多发颅内动脉粥样硬化性狭窄对轻型卒中和短暂性脑缺血发作早期卒中复发风险影响研究

目的 探讨多发颅内动脉狭窄对轻型缺血性卒中和TIA早期卒中复发的影响。 方法 纳入氯吡格雷用于急性非致残性脑血管事件高危人群的疗效（Clopidogrel in High -risk Patients with Acute Non-disabling Cerebrovascular Events,CHANCE）研究影像亚组1089例非心源性高危 TIA和轻型缺血性卒中患者。根据患者入院时MRA序列的检查结果分为无颅内动脉狭窄、单发颅内动 脉狭窄和多发颅内动脉狭窄3组。随访患者90 d卒中复发（缺血性和出血性卒中）事件。采用Cox回归 分析多发颅内动脉狭窄对轻型缺血性卒中和TIA患者90 d卒中复发风险的影响。 结果 无颅内动脉狭窄、单发颅内动脉狭窄和多发颅内动脉狭窄组分别有608例、298例和183 例患者;90 d卒中发生风险比例分别为5.43%、9.06%和18.03%。与无颅内动脉狭窄患者相比,伴 有颅内动脉狭窄（包含单发和多发颅内动脉狭窄）患者卒中复发风险显著高于非颅内动脉狭窄患者 （12.50% vs 5.40%,P＜0001）。其中,多发颅内动脉狭窄卒中复发风险最高（18.03%）,是无颅内动脉 狭窄患者的3.578倍（HR 3.578,95%CI 2.189～5.850）。 结论 多发颅内动脉狭窄是非心源性TIA和轻型卒中患者早期卒中复发的独立危险因素。     

TIA与TIA形式的脑梗死的相关因素分析

目的分析TIA及TIA形式的脑梗死的临床特点,探索其临床相关因素。方法回顾性分析83例初步诊断为TIA并在症状首发后24 h内行常规MRI及DWI检查的患者,发病1周内行颈部动脉血管彩超、TCD。记录发病后7 d内的临床转归。根据DWI结果分为DWI+组及DWI-组,确定DWI阳性率。比较DWI+组及DWI-组临床特征差别。分析两组患者动脉粥样硬化斑块的部位、性质、数量及颅内外血管狭窄的部位、程度。结果DWI阳性率为36.1%。DWI阳性与动脉粥样硬化相关(P=0.03),与颈部动脉动脉粥样硬化斑块数目相关(P=0.04),TIA症状首发后7 d内,30.0%DWI+组患者TIA症状反复发作或表现为临床症状持续存在,高于DWI-组(22.6%)。结论临床表现为TIA的病例大于1/3急性期已经形成了脑梗死,动脉粥样硬化斑块数量越多,DWI阳性的可能性越大,DWI+的患者7 d内更易进展。     

TIA患者不同b值磁共振弥散加权成像研究

目的观察短暂性脑缺血发作(TIA)患者磁共振弥散加权成像(DWI)提高b值后的影像学表现,探讨TIA患者DWI高b值的临床应用价值。方法收集2014年3月至2015年3月在河北医科大学第二医院临床诊断的TIA而结构影像学(CT,MRI)无责任病灶的TIA患者44例,所有患者均在发病3 d内行常规MRI和不同b值DWI(b=1000、b=2000和b=3000)检查。比较DWI不同b值对TIA责任病灶的敏感性、病灶范围及图像伪影的影响,定量分析TIA责任病灶的体积大小、ADC值变化。结果提高DWI b值,并没有提高发现TIA患者责任病灶的敏感性,但可以发现部分病例存在更多层面的责任病灶。定性分析发现全部患者的责任病灶随着b值的提高,病灶显示更明显,在25例DWI阳性病例中有12例,12/25例患者责任病灶的范围有所增加。当b值过度提高(b=3000),会降低图像的质量,导致伪影加重,而不易区分真正的责任病灶。定量分析发现随着b值的提高,责任病灶的平均体积也在增加(P<0.05),而ADC值却在下降(P<0.05)。结论提高DWI b值(b=2000,b=3000)更有助于反应TIA患者责任病灶的体积,有助于发现潜在的微小的不易发现的病灶,但b值过度提高(b=3000)会降低图像的质量,因此建议取DWI(b=2000)对诊断及评估TIA患者更有优势。     

