高凝状态相关性非单一动脉供血区多发急性脑梗死的临床特点和微栓子监测

目的 研究高凝状态相关性非单一动脉供血区多发急性脑梗死的临床和影像学特点、微栓子监测,探讨其可能的发病机制。方法 收集就诊于我院神经内科的高凝状态相关性非单一动脉供血区多发急性脑梗死患者的临床资料、实验室检查、头MRI、TCD微栓子监测,总结分析其特点。结果 共收集22例患者。均以局灶性神经功能缺损急性起病,包括偏瘫、失语、偏身感觉障碍、构音障碍、偏盲、皮质盲。高凝状态相关性基础疾病如下:系统性恶性肿瘤10例,高同型半胱氨酸血症(中重度,HCY50μmol/L)5例,肾病综合征2例,抗磷脂综合征2例,溃疡性结肠炎1例,真性红细胞增多症1例,阵发性睡眠性血红蛋白尿症1例。18例在卒中发病后高凝状态相关性基础疾病才被首次确诊。DWI示多发急性梗死灶,不符合单一动脉供血区,累及双侧前循环或前后循环,病灶累及大脑半球脑叶皮层/皮层下22例,深部12例,小脑10例,脑干2例。22例行微栓子监测者10例阳性。结论 对于非单一动脉供血区多发急性脑梗死,要注意筛查高凝状态相关性基础疾病,高凝状态和微栓塞可能都参与其发病机制。     

以急性脑梗死为首发表现的躯体恶性肿瘤34例分析

目的探讨以急性脑梗死为首发表现的躯体恶性肿瘤患者的临床特点和可能的发病机制。方法回顾性分析2007-01-01—2016-12-31第二军医大学附属长海医院和上海市杨浦区市东医院确诊的以急性脑梗死为首发表现的34例隐匿性躯体恶性肿瘤患者的临床资料。结果 34例患者中男29例,女5例,平均年龄(66.94±10.09)岁。无传统脑卒中危险因素者6例(17.65%)。所有患者以局灶性神经功能缺损为主要表现,其中3例出现昏迷。24例患者(70.59%)外周血D-二聚体水平升高。14例(41.18%)患者头颅DWI检查示急性多动脉供血区梗死灶。首次因急性脑梗死入院MRI检查发现有陈旧性无症状脑梗死者18例(52.94%)。肿瘤类型以肺癌(11例,32.35%)最多见,其次是肾癌(7例,20.59%)、结直肠癌(4例,11.76%)、胰腺癌(4例,11.76%)。诊断癌症时即有远处转移者9例(26.47%)。病程中出现脑梗死复发者5例(14.70%)。多数患者预后不良。入院后30d改良Rankin量表评分3~5分9例(26.47%),6分(死亡)6例(17.65%)。高血浆D-二聚体水平(P=0.000)与恶性肿瘤有远处转移(P=0.025)是患者30d神经功能预后差的相关危险因素。结论对于不符合单支动脉供血区的急性多发性脑梗死且D-二聚体明显升高的患者,特别是脑梗死再发者需要考虑合并隐匿性躯体恶性肿瘤的可能;高D-二聚体水平及恶性肿瘤有远处转移的患者一旦发生脑梗死,其神经功能预后更差。     

TCD微栓子监测对急性脑梗死的临床价值

目的探讨经颅多普勒(TCD)微栓子监测技术对急性脑梗死患者的作用。方法选取2018-06—2018-09信阳市中心医院收治的急性脑梗死患者209例,采用MRI检查脑梗死情况,并行NIHSS评分。入院后1、3、7 d分别对患者脑动脉系统行TCD微栓子监测,统计脑动脉系统微栓子的患者数和微栓子数,出院后随访3个月采用巴氏量表评估生活能力指数。结果入院后第1、3天大面积脑梗死组患者微栓子数量和阳性率显著高于小面积脑梗死组,差异有统计学意义(P0.05)。入院后第7天大面积脑梗死组微栓子数量和阳性率与小面积脑梗死组相比未见明显差异(P0.05)。入院后所有患者微栓子数量和阳性率显著下降,差异有统计学意义(P0.05)。大面积脑梗死患者入院时NIHSS评分显著高于小面积脑梗死患者,差异有统计学意义(P0.05)。出院3个月后微栓子检测阳性患者生活能力指数评分显著低于阴性患者,差异具有统计学意义(P0.05)。结论 TCD微栓子监测能侧面反映患者脑梗死的严重程度,并且对于预测患者预后具有一定作用。     

