缺血性进展性脑卒中的相关危险因素分析

目的 分析缺血性进展性脑卒中的相关危险因素,为探讨缺血性进展性脑卒中的发病机制提供参考.方法 对356例缺血性进展性脑卒中患者的临床资料进行回顾性分析,入选患者分为进展性脑卒中组(进展组)和非进展组,按OCSP分为四型,比较各亚型的发生率,对缺血性进展性脑卒中的相关因素进行Logistic回归分析,筛选缺血性进展性脑卒中发生的危险因素.结果 完全前循环梗死亚型进展性脑卒中发病率最高,与其它亚型比较差异有显著性(P＜0.05);部分前循环梗死亚型进展性脑卒中发病率高于腔隙性梗死和后循环梗死亚型(P＜0.05).但后两者之间差异无显著性.进展组高血压史和颈动脉粥样硬化发生率显著高于非进展组(P＜0.05),进展组入院时血糖、胆固醇、甘油三酯、纤维蛋白原水平显著高于非进展组(P＜0.05);颈动脉粥样硬化和高血糖是缺血性进展性脑卒中发生的危险因素.结论 OCSP各亚型进展性脑卒中发病率各不相同,完全前循环梗死亚型进展性脑卒中发病率最高;颈动脉粥样硬化和高血糖是缺血性进展性脑卒中发生的危险因素.     

急性缺血性脑卒中患者血清正五聚蛋白3水平的变化及影响因素

目的探讨急性缺血性脑卒中患者血清正五聚蛋白(PTX)3水平的变化及影响因素。方法选择2014年4月至2015年4月就诊的急性缺血性脑卒中患者100例,根据患者病情、PTX3水平、梗死面积、预后效果进行分组。另选择健康体检者100人为对照组。比较不同病情分型、梗死面积及预后结果患者血清PTX3水平变化,并分析可能影响急性缺血性脑卒中患者血清PTX3水平的相关因素。结果急性缺血性脑卒中患者血清PTX3水平明显高于对照组(P0.05),随着病情加重、梗死面积增大及预后效果恶化,患者血清PTX3水平均显著升高(均P0.05);单因素和多因素Logistic回归分析法确定高血压病史、低密度脂蛋白(LDL)和同型半胱氨酸(Hcy)是急性缺血性脑卒中患者血清PTX3水平的影响因素。结论急性缺血性脑卒中患者血清PTX3水平显著升高,并且与疾病的发生及发展密切相关,临床上注意影响血清PTX3的危险因素,改善患者的生存质量。     

洛伐他汀对缺血性脑卒中的防治研究

目的探讨洛伐他汀防治缺血性脑卒中的效果。方法分别应用洛伐他汀（治疗组）及安慰剂（对照组）治疗缺血性脑卒中伴血脂异常的患者,观察洛伐他汀对缺血性脑卒中危险因素、发病时的严重程度、预后、梗死体积及复发的影响。结果两组TC、TG、HDL、LDL、脂蛋白、血压、血糖及胰岛素的差异均有统计学意义（P〈0.01或〈0.05）;治疗组第14天、1个月神经功能缺损明显改善（P〈0.05）;两组发病后第14天梗死体积、3个月神经功能缺损评分均有统计学差异（P〈0.01）。3个月时总有效率、2 a内复发率、复发患者的神经功能缺损、梗死体积均有统计学差异（P〈0.05）。结论洛伐他汀不仅有调脂作用,还具有改善胰岛素抵抗以及神经保护作用,并能改善脑卒中预后、缩小梗死体积、降低缺血性脑卒中的复发。     

进展性缺血性脑卒中患者47例临床观察

目的了解进展性缺血性脑卒中可能的危险因素,以指导临床,改善脑卒中患者的预后。方法回顾性观察47例进展性缺血性脑卒中和47例非进展性缺血性脑卒中的各项理化指标,并经相关统计学处理。结果进展性缺血性脑卒中组的外周血白细胞、血糖、颈动脉内膜中层厚度和超敏C反应蛋白均高于对照组非进展性缺血性脑卒中组,差异具有统计学意义(均P<0.05、<0.01);进展性缺血性脑卒中组颈动脉粥样斑块软斑的检出率为29.79%,非进展性缺血性脑卒中组颈动脉粥样斑块软斑的检出率仅为10.64%,差异有统计学意义(P<0.05)。结论缺血性脑卒中患者若入院时外周血白细胞、超敏C反应蛋白和血糖明显升高,责任血管内膜中层增厚,尤其是伴有粥样斑块软斑者,预示着脑卒中有进展可能,临床应高度警惕并作积极的干预和处理。     

