cerebral vascular lesions in stroke patients.

Methods

A consecutive series of acute ischemic stroke patients were included for this analysis from October, 2002, to March, 2006. HbA1c was examined on admission, and MR imaging was performed for analysis of large artery diseases (LADs) and small artery diseases (SADs). Symptomatic or asymptomatic LAD was diagnosed by MR angiography, and SAD was classified as leukoaraiosis, microbleeds, or old lacunar infarctions.

Results

A total of 639 stroke patients were analyzed (diabetics, n = 247; non-diabetics, n = 392). There was no relationship between the level of HbA1c and any type of cerebrovascular lesion in the non-diabetic patients. In contrast, HbA1c showed a significant negative association with symptomatic LAD and leukoaraiosis in the diabetic patients using univariate analysis (p = 0.01 and p < 0.05, respectively). These associations did not remain significant, however, after adjustment for age and hypertension. This was, in part, because the HbA1c level in our diabetic population decreased gradually with age (p = 0.03).

Conclusions

Our results indicate that HbA1c is not associated with risk for various types of cerebrovascular lesions in ischemic stroke patients. The negative association between age and HbA1c in diabetic patients should be further investigated.     

HbA1c is associated with increased all-cause mortality in the first year after acute ischemic stroke

Abstract

Objectives:

To assess the association between baseline HbA1c and the poor outcomes within 1 year after acute ischemic stroke.

Methods:

Acute ischemic stroke patients with HbA1c values at baseline (n = 2186) were selected from the abnormal glucose regulation in patients with acute stroke across China study (ACROSS). Logistic regressions were performed to assess the association between HbA1c quartiles (<5·5% [37 mmol/mol], 5·5 to <6·1% [37 to <43 mmol/mol], 6·1 to <7·2% [43 to <55 mmol/mol], and ≥7·2% [≥55 mmol/mol]) and the poor outcomes within 1 year. Poor outcomes were defined as all-cause mortality (modified Rankin scale [mRS] = 6) and poor functional outcome (mRS [2–6]).

Results:

The risk for all-cause mortality was significantly increased in HbA1c level >5·5% [>37 mmol/mol] when compared to HbA1c quartile <5·5% [<37 mmol/mol] and dramatically increased to two to three times higher in the highest HbA1c quartile ≥7·2% [>55 mmol/mol] (1-year all-cause mortality model, odds ratios [ORs] were 1·07, 1·01, and 2·45, P for trend 0·009). After the further analysis with previous diabetes mellitus (DM) and post-stroke insulin use stratified, the risk of mortality was increased across the HbA1c levels (P for trend 0·020) and dramatically augmented in HbA1c ≥7·2% [>55 mmol/mol] in patients without a history of DM and without post-stroke insulin use.

Discussion:

Elevated HbA1c (from 5·5% [37 mmol/mol]) presenting pre-stroke glycemia status has a significant trend in increasing the risk of 1-year all-cause mortality. HbA1c ≥7·2% (>55 mmol/mol) is an independent risk predictor for 1-year all-cause mortality after acute first-ever ischemic stroke. Such an association might be altered by glycometabolism status.