脂蛋白相关磷脂酶A2水平、微栓子信号与大动脉粥样硬化型急性脑梗死患者短期预后的关系

目的研究大动脉粥样硬化型急性脑梗死患者住院时的脂蛋白相关磷脂酶A2水平、微栓子信号对其短期预后的影响。方法募集起病72 h内的大动脉粥样硬化型急性脑梗死患者238例,收集其入院时的临床资料及实验室资料等。根据改良Rankin量表评分将患者分为预后良好组(0~2分)和预后不良组(2分)。将研究对象分为4组:脂蛋白相关磷脂酶A2正常、微栓子信号阴性组(NL/NM);脂蛋白相关磷脂酶A2正常、微栓子信号阳性组(NL/IM);脂蛋白相关磷脂酶A2升高、微栓子信号阴性组(IL/NM);脂蛋白相关磷脂酶A2升高、微栓子信号阳性组(IL/IM)。采用非条件Logistic回归分析脂蛋白相关磷脂酶A2水平、微栓子信号与急性脑梗死短期预后的关系。结果急性脑梗死患者预后不良组入院时的脂蛋白相关磷脂酶A2水平、微栓子信号阳性率均高于预后良好组(均P0.05)。经多因素调整后,与NL/NM相比,NL/IM、IL/NM和IL/IM组发生预后不良的OR值(95%CI)分别为0.719(0.112~4.627)、4.687(1.506~14.588)和14.868(3.373~65.538)。结论急性脑梗死患者入院时脂蛋白相关磷脂酶A2水平是其短期预后不良的独立危险因素,微栓子信号阳性显著放大了高水平脂蛋白相关磷脂酶A2对发生短期预后不良的作用,脂蛋白相关磷脂酶A2/微栓子信号是大动脉粥样硬化型急性脑梗死短期预后不良的预测指标。     

经颅多普勒在缺血性脑卒中微栓子监测中的应用

目的应用经颅多普勒对不同类型缺血性脑卒中患者进行微栓子监测．了解缺血性卒中患者微栓子的发生率及其可能发病机制。方法应用德国DWL公司双通道双深度DopX2—0352型经颅多普勒（TCD）检测仪,对30例患者进行双大脑中动脉（MCA）微栓子监测,记录不同病例组微栓子阳性病例数。结果大血管闭塞病例10例中发现微栓子者3例（30％）,6例有潜在心源性疾病2例（33．3％）监测到微栓子,6例腔隙性脑梗死患者均未检测到微栓子,8例短暂性脑缺血患者1例（12．5％）监测到微栓子。结论提示微栓子阳性与动脉源及心源性血栓形成并脱落有关,微栓子参与缺血性脑卒中形成,但不排除小动脉本身硬化病变闭塞所致。     

急性双侧前后循环脑梗死与恶性肿瘤

目的通过对表现为急性脑梗死且双侧、前后循环均受累的Trousseau综合征的分析,探讨其与恶性肿瘤的关系。方法收集并分析首发表现为急性双侧前后循环脑梗死的Trousseau综合征3例,并进行相关文献复习。结果 3例均以单纯急性脑卒中起病,头部MRI显示为急性双侧前后循环脑梗死,伴凝血功能异常和肿瘤标记物增高。肿瘤诊断分别为胆管细胞癌、肺癌和乳腺癌。结论本研究首次报道了表现为急性双侧前后循环脑梗死的Trousseau综合征。结合影像学和实验室检查,推测3例脑梗死的形成主要与肿瘤造成的高凝状态有关。当老年患者以急性卒中起病,影像学检查提示特征性的急性双侧前后循环脑梗死时,要高度警惕存在恶性肿瘤的可能。     