缺血性脑卒中进展期与非进展期患者血压及脂代谢的对比及其相关性

目的 探讨进展性缺血性脑卒中与高血压的相关性.方法 选取34例进展性脑卒中患者和30例非进展性脑卒中患者,观察两组血脂、血压波动、感染及血管病变情况.结果 进展性缺血性脑卒中患者合并高血压例数明显高于非进展性脑卒中患者(P＜0.01),两组感染率(P＜0.01),血管病变差异显著(P＜0.05).与非进展性脑卒中组比较,进展性脑卒中组胆固醇水平、甘油三酯、纤维蛋白原及血糖均明显增高(P＜0.05,P＜0.01),动态血压波动情况明显(P＜0.05,P＜0.01).结论 进展期脑卒中患者高血压患者发生率高,高血压是影响缺血性脑卒中进展的主要因素.     

缺血性脑卒中合并脑心综合征69例临床分析

目的探讨脑心综合征在进展性缺血性脑卒中的发病率、临床特点及预后。方法对210例急性缺血性脑卒中患者入院后的心电图,心肌酶谱等进行动态观察,并对临床资料进行分析。结果脑心综合征在急性缺血性脑卒中的发生率为32.86%,其中78.26%的脑心综合征患者呈进展性卒中发病,脑叶梗死明显高于其他部位梗死（P〈0.01）,有意识障碍患者100%发病。脑心综合征的心电图主要表现为心律失常、心肌缺血等,心肌酶谱异常率为40.74%。结论缺血性脑卒中常合并继发性心脏损害,故对临床表现为脑心综合征的急性缺血性卒中患者,要从各个环节尽早针对性干预卒中的进展,为早期康复提供有利条件。     

低氧诱导因子-1α、脑红蛋白与缺血性脑卒中严重程度及预后的相关性

目的观察缺血性脑卒中患者血浆低氧诱导因子(HIF)-1α及脑红蛋白(Ngb)的浓度,揭示HIF-1α、Ngb对缺血性脑卒中患者病情严重程度及预后的影响。方法选取2014年1~3月80例首次发病缺血性脑卒中患者作为研究对象,采用酶联免疫吸附法(ELISA)测定血浆HIF-1α和Ngb的浓度,然后在患者接受治疗的第1天及第14天分别进行NIHSS评分。结果血浆低HIF-1α组与高HIF-1α组患者相比,缺血性脑卒中严重程度轻、预后好(P<0.05);血浆低Ngb组比高Ngb组患者缺血性脑卒中严重程度轻、预后好(P<0.05)。Logistic回归分析显示血浆HIF-1α和Ngb水平影响缺血性脑卒中患者预后独立于年龄、血压、性别、血脂和血糖等危险因素(P<0.05);缺血性脑卒中患者血浆HIF-1α与Ngb的浓度呈正相关。结论 HIF-1α及Ngb可通过神经保护作用改善缺血性脑卒中的严重程度及预后;监测缺血性脑卒中患者血浆HIF-1α和Ngb的含量,可作为判断缺血性脑卒中严重程度、评价神经功能恢复情况、评估疾病预后的新的重要参考指标;HIF-1α与Ngb的表达具有相关性。     

急性缺血性脑卒中的治疗

急性缺血性脑卒中是指发病30天内的缺血性脑卒中。包括超早期(3~6 h)、早期(3~5天内)以及直至30天。这段时间的治疗对患者预后有非常重要意义,故急性期对患者进行科学的、合理的、符合循证医学的规范化治疗至关重要。1恢复或改善脑血流灌注的措施1.1恢复或改善脑缺血区域的血流     

