老年非瓣膜性房颤脑卒中危险分层及抗凝现状分析

目的　对非瓣膜性房颤 (NVAF)脑卒中危险分层及基层医院抗凝现状分析。方法　选择NVAF住院患者 1 2 0例并分成ABC三组 ,分别统计脑卒中发生率 (五年 )。将治疗分a组 (未抗凝 ) ,b、c组 (阿司匹林抗血小板聚集 ) ,d组 (华法林抗凝 )。结果　 1 2 0例中A组脑卒中人数 1 3人 (59.1 % )。B组脑卒中人数 2 2人 (2 9.3 % )。C组 1人 (4.3 % )。A组与B组 ,B组与C组比较有明显差异 (P <0 .0 5)。d组脑卒中发生率为 0 ,明显优于a组。阿斯匹林≥ 1 50mg d(c组 ) ,脑卒中发生人数 3人 (1 2 .5 % ) ,与a组比有明显差异 (P <0 .0 5)。结论　A、B组脑卒中发生率明显高于C组 ,口服华法令及阿斯匹林可降低脑卒中发生率。基层医院对NVAF患者抗凝治疗不充分 ,脑卒中发生率高。     

阿司匹林间歇疗法在脑卒中二级预防中的临床价值

目的观察阿司匹林间歇疗法与常规疗法在脑卒中二级预防中临床价值的差异。方法收集250例脑卒中恢复期患者,按随机单盲开放对照原则分为间歇疗法组(间歇组)(每8周内停药1周)和常规疗法组(单规组)各125例,均给予阿司匹林100mg Qd治疗2年。结果(1)2组脑卒中再发率无明显差异;(2)2组患者的血小板聚集率和凝血功能无明显差异;(3)间歇组上消化道出血、腹痛、腹泻等不良反应发生率较常规组明显下降(P<0.01)。结论阿司匹林间歇疗法较常规疗法能有效减低了长期治疗导致的消化道不良反应,同时有效降低脑卒中的再发率,在脑卒中二级预防中具有重要的临床应用价值。     

刺激颈迷走神经引起的心动过速及其对心脏功能的影响

刺激犬的颈迷走神经外周端时可引起心动过缓,而对心脏的抑制作用则逐渐减弱,表现为心率逐渐恢复(但比对照慢)。刺激后DBP立即下降,而SBP系逐渐下降,且下降程度没有DBP大。在刺激时及停止后均出现ES,其分别占刺激次数的47％和53％。在刺激停止后出现PVT(平均加速24.5次/min),PVT期间R波和BP波数不等,SV和BP轻度降低。LVET缩短和PEP/LVET比值升高,出现ES时,SV和BP较ES前显著降低。反映PVT时心脏功能降低。PVT的要理不太清楚,本研究表明反射性迷走撤退在PVT中不起作用。Q-T/Q-S_2比值增大是CA释放的间接证据。心得安可减弱PVT,阿托品可增强PVT,说明PVT由迷走静经释放CA所致。     

基层医院组建卒中小组的初步探讨

目的总结探索在基层医院组建卒中小组，治疗急性脑卒中的模式。方法组建包括社区网络在内的院内卒中小组，对脑卒中患者进行动态的全面评估和系统的个体化治疗。结果规范了急性脑卒中的临床治疗行为，改善了患者预后。结论在基层医院建立卒中小组是一种可行的治疗模式。     

Impact of Retrograde Cerebral Perfusion on Ascending Aortic and Arch Aneurysm Repair

Purpose. The effect of retrograde cerebral perfusion on the incidence of stroke and death among patients undergoing repair of aneurysms of the ascending aorta and transverse arch was determined.

Material and Methods. Between January 1991 and March 1995, 161 patients were operated on for aneurysms of the ascending aorta and transverse arch. Thirty-three of the patients (20%) had an aneurysm of the ascending aorta only and 128 (80%) had aneurysms of both the ascending aorta and the transverse arch. All the patients underwent cardiopulmonary bypass, profound hypothermia, and circulatory arrest, and 120 (74%) also underwent retrograde cerebral perfusion. Median pump time was 143 minutes (range, 21 to 461 minutes). Median circulatory arrest time was 42 minutes (range, 8 to 111 minutes), and median myocardial ischemic time was 71 minutes (range, 14 to 306 minutes).

Results. The overall 30-day mortality rate was 6% (9 patients) and the incidence of stroke was 4% (7 patients). The use of retrograde cerebral perfusion demonstrated a protective effect against stroke (3 of 120 patients, or 3%) compared with no retrograde cerebral perfusion (4 of 41 patients, or 9%; odds ratio, 0.24; confidence interval, 0.06 to 0.99; p < 0.049). This was most significant in patients more than 70 years of age; none of the 36 elderly patients who received retrograde cerebral perfusion had a stroke, compared with 3 of the 13 (23%) who did not (p < 0.003). Only pump time was associated with an increased risk of stroke (odds ratio, 1.01; 95% confidence interval, 1.00 to 1.02; p < 0.005). Pump time also was associated with increased mortality (odds ratio, 1.01; 95% confidence interval, 1.00 to 1.02; p < 0.008).

Conclusion. Retrograde cerebral perfusion decreased the incidence of stroke in patients undergoing repair of aneurysms of the ascending aorta and transverse arch.     