重新定义TIA的临床和磁共振弥散加权成像的研究

目的通过研究短暂性脑缺血发作（transient ischemicattack，TIA）的临床特征及其与磁共振弥散加权成像（Diffusion-WeightedMRI，DWI）异常改变的关系，进一步探讨TIA新定义在临床中的应用价值。方法以2006年4月-2007年9月在本院住院的TIA患者为研究对象，入选患者完成MRI检查，前瞻性收集其临床资料和检查结果，并分析临床特征与DWI异常的关系。结果共76例TIA患者入选，其中33例（43％）患者DWI异常（阳性）；22例症状持续≥1h的患者中有19例DWI阳性（86％）；症状持续≥1h、有失语、运动障碍的患者DWI阳性率高（P〈0．05）；33例DWI阳性的患者中22例常规MRI也发现相关病灶，但8例是经回顾分析才发现。结论将近一半的TIA患者DWI有急性缺血性病灶；症状持续≥1h、失语和运动障碍与DWI异常有关；新定义有助于TIA的早期评估和治疗，但其部分受限于对影像学检查的依赖。     

TIA磁共振弥散加权成像异常的相关因素分析

目的探讨短暂性脑缺血发作(TIA)磁共振弥散加权成像(DWI)异常的相关因素。方法对2006年1月～2006年12月临床诊断为TIA的住院患者45例进行回顾性分析,比较DWI异常组和正常组的临床特征,并采用Logistic回归分析判定与DWI异常有关的独立因素。结果DWI异常14例(31%);多元回归分析提示TIA症状持续时间≥1h(OR=2.5,95%CI:1.3～8.6)和症状表现为失语伴运动障碍(OR=8.9,95%CI:2.1～36.5)与DWI异常独立相关。结论TIA患者DWI异常与TIA症状持续时间和症状表现为失语伴运动障碍有关。     

传统定义TIA与DWI异常的探讨

目的 研究短暂性脑缺血发作(TIA)磁共振弥散加权成像(DWI)的异常改变,进一步探讨TIA传统定义与新定义在影像方面的差别.方法 以2007-07～2008-09在本院住院的TIA患者为研究对象,入选患者完成MRI检查,收集检查结果及临床资料并分析DWI异常.结果 共68例TIA患者入选,其中30例(44%)患者DWI异常(阳性);19例症状持续≥1h的患者中16例DWI阳性(84%);DWI阳性率随时间的延长增高.结论 依据TIA传统定义24h症状持续≥1h的患者中更多发生DWI异常,具有脑实质缺血性损害,支持TIA新定义的合理性.     

动脉粥样硬化性大脑中动脉区域TIA功能磁共振成像分析

目的利用弥散加权成像(DWI)、磁共振血管成像(MRA)对大脑中动脉(MCA)区域TIA进行解剖性定位,评价磁共振对临床实践的指导意义。方法对32例TIA患者,在发作1.5h~7d内行头部MRI、DWI、MRA检查,对DWI图像上的高信号与T2WI像、MRA、临床症状、体征进行对照研究。结果2例DWI正常,但MRA颅内大脑中动脉闭塞,病变血管与临床症状相一致。12例DWI正常,MRA仅轻度狭窄或正常。3例DWI有高信号,T2WI无相应病灶为超早期脑梗死,其中MRA1例动脉硬化样改变,2例大脑中动脉闭塞,病灶与体征相符。15例DWI有高信号、T2WI有相应病灶,2例为早期脑梗死、13例为腔隙性脑梗死,其中MRA8例颅内大血管轻到中度狭窄,2例严重狭窄。MRI显示20例(62.5%)存在多发陈旧腔隙性梗死灶。对于TIA患者发作时MRA相应病变进行χ2四格表精确检验,DWI异常组与正常组比较P<0.05,MRA大血管病变是TIA预后形成梗死的独立危险因素。结论对TIA患者行MRI、DWI、MRA检查,能及时发现超早期脑梗死,还能对新发腔隙性脑梗死准确定位,科学指导临床早期干预治疗。MRA可提供1.2级大血管的供血状态,指导后续的2级预防。     

短暂性脑缺血发作及轻型卒中患者认知功能下降的随访研究

目的既往的研究对短暂性脑缺血发作(transient ischemic attack,TIA)及轻型卒中后的认知功能障碍的关注较少。我们将对此类患者发生认知功能障碍的危险因素进行探讨。方法我们筛选了2012年7月至12月期间,连续住院的TIA及轻型卒中患者。于发病后第3个月及第18个月各进行一次认知功能评估,截止至2014年3月31日。结果共209例TIA及轻型卒中患者入组。其中,共24例(11.5%)出现了认知功能显著下降。Logistic回归分析,结果显示:受教育年限(比数比OR=0.869,P=0.021),心房纤颤(OR=5.950,P=0.001)、多发性腔隙性脑梗死(OR=5.179,P=0.020)是TIA/轻型卒中患者中远期认知功能下降的独立危险因素。结论对于TIA/轻型卒中的患者有必要对其认知功能进行随访,对于有心房纤颤及颅内多发性腔隙性脑梗死的患者应关注其认知功能变化,加强随访,必要时尽早给予干预治疗措施,以减少其发生认知功能下降的风险。     