神经系统疾病

腔内血管成形及支架植入术治疗缺血性脑血管疾病的并发症及其处理；脑卒中急性期血压与预后的关系；帕罗西汀治疗脑卒中后抑郁疗效观察；益气养阴扶正法对脑卒中偏瘫患者康复的影响；不同时期血压控制对卒中患者预后的影响。[编者按]     

老年缺血性脑卒中患者康复治疗效果的影响因素

目的分析老年缺血性脑卒中患者康复治疗效果的影响因素。方法选取80例老年缺血性脑卒中患者,对所有患者实施为期6个月的康复治疗,治疗结束后采用日常生活活动能力(ADL)量表、Fugl-Meyer运动功能评估(FMA)量表评估康复效果,根据康复效果将所有老年缺血性脑卒中患者分为康复组与未康复组,统计患者临床资料,包括年龄、性别、是否合并高血压、是否存在动脉粥样硬化、是否便秘、是否失眠、是否抑郁、吸烟史、饮酒史、是否存在胃肠功能紊乱、是否存在肺部感染、空腹血糖水平、超敏C反应蛋白(hs-CRP)水平等,分析上述资料差异性,找出影响老年脑卒中患者康复治疗结果的危险因素。结果入选80例老年缺血性脑卒中患者经6个月康复治疗后,38例(47.50%)未康复,42例(52.50%)康复。单因素分析显示,未康复组在年龄、性别方面与康复组相比,差异无统计学意义(P0.05);未康复组在合并高血压、动脉粥样硬化、便秘、失眠、抑郁、吸烟史、饮酒史、胃肠功能紊乱、肺部感染、空腹血糖水平、hs-CRP水平与康复组相比,差异有统计学意义(P0.05)。经Logistic回归分析,合并高血压、动脉粥样硬化、便秘、失眠、抑郁、吸烟史、饮酒史、胃肠功能紊乱、肺部感染、高空腹血糖水平、hs-CRP水平增高是影响老年缺血性脑卒中患者康复治疗结果的危险因素(OR1,P0.05,P0.01)。结论针对影响老年缺血性脑卒中患者康复治疗效果的危险因素,治疗中采取有效的预防措施,确保治疗效果,以期改善患者生活质量。     

New atrial fibrillation after acute myocardial infarction independently predicts death: the GUSTO-III experience

BACKGROUND: Atrial fibrillation (AF) or flutter occurring after myocardial infarction may occur alone or in association with other complications. Whether the arrhythmia portends a poor prognosis independent of other complications with contemporary therapy is unknown. METHODS AND RESULTS: As part of the Global Use of Strategies To Open occluded coronary arteries (GUSTO-III) trial, we evaluated whether postinfarction complications were associated with the subsequent development of AF and whether AF independently predicted death over periods of 30 days and 1 year. Information including exact timing was collected on deaths and major in-hospital postinfarction complications up to 30 days. Of the 13,858 patients with sinus rhythm at enrollment, 906 later had AF or flutter and 12, 952 did not. We compared outcomes between these 2 groups, adjusting for differences in baseline characteristics and prefibrillation complications. Worsening heart failure, hypotension, third-degree heart block, and ventricular fibrillation were independent predictors of new-onset AF. The unadjusted odds ratio (OR) for death among patients with versus those without AF was 2.74 (95% confidence interval [95% CI], 2.56-3.34). After adjusting for baseline differences, the OR was reduced to 1.63 (95% CI, 1.31-2.02). Adjustment for other in-hospital complications before the onset of AF further reduced the OR to 1.49 (95% CI, 1.17-1.89). CONCLUSIONS: Atrial fibrillation or flutter occurs secondary to other postinfarction complications but independently portends a worse prognosis. Prevention and management may improve outcome.     