急性脑梗死患者微栓子监测与颈动脉硬化的相关性分析

目的探究微栓子、颈动脉粥样硬化斑块与急性脑梗死的相关性分析。方法选择2012-09—2014-09我院收治的77例急性脑梗死住院患者,斑块组46例,无斑块组31例。采集静脉血行TC、TG、LDL-C、HDL-C检测,行脑动脉微栓子监测与动脉彩色超声检查。结果斑块组高血压、吸烟、糖尿病、高TC血症、高LDL-C血症显著高于无斑块组;不稳定性斑块微栓子阳性率显与稳定性斑块微栓子阳性率比较;单发微栓阳性率与多发微栓子阳性率比较,差异具有统计学意义(P0.05)。结论大部分急性脑梗死患者并发颈动脉粥样硬化斑块,其中微栓子主要来自不稳定斑块。微栓子存在即易导致脑梗死,应及时对症治疗。     

伴有颈动脉斑块的急性前循环脑梗死患者的微栓子研究

目的 探讨颈动脉斑块、微栓子和急性前循环脑梗死的关系。方法 选择住院的急性前循环脑梗死患者65例,经颈动脉超声检查分为伴有颈动脉斑块组45例和不伴有颈动脉斑块组20例,2组均行微栓子监测。结果 伴有颈动脉斑块组与不伴有颈动脉斑块组吸烟、高血压病、糖尿病、高脂血症相比无明显差异(P>0.05); 伴有颈动脉斑块患者的微栓子阳性率为38%,不伴有颈动脉斑块患者为13%,2组相比有明显差异(P<0.05); 软斑组微栓子阳性率为45%,硬斑组微栓子阳性率为18%,2组相比有明显差异(P<0.05)。结论 急性前循环脑梗死患者多有颈动脉斑块,软斑块是微栓子的主要来源,微栓子是急性脑梗死发病的重要危险因素,对二者早期干预是防治脑卒中的重要措施之一。     

急性缺血性卒中经颅多普勒超声微栓子信号监测临床研究

目的探讨大脑中动脉微栓子信号与急性缺血性卒中的相关性,以及单联和双联抗血小板治疗效果。方法采用经颅多普勒超声(TCD)监测129例急性缺血性卒中患者大脑中动脉微栓子信号,单因素和多因素前进法Logistic回归分析筛查微栓子信号阳性危险因素,阿司匹林单药或联合氯吡格雷双联抗血小板治疗,评价药物疗效和预后。结果 129例患者中42例(32.56%)微栓子信号阳性。Logistic回归分析显示,高脂血症是微栓子信号阳性的独立危险因素(OR=0.335,95%CI:0.147~0.764;P=0.009)。经抗血小板治疗后,双抗组患者微栓子信号消失率高于单抗组(χ~2=16.701,P=0.000);与治疗前相比,两组患者治疗后NIHSS评分减少(P=0.000),与单抗组相比,双抗组患者治疗后NIHSS评分亦减少(P=0.025),表明抗血小板治疗有效且双联抗血小板治疗效果优于单抗治疗。结论高脂血症是TCD监测微栓子信号阳性的独立危险因素,双联抗血小板治疗可以阻止微栓子信号形成并改善患者近期预后。     

急性脑梗死患者微栓子监测与颈动脉硬化的相关性分析

目的：探讨急性脑梗死患者微栓子监测与颈动脉硬化的关系。方法选取我院2013-01-2013-12收治的60例急性缺血性脑血管病患者为研究组,并选取同期60例非急性缺血性脑血管病患者为对照组,对2组患者实施经颅多普勒微栓子监测。结果研究组微栓子阳性率40.0％,对照组为38.3％,2组比较差异无统计学无意义（ P＞0.05）;微栓子阳性患者颈动脉斑块发生率59.6％（28/47）,微栓子阴性患者39.7％（29/73）,2组比较差异有统计学意义（ P＜0.05）。微栓子阳性患者不稳定颈动脉斑块发生率96.4％（27/28）,微栓子阴性患者为51.7％（15/29）,2组比较差异有统计学意义（ P＜0.05）。结论微栓子监测对指导和预防颈动脉硬化的急性脑梗死患者具有较好的效果,具有一定的应用价值。     