磁共振弥散加权成像与短暂性脑缺血发作预后的相关性研究

短暂性脑缺血发作(transient isclneroic attack,TIA)是临床常见的脑血管病,也是一种可以控制的脑血管病.磁共振弥散加权成像(diffusion weight imaging,DWI)是利用水分子弥散运动的特件进行弥散测量和成像,对急性腩缺血的榆测较传统MRI检查更为敏感.近年来随着DWI的广泛应用,对TIA的定义、诊断及预后的评价取得了较人的进展.本文主要对DWI异常与TIA患者的预后的相关性进行概括综述.     

DWI与TIA预后关系的研究进展

磁共振弥散加权成像(diffusion weight imaging,DWI)对急性脑缺血病变的检测较传统头部磁共振(Magnetic resonance imaging,MRI)检查敏感性更高.国外研究发现21％～67％传统定义下的短暂性脑缺血发作(transient ischemic attack,TIA)患者可见MRI- DWI异常[1],因此MRI- DWI的异常与否对判断TIA的短期预后有重要价值.而这方面的综述报道较少,我们将近年国内外这方面的研究进展综述如下.     

Silent stroke in patients with transient ischemic attack or minor ischemic stroke. The Dutch TIA Trial Study Group.

BACKGROUND AND PURPOSE: We studied silent stroke (i.e., infarcts on computed tomographic scan not related to later symptoms) in patients after transient ischemic attack or minor ischemic stroke. METHODS: Ours is a cross-sectional study of 2,329 patients who were randomized in a secondary prevention trial after transient ischemic attack or minor ischemic stroke and had no residual deficit after the qualifying event. RESULTS: Silent stroke was observed in 13% of the 2,329 patients. Lacunes formed 79%, cortical lesions 14%, and border zone lesions 7% of all silent strokes. Silent lacunes were most often located in the basal ganglia and symptomatic lacunes most often in the corona radiata. Age, hypertension, and current cigarette smoking were related to the presence of silent stroke. Silent stroke was equally common in different types of transient ischemic attack, including transient monocular blindness. Residual symptoms of any kind were more common in patients with silent stroke than in those without. CONCLUSIONS: Because only the sites of silent stroke infarcts differed slightly from those of symptomatic infarcts and the frequency of vascular risk factors was similar to that of symptomatic infarcts, silent stroke may have the same bearing on future risk as known prior stroke.     

Prognosis of ischemic stroke in childhood: a long-term follow-up study

Little is known about long-term physical sequelae, cognitive functioning, and quality of life in children who have experienced ischemic stroke. Thirty-seven patients under 16 years of age were studied; the median interval after stroke was 7 years. CT-scans were reassessed to determine the type of infarction at baseline. Occurrences of death, of new cardiovascular events, and of seizures during follow-up were recorded. Surviving patients were invited for a follow-up examination, including physical check-up, global screening of cognition, and an inventory of subjective health perception. Only two patients were lost to follow-up. During follow-up four died, nine developed seizures, eight had transient ischemic attacks, and two experienced a recurrent ischemic stroke. None of the patients had cardiac complications during follow-up. In 11 of 27, no functional impairment was found, in 15 there was a hemiparesis of varying severity, and in one a paraplegia. There was a significant shift in cognitive functioning towards lower levels, especially in children with epilepsy. Remedial teaching was frequently needed. Many of the parents' perceived their child's behavior to be very changeable. Three-quarters of the children considered themselves as healthy as other children, and almost all of them as happy. The physical and functional prognosis after ischemic stroke in childhood is relatively good, particularly in children with no serious causative illness, but special education is often needed and social changes occur.     

The association between high on-treatment platelet reactivity and early recurrence of ischemic events after minor stroke or TIA

Objectives: To evaluate the role of HTPR in predicting early recurrence of ischemic events in patients with minor ischemic stroke or high-risk TIA.

Methods: From January 2014 to September 2014, a single center continuously enrolled patients with minor ischemic stroke or high-risk TIA and gave them antiplatelet therapy consisting of aspirin with clopidogrel. HTPR was assessed by TEG after 7 days of antiplatelet therapy and detected CYP2C19 genotype. The incidence of recurrent ischemic events was assessed 3 months after onset. The incidence of recurrent ischemic events was compared between the HTPR and NTPR groups with the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to determine the risk factors associated with recurrent ischemic events.