Postinfarction angina: results of early revascularization

To assess the efficacy of surgical revascularization for postinfarction angina within 30 days of acute infarction, the clinical course of 103 patients treated surgically from January 1979 to July 1982 was reviewed. There were 84 men (82%) and 19 women (18%) with a mean age of 58 years (range 34 to 80). Group A (11 patients) underwent surgery within 24 hours of infarction, Group B (21 patients) within 7 days and Group C (71 patients) within 30 days. Eighty-four patients (82%) had subendocardial infarctions and 19 patients (18%) had transmural infarction. Transmural infarction was more common in patients in Group A (36%) than in those in either Group B (19%) or Group C (15%). There were two deaths, both in Group C (1.9%), within 30 days of surgery. The use of intraaortic balloon or inotropic support and the occurrence of major arrhythmias or perioperative infarction was noted in 30 patients (29%) (64% in Group A, 33% in Group B and 18% in Group C). The average time in the intensive care unit was 3.2 days, with an average total hospital stay after surgery of 8.3 days. Late follow-up (mean 15.4 months, range 1 to 39) is complete for 97 patients (97%). There were no late myocardial infarctions and 93 patients (96%) were essentially free of angina. The only late death (1.0%) was caused by septicemia from delayed sternal wound infection. This study suggests that myocardial revascularization within the first 30 days after myocardial infarction can be accomplished with an acceptable operative mortality in selected patients with postinfarction angina refractory to medical management.     

Clinical predictors of angina following myocardial infarction.

To determine if angina following myocardial infarction could be predicted before hospital discharge we prospectively evaluated 219 consecutive patients admitted to the coronary care unit with acute myocardial infarction. Of the 166 who survived to one year, angina was present before infarction in 53 per cent and after infarction in 61 per cent. Angina did not recur postinfarction in 26 per cent of the patients who had angina before infarction. However, in 47 per cent of those without previous angina it developed postinfarction. Although postinfarction angina correlated with the presence of angina before infarction (p < 0.0005), it did not correlate significantly with age, sex, site of infarction, Killip class on admission nor the presence of a previous infarction.To improve our ability to predict angina after infarction we performed exercise tests to 5 metabolic equivalents (METS), or 70 per cent of age-predicted maximal heart rate, before hospital discharge on all patients less than 70 years old who were without chest pain within four days or without overt heart failure. Of the 105 patients exercised, 31 (86 per cent) of the 36 with positive tests had angina during the subsequent year compared to only 25 (36 per cent) of the 69 with negative tests (p < 0.001). Postinfarction angina occurred in 96 per cent (23 of 24) of the patients who had both angina before infarction and a positive test, but in only 26 per cent (10 of 39) of the patients with neither finding (p < 0.001).We conclude that the presence of angina prior to infarction and a positive limited exercise test performed before hospital discharge are predictive of angina following infarction. Myocardial infarction abolishes angina in a quarter of the patients, but angina develops postinfarction in nearly half of the patients who did not have angina previously.     

Noninvasive assessment of patients with ischemic heart disease

The diagnosis of acute myocardial infarction can be strengthened in selected patients by the use of pyrophosphate scanning. Such scans may provide useful information about the relative size of myocardial infarction. Radionuclide angiography and two-dimensional echocardiography are useful for determining the extent of myocardial dysfunction following infarction. Two-dimensional echocardiography is especially suitable for use in the acute care setting and can provide excellent anatomic images to help diagnose the mechanical complications of infarction, such as mural thrombus formation and ventricular septal rupture. Therefore, many investigators believe that two-dimensional echocardiography is indicated for evaluating every myocardial infarction patient.The predischarge assessment of the postinfarction patient is critical for planning a rational rehabilitation program. Uncomplicated patients should have low level treadmill exercise tests to detect unsuspected problems which indicate a poor prognosis, such as angina pectoris. Continuous ambulatory electrocardiogram recordings are useful for excluding prognostically important, but asymptomatic, dysrhythmias. Two-dimensional echocardiography and radionuclide angiography also are helpful for assessing the extent of myocardial dysfunction and defining left ventricular aneurysms and mural thrombi.     

Results of hospital rehabilitation of 1000 patients with myocardial infarction.