Microembolic signals within 24 hours of stroke onset and diffusion-weighted MRI abnormalities

BACKGROUND: The clinical relevance of the microembolic signals (MES) detected by transcranial Doppler sonography (TCD) in acute stroke remains unclear. In a prospective study the authors analyzed the relationship between MES and the findings on diffusion-weighted magnetic resonance imaging (DWI) in acute stroke patients. METHODS: We performed TCD for a period of 30 min to detect MES in patients within 24 h of stroke onset, and DWI was done within the initial 7 days. MES were assessed from Doppler waves obtained from the middle cerebral artery contralateral to the side of the neurological deficits. The acute ischemic lesions observed on DWI were classified by their diameter (small, medium or large) and by their site (cortical, superficial perforator territory, internal borderzone or deep perforator territory). RESULTS: We obtained Doppler waves from 39 vessels in 37 patients; 2 patients had bilateral deficits. MES were detected in 12 vessels (MES-positive group) and not detected in 27 vessels (MES-negative group). No significant differences in clinical features were observed between the 2 groups. The number of small lesions was significantly higher in the MES-positive group than in the MES-negative group (p = 0.02). The numbers of cortical and superficial perforator infarcts were significantly higher in the MES-positive group than in the MES-negative group (p = 0.002 and 0.02, respectively). CONCLUSION: In acute ischemic stroke, MES detected by TCD in the acute phase may produce small cortical and subcortical lesions found on DWI.     

烟雾病患者微栓子信号与临床表现及梗死灶关系的初步观察

目的 分析烟雾病患者的微栓子信号（microembolic signal,MES）与临床表现及梗死灶的关系。方法 总结了6例在常规经颅多普勒超声（transcranial Doppler,TCD）检查中出现MES的烟雾病患者的临床资料及弥散加权成像（diffusion-weighted imaging,DWI）影像资料,分析MES与患者临床表现及DWI上梗死灶之间的关系。结果 6例患者的MES均出现在大脑中动脉（middle cerebral artery,MCA）,3例（50%）闭塞,3例（50%）狭窄。6例中5例（83.33%）患者一个月内出现过缺血性症状,其中3例（50%）症状发生在无MES侧MCA供血区域;1例（16.67%）症状交替发生在MES同侧或对侧MCA供血区;1例（16.67%）为后循环缺血。5例（83.33%）患者DWI上出现梗死灶,在MES同侧MCA供血区内出现梗死灶的共有4（66.67%）例,无MES侧MCA供血区内出现梗死灶的共有5例（83.33%）。均为（100%）多发性梗死,皮层梗死为最常见梗死类型。结论 无论近期是否出现过缺血症状,烟雾病患者狭窄或闭塞的MCA均可发现MES。这些MES的存在与临床症状及梗死灶的相关性有待进一步研究。     

大脑中动脉狭窄患者急性脑梗死发病机制:一项弥散加权磁共振和微栓子监测研究

目的我们前瞻性研究了30例经颅多谱勒超声(TCD)和核磁血管成像(MRA)检查证实大脑中动脉(MCA)狭窄,并在该供血区域出现急性缺血性卒中患者,以探讨MCA狭窄的可能机制。方法全部病人均进行微栓子监测以及弥散加权磁共振(DWI)检查。急性梗死分成单发和多发梗死,梗死部位分成皮层梗死(CI)、交界区梗死(BI)和深穿支动脉梗死(PAI)。微栓子信号(MES)和DWI梗死病灶分别由两位不同的医生在不知道对方资料的情况下确认。结果DWI结果发现急性多发脑梗死和单发梗死各15例(50%)。多发梗死病人中,成链状排列的BI最常见(11例,占73%)。单发梗死中只有PAI是最常见的类型(10例,占67%)。10例(33%)病人检测到MES,每30min内MES的中位数为15(3-102)个。MES在多发梗死中的发生频率(9/15,60.0%)明显高于单发梗死(1/15,6.7%)(P=0.002)。MES的数目能预测DWI上脑梗死的数目(线性回归,调整后R2=0.475,P<0.01)。结论MCA狭窄梗死最常见的原因有两个:①穿支动脉闭塞引起的皮层下小的腔隙性梗死;②由动脉-动脉的栓子不能被清除而造成的多发小梗死,尤其是在交界区更明显。     