Results: We enrolled 278 eligible patients with minor ischemic stroke or high-risk TIA. Through TEG testing, patients with HTPR were 22.7%, and carriers were not associated with HTPR to ADP by TEG-ADP(%) (p = 0.193). A total of 265 patients completed 3 months of follow-up, and Kaplan-Meier analysis showed that patients with HTPR had a higher percentage of recurrent ischemic events compared with patients with NTPR (p = 0.002). In multivariate Cox proportional hazards models, history of ischemic stroke or TIA (HR 4.45, 95% CI 1.77–11.16, p = 0.001) and HTPR (HR 3.34, 95% CI 1.41–7.91, p = 0.006) was independently associated with recurrent ischemic events.

Discussion: In patients with minor stroke or TIA, the prevalence of HTPR was 22.7%, and HTPR was independently associated with recurrent ischemic events.     

Persistent hyperfibrinogenemia in acute ischemic stroke / transient ischemic attack (TIA)

Increased fibrinogen concentration is a well known phenomenon following acute ischemic stroke. However, the natural course of this hyperfibrinogenemia is uncertain. We aimed to clarify whether it is of a transient or more persistent nature in patients who harbor an underlying morbid biology of atherothrombo-inflammation. Venous blood for fibrinogen measurements was obtained from the control group participants and from stroke patients within 24 hours of admission, as well as 12 months following the acute event. In order to perform a time course analysis, we divided our cohort into tiles of time from symptoms' onset and compared the fibrinogen concentrations using ANOVA. Elevated fibrinogen concentrations were found in stroke patients on admission compared with matched controls (p < 0.001). Analysis of variance in the different tertiles of time from symptoms' onset identified that fibrinogen concentrations were already relatively high during the initial phase of the event and did not differ significantly between the tiles (p = 0.268). Moreover, when we calculated the absolute differences between the patients' fibrinogen concentrations and that of the matched controls there was clearly a minor increment during the time course from symptoms' onset in the stroke patients group. In conclusion, persistent hyperfibrinogenemia is present in patients with acute ischemic cerebral events and it might be present during the earlier stages of the disease as presently shown. Prompt and long-term, rather than short term, interventions to reduce the concentrations of this protein might therefore be of relevance.     

Prevalence of extracranial carotid stenosis in Thai ischemic stroke/TIA patients

Stroke is a leading cause of death and morbidity in Thailand. The purpose of this study was to look for prevalence of significant extracranial carotid stenosis (ECCS) in Thai ischemic stroke/transient ischemic attack (TIA) patients and baseline characteristics of this subgroup.

Methods

All acute/subacute ischemic stroke/TIA patients who were treated at Thammasat hospital and had carotid duplex done, during August 2006–July 2007, were included. Carotid duplex studies were performed in all clinically stable patients. The degree of stenosis was defined according to the standard velocity criteria. Stroke subtypes were classified by TOAST criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined cause (OC) and stroke of undetermined cause (UND).

Results

One-hundred and eighty-four cases were included. Prevalence of significant ECCS was 9.2%. SAO subtype was the most common stroke subtype in our study (45%). Significant ECCS was found in 18.4%, 6% and 8.3% patients with LAA, SAO and CE stroke subtype, respectively.

Conclusion

Significant ECCS in Thai ischemic stroke/TIA patients is uncommon. Low prevalence of coronary artery disease and peripheral artery disease in Thai stroke patients and/or high SAO stroke subtype in our patients may explain this.     

The occurrence of seizures after ischemic stroke does not influence long-term mortality; a 26-year follow-up study

Objective

Epileptic seizures are a common complication after stroke. The relation between occurrence of seizures after stroke and long-term mortality remains elusive. We aimed to assess whether seizures in an early or late phase after ischemic stroke are an independent determinant of long-term mortality.

Methods

We prospectively included and followed 444 ischemic stroke patients with a first-ever supratentorial brain infarct for at least 2 years after their stroke regarding the occurrence of seizures. The final follow-up for mortality is from April 2015 (follow-up duration 24.5–27.8 years, mean 26.0 years, SD 0.9 years). We compared patients with early-onset seizures with all seizure-free patients, whereas the patients with late-onset seizures were compared with the 1-week survivors without any seizures. We used Cox-regression analyses to correct for possible confounding factors.

Results

Kaplan–Meier analysis showed significantly higher mortality for the patients with early-onset seizures (p?=?0.002) but after correction for known risk factors for (long term) mortality early-onset seizures had no independent influence on long-term mortality (HR 1.09; 95% CI 0.64–1.85). In patients with late-onset seizures, no significant influence from late-onset seizures on long-term mortality was found (univariate p?=?0.717; multivariate HR 0.81; 95% CI 0.54–1.20).

Conclusion

Both early-onset and late-onset seizures do not influence long-term mortality after ischemic stroke.