Hospital rehabilitation of patients with myocardial infarction was conducted according to the model worked out by the Institute of Cardiology in Warsaw and modified at the Department of Cardiology of the Medical Academy in Lublin. According to their clinical condition, the patients were divided into 3 groups. Group A comprised patients with extensive myocardial infarction and complications; duration of hospital stay was 28 days. Group B included patients with extensive infarction without complications; hospital stay was 21 days. Group C included patients with limited myocardial necrosis and a mild course of the disease, and duration of stay of 14 days. Out of 1000 patients with myocardial infarction 134 (13.4%) died within the first 4 days after admission, i.e. before the beginning of rehabilitation treatment; 56 (5.6%) died during rehabilitation. The group of patients undergoing rehabilitation treatment comprised 866 patients (86.6%), including 382 (44.1%) in group A, 404 (46.6%) In group B, and 80 (9.3%) in group C. The mean duration of hospital stay of all patients with myocardial infarction was 24.3 days; in 80 cases (9.9%) it was 14 days, in 397 cases (49.0%) 21 days, and in 236 cases (29.1%) 28 days. In 97 cases (12.0%) hospitalization was longer than 28 days. Work was resumed by 30% of white and blue collar workers and 89.5% or farmers within the productive age groups.     

应用数学模型预测高血压性脑出血预后

目的 建立数学模型，并借此预测高血压性脑出血的预后。方法 对67例术后高血压性脑出血患者进行回顾性研究，按照格拉斯哥预后(GOS)评分，将患者分为两组，预后良好41例，预后不良26例，对两组患者的13个项目进行多因素逐步判别分析。结果 出血量、出血部位、二次手术、并发症和康复期治疗5个变量为判断预后的主要因素。据此建立判别函数式，预后良好的回代正确率为95．1％，预后不良的正确率为96．2％，总的判别正确率为95．5％。结论 本判别函数在理论上能较准确地对预后作出判断，可能具有一定的临床参考价值。     

高血压脑出血患者短期预后的影响因素

目的探讨影响高血压脑出血短期预后的相关因素。方法回顾性分析366例高血压脑出血患者病历资料,根据临床预后情况分为好转(痊愈、进步)组和未好转(病情无变化、恶化、死亡)组,比较分析其相关影响因素。用回归分析筛选有独立影响的预后因素。结果性别、周围血白细胞数、血小板、糖尿病史、收缩压、舒张压、占位效应、出血部位及肺部感染等因素与预后无显著相关(均P>0.05);而意识障碍、D-二聚体(D-D)、合并脑疝、出血是否破入脑室和年龄等因素与预后相关(均P<0.05)。结论维持血压正常是预防高血压脑出血的重要环节,积极预防和治疗并发症,对改善高血压脑出血患者的预后具有重要意义。     

慢性硬膜下血肿预后影响因素的回顾性分析(附114例报告)

目的阐明影响慢性硬膜下血肿（CSDH）行钻孔引流术后预后的相关因素。方法对1996年1月至2004年6月北京大学第三医院神经外科手术治疗的114例CSDH患者的临床资料进行回顾性总结，收集患者的一般情况、临床与影像学表现、手术并发症、预后等进行统计学分析。结果114例患者中男100例（87．7％），女14例（12．3％），术后良好康复者84例（73．7％），预后不良者30例（26．3％）。两组在患者年龄、入院时Markwalder＇s分级、凝血功能、合并脑梗死、术后并发症方面存在显著差异。Logistic回归分析显示，患者入院时的神经功能状态、凝血功能障碍以及术后并发症与预后确实存在相关性。结论影响CSDH预后的因素包括：患者年龄、入院时的神经功能状态、先前合并的脑梗死、凝血功能障碍、术后并发症。某些术后并发症可以导致患者术后神经功能变差，应当尽量预防这些并发症。     