Diffusion weighted MRI imaging and MES detection in the assessment of stroke origin

OBJECTIVES: This study compares the additional benefit of diffusion-weighted MRI (DWI) and microembolus detection by transcranial Doppler ultrasonography (TCD) in the assessment of stroke etiology. METHODS: Fifty-five acute anterior circulation stroke or TIA patients were investigated by both cranial DWI and bilateral TCD of the middle cerebral arteries (1 hour). RESULTS: In one of the 13 patients without acute ischemic lesions visualized on DWI, microembolic signal (MES) detection was positive. However, in 33 out of 44 patients without MES, DWI revealed at least one lesion. In two patients with unilateral territorial infarction and otherwise normal cardiovascular work-up, bilateral MES were found thus localizing the embolic source into the aortic arch or the heart. In a further patient with a dissection, the occurrence of contralateral MES raised doubts on a dissection to be the cause of the infarct. DISCUSSION: There is a contribution of both techniques to the understanding of stroke etiology. The impact of DWI is, however, superior to that of MES detection. Longer TCD recording times may diminish this discrepancy.     

Distribution of cerebral microembolism in the anterior and middle cerebral arteries

BACKGROUND AND PURPOSE: Cerebral infarcts occur more frequently along the middle (MCA) than the anterior cerebral artery (ACA) territory. The reason(s) for this difference remains speculative. The objective of this study was to investigate the distribution of cerebral microemboli as detected by transcranial Doppler ultrasound (TCD) along the MCA and ACA territories. METHODS: Records of consecutive patients examined for the presence of cerebral microembolism during a 32-month period at the Neurovascular Laboratory were reviewed. Of the original 375 TCD studies in 268 patients, 28 studies in 24 patients demonstrated microembolic signals (MES) and monitored the MCA and ACA on the same side. TCD studies were performed on TC-2000 or TC-2020 instruments. MES positive studies were saved and off-line reviewed. MES satisfied previously established criteria. RESULTS: MES were more frequent in the MCA than the ACA in 85.7% (24/28) of studies (P < 0.01). Of the total number of MES (n = 979), 29.6% (n = 290) were detected in the ACA and 70.4% (n=689) in the MCA (P<0.01). The mean (+/- SD) intensity of MCA MES of 12.2 (+/- 2.4) dB was significantly lower than that of ACA MES of 14.8 (+/-3.2) dB (P=0.05). The mean (+/-SD) duration of MCA MES of 38.1 (+/- 45.3) ms was longer than that of ACA MES of 30.7 (+/-34.0) ms (P=0.05). CONCLUSIONS: Cerebral microembolism occurs more frequently in the MCA than the ACA, which may explain the uneven distribution of cerebral infarcts along these arterial territories. Furthermore, there are significant differences in the characteristics of ACA and MCA MES.     

D-dimer >2.785 μg/ml and multiple infarcts ≥3 vascular territories are two characteristics of identifying cancer-associated ischemic stroke patients

ABSTRACT

Background: The patterns and mechanisms underlying stroke in cancer patients differ from those of the conventional etiology. In this study, we further investigated the characteristics distinguishing cancer-associated ischemic stroke (CAIS) and the relationship of D-dimer value with CAIS.

Methods: Sixty-one acute ischemic stroke patients with cancer (cancer group) and 76 stroke patients without cancer (control group) were recruited. Cerebrovascular distribution was divided into 3 circulations and 23 vascular territories, and acute multiple brain infarcts (AMBIs) were defined as discrete MRI diffusion-weighted imaging (DWI) lesions in >1 vascular territory.