Blood Flow Increase by Cervical Spinal Cord Stimulation in Middle Cerebral and Common Carotid Arteries

The effect of spinal cord stimulation (SCS) on cerebral blood flow (CBF) has, in the past, been evaluated by semiquantitative techniques, but has not been used to treat CBF diseases. The aim of this study was to assess the effect of cervical SCS on regional blood flow by both semiquantitative and quantitative methods. Thirty‐five patients with cervical SCS‐implanted devices were enrolled. The following parameters were measured before and after cervical SCS: systolic and diastolic velocity (cm/s) in the middle cerebral artery (MCA) by transcranial Doppler (TCD) and volume blood flow quantification (ml/min) in the common carotid artery (CCA) by color Doppler. During cervical SCS there was a significant and bilateral increase in systolic (21%) and diastolic (26%) velocity in the MCA and in CCA blood flow (50%). We conclude that cervical SCS increases blood flow in the middle cerebral artery and common carotid artery. The consistent increase supports the potential usefulness of cervical SCS as an adjuvant treatment for cerebral blood flow diseases.     

CLOTBUST: Design of a Randomized Trial of Ultrasound-Enhanced Thrombolysis for Acute Ischemic Stroke

BACKGROUND: Intravenous tissue plasminogen activator (TPA) therapy can be monitored with 2 MHz transcranial Doppler (TCD). This article describes the design of CLOTBUST (combined lysis of thrombus in brain ischemia using transcranial ultrasound and systemic TPA), the first prospective international multicenter randomized clinical trial of noninvasive externally applied ultrasound to enhance systemic thrombolysis in human stroke. SUBJECTS: Patients with acute ischemic stroke eligible for intravenous TPA therapy within 3 hours of symptom onset who have detectable middle cerebral artery occlusion on a prebolus TCD are included in this trial. All patients receive standard 0.9 mg/kg TPA therapy. Patients are randomized (1:1) to either 2 hours of continuous monitoring with TCD or placebo monitoring. FDA-approved portable diagnostic TCD equipment and standard headframes (Marc series, Spencer Technologies, Seattle, WA) are used. Output of TCD units is set at 100% power achievable at depths of insonation that display the worst TIBI flow grade signals. METHODS AND END-POINTS: Acute MCA occlusion on prebolus TCD is defined as thrombolysis in brain ischemia (TIBI) flow grades 0-3. Treating physicians are blinded to randomization assignment, and certified scorers measure stroke severity using the National Institute of Health Stroke Scale (NIHSS). Safety of continuous TCD monitoring is determined by rates of symptomatic (NIHSS score increase by 4+ points) intracerebral hemorrhage within 72 hours after initial symptom onset. Potential enhancement of TPA therapy will be determined using combined primary end-point of early complete recanalization on TCD (TIBI flow grades 4-5), dramatic recovery (NIHSS < or = 3 points), or decline in the NIHSS > or = 10 points repeatedly measured every 30 minutes within 2 hours after TPA bolus. Other end-points include recovery at 24 hours and 3 months, modified Rankin scores (mRS) are obtained at 90 days, and favorable outcome is determined as NIHSS or mRS scores 0-1. CONCLUSIONS: The aim of phase II CLOTBUST trial is to determine the rates of early complete recanalization and dramatic/early clinical recovery in TPA + TCD and TPA groups. The sample size is set at 126 patients since a medium effect size (.50) is anticipated for TPA + TCD group vs TPA alone to achieve combined primary end-point.     

Functional decline in frail community-dwelling stroke patients

Patients who suffer a stroke event are at high risk of functional decline after the post-acute rehabilitation period. The aim of the present study was the evaluation of factors associated with functional decline in a large sample of older patients with stroke living in the community. The study population consisted of all patients admitted to home care programs after a post-acute rehabilitation program--with at least 1 year of follow-up--in twenty-two Italian Home Health Agencies from 2000 to 2002 (n=1338). For the present study we selected 355 (26%) patients with diagnosis of stroke. After 1 year of in-home care program, 149 out of 355 stroke survivors (42%) had presented a worsening in the activities of daily living (ADL) scale score. In the final adjusted model, patients with cognitive impairment (OR 2.59, 95% CI, 1.45-4.64), pressure ulcer (OR 2.74, 95% CI, 1.45-5.18), urinary incontinence (OR 1.64, 95% CI, 1.01-3.29), or hearing impairment (OR 1.83, 95% CI, 1.02-3.29) were more likely to significantly decline in physical functioning after a period of 1 year in-home care program. Our study documents that functional decline of stroke patients was largely dependent on specific subjects' clinical characteristics. Three of four concomitant disabling conditions associated in our sample with functional decline--pressure ulcer, urinary incontinence, hearing--can be prevented and eventually treated or modified. Appropriate post-acute rehabilitation programs and adequate home care interventions focused on the prevention and treatment of these conditions might be correlated to better outcomes in older post-stroke patients.     

Computed tomographic changes of the brain and clinical outcome of patients with seizures and epilepsy after an ischaemic hemispheric stroke.

It is not well established whether seizures and epilepsy after an ischaemic stroke increase the disability of patients. Seventy-two patients with delayed seizures after a hemispheric infarct (37 with a single seizure and 35 with epilepsy) were included in the study. The modified Rankin scale was used to compare disability of the patients at 1 month after stroke and at 2 weeks after single or the last seizure, in case of epilepsy. The size of the X-ray hypoattenuation zone was compared on computed tomographic (CT) scans, performed in the weeks after the stroke and 1 week after single or repeated seizures. Lesion size was determined by superimposing the CT slices on digital cerebral vascular maps, on which the contours of the infarct area were delineated. The extent of the infarcts was expressed as the percentage fraction of the total surface area of the cerebral hemisphere. Groups with a single seizure and with epilepsy were mutually compared. Infarcts predominated in the parieto-temporal cortical regions. In the overall group the median Rankin score worsened significantly after seizures. The average size of the X-ray hypoattenuation zone was also significantly increased on the CT scans after the seizures, compared with those after stroke, without clear evidence of recent infarction. Mutual comparison of patients with a single seizure episode