老年重症动脉瘤性蛛网膜下腔出血患者预后的影响因素分析

目的分析老年重症动脉瘤性蛛网膜下腔出血(aSAH)患者预后的影响因素。方法回顾性连续纳入2015年3月至2017年3月首都医科大学宣武医院神经外科重症监护室老年重症aSAH患者49例,年龄≥65岁,且Hunt-Hess分级Ⅲ~Ⅴ级,经头部CT诊断有蛛网膜下腔出血,经DSA或CT血管成像证实为单发颅内责任动脉瘤。患者均予以多模态监测基础上的集束化神经重症监护治疗,对颅内动脉瘤采用开颅夹闭或血管内介入治疗,动脉瘤处理后进行重症监护治疗。根据患者出院后30 d格拉斯哥预后量表分级结果评估预后,其中Ⅳ~Ⅴ级为预后良好,Ⅰ~Ⅲ级为预后不良,并分为预后良好组(17例)和预后不良组(32例)。记录两组患者的一般资料及并发症情况,并进行组间比较。一般资料包括性别、年龄、高血压病、糖尿病、冠心病、责任动脉瘤部位、Hunt-Hess分级;并发症包括脑血管痉挛、新发脑梗死、肺部感染、肝功能异常、低蛋白血症、贫血和电解质紊乱(钠或钾离子异常)。对老年重症aSAH患者进行预后良好与预后不良的单因素分析,并对其预后不良的影响因素进行多因素Logistic回归分析。结果(1)49例患者住院时间为9~40 d,平均(17±7)d;住院期间死亡2例,存活的47例患者均获得随访,随访期间死亡1例,病死率为6.1%(3/49);脑血管痉挛发生率为38.8%(19/49),新发脑梗死发生率为24.5%(12/49),肺部感染发生率为67.3%(33/49),肝功能异常发生率为22.4%(11/49),低蛋白血症发生率49.0%(24/49),贫血发生率为53.1%(26/49),电解质紊乱发生率83.7%(41/49)。(2)两组患者年龄、性别、高血压病、糖尿病、冠心病、责任动脉瘤部位和动脉瘤处理方式的差异均无统计学意义(均P>0.05);预后良好组Hunt-Hess分级Ⅲ、Ⅳ、Ⅴ级分别为11、5、1例,预后不良组Hunt-Hess分级Ⅲ、Ⅳ、Ⅴ级分别为3、21、8例,两组不同程度Hunt-Hess分级的差异有统计学意义(Z=13.749,P<0.01)。(3)两组患者并发症发生率的差异均无统计学意义(均P>0.05);不同Hunt-Hess分级的老年重症aSAH患者并发症发生率的差异均无统计学意义(均P>0.05)。(4)以预后不良为因变量,年龄(由低到高)、Hunt-Hess分级>Ⅲ级、新发脑梗死为自变量,进一步行影响老年重症aSAH患者预后的多因素Logistic回归分析,结果显示,Hunt-Hess分级>Ⅲ级是预后不良的危险因素(OR=20.408,95%CI:3.559~111.111,P=0.001),年龄、新发脑梗死非老年重症aSAH患者预后的影响因素(均P>0.05)。结论Hunt-Hess分级>Ⅲ级可增加老年重症aSAH患者预后不良的风险。临床评估后,除积极处理责任动脉瘤,还需行多模态监测基础上的集束化重症监护治疗,以改善患者预后。     

Time course of left ventricular dilation after myocardial infarction: influence of infarct-related artery and success of coronary thrombolysis

Dilation of the left ventricle after myocardial infarction is common, occurs rapidly (within 2 weeks of infarction) and may be self-limited. To evaluate the time course of postinfarction left ventricular dilation and to assess the impact of successful coronary thrombolysis, serial radionuclide left ventricular volume analyses were performed in 36 patients undergoing attempted thrombolysis for acute transmural myocardial infarction. All patients underwent cardiac catheterization, coronary angiography and attempted thrombolysis within 7 h of the onset of symptoms. The site of coronary occlusion was the left anterior descending coronary artery in 17 patients, the right coronary artery in 18 and, in 1 patient, occluded bypass grafts to the right and left circumflex coronary arteries. Attempted reperfusion using a thrombolytic agent was successful in 22 individuals, occurring 5 +/- 1 h after the onset of symptoms. Gated radionuclide ventriculography was performed early (mean time 1 day after admission, n = 36), subacutely (mean time 11 days postinfarction, n = 36) and late after infarction (mean time 10.5 months, n = 25), and a geometric technique was used to measure serial left ventricular end-diastolic volume. Left ventricular end-diastolic volume for the entire group increased significantly (p less than 0.01) from 153 +/- 30 ml at baseline to 172 +/- 45 ml (at 11 days) to 220 +/- 63 ml (at 10.5 months). Twenty of 36 patients showed greater than 20% increase in left ventricular end-diastolic volume (dilation) with time. This appeared early in seven patients, occurred remote from infarction in seven others and showed a progressive pattern in six.(ABSTRACT TRUNCATED AT 250 WORDS)