Results: Cancer patients had higher average D-dimer and fibrinogen degradation product values, and fewer stroke risk factors. The numbers of infarct-affected vascular territories, AMBIs, and AMBIs in multiple circulations were significantly higher in the cancer group. Receiver operating characteristic analysis showed that the cutoff value of D-dimer was 2.785 μg/ml; and above features were particularly evident in cancer patients whose D-dimer values were >2.785 μg/ml, while those with D-dimer values ≤2.785 μg/ml were similar to controls.

Conclusions: D-dimer >2.785 μg/ml may be an effective cutoff value and a sensitive index for identifying CAIS patients. AMBIs in ≥3 vascular territories and AMBIs in both the anterior and posterior circulations are two imaging characteristics of CAIS.     

Stroke as the first manifestation of concealed cancer

BACKGROUND AND PURPOSE: Trousseau's syndrome (TS) is defined as a malignancy-related thromboembolism occurring in patients with an underlying or undiagnosed malignancy. Stroke seldom occurs as the first manifestation of a cancer. We investigated the clinical and radiological features of patients with TS. METHODS: We reviewed the clinical, pathologic, and radiological records of consecutive stroke patients, whose cancers were diagnosed at stroke presentation. Cancer-related stroke was defined if no definite cause was confirmed and malignancy was detected within 6 months of first stroke onset without cancer-related treatment. All patients underwent brain diffusion-weighted MRI (DWI), MR angiography, and echocardiography. The sizes, numbers, and locations of all hyperintense lesions in the DWI were noted. RESULTS: Ten patients were finally analyzed. Histologically, cancers were often proven to adenocarcinomas (50%, 5/10) of advanced stage. Six of 10 patients tested (60%) had elevated D-dimer. Seven of the 10 patients (70%) showed bihemispheric anterior and posterior involvement. DWI features showed numerous small and medium or large lesions in multiple territories in 9 patients (90%). CONCLUSIONS: The authors emphasize that when presented with multiple bihemispheric infarctions on DWI and an unknown etiology, the neurologist must consider the existence of a concealed cancer.     

以多发性急性脑梗死为表现的Trousseau综合征临床及影像学特点分析

目的 探讨以多发性急性脑梗死为表现的Trousseau综合征临床、实验室检查及影像学特点。方法收集了11例以多发性急性脑梗死为表现的Trousseau综合征患者的临床资料、实验室检查、影像学资料,进行总结分析。结果 11例患者男性4例,女性7例,年龄为45~80岁;肺癌4例,肺癌伴肝转移2例,直肠癌1例,胰腺癌1例,胃癌2例,卵巢癌1例;D-二聚体为10.11~40.56 mg/L,平均为29.10 mg/L;头磁共振表现为多个动脉支配区的多发性脑梗死。结论 肿瘤相关性多发性急性脑梗死是Trousseau综合征的一种表现形式,其表现特点为累及多个动脉支配区的多发性急性脑梗死伴有血D-二聚体显著升高,这些特征性表现可以作为隐匿性癌症的线索之一。     

Micro embolic signals in patients with cerebral ischaemic events

The aim of this study was to evaluate the occurrence of micro embolic signals (MES) in patients with a cerebral ischaemia using transcranial doppler monitoring and to find out its diagnostic relevance. We prospectively performed bilateral multigated transcranial doppler monitoring from both middle cerebral arteries in 359 patients with an acute or recent (<4 weeks) cerebral ischaemic event, and in 182 control subjects without a cerebral ischaemic event. MES were analysed according to the standardised protocol. Patients with cerebral ischaemic events had a significantly higher (p<0.00001) rate of MES occurrence (31.8%) than control subjects (5.5%). MES were detected significantly higher in patients with partial or total anterior circulation infarcts (39.1%) than in those with lacunar infarcts (26.0%) or transient ischaemic attacks (27.3%). A correlation of MES and neuroimaging finding was also tried. TCD was found to have a predictive role in microemboli monitoring, predominantly in patients with large vessel territory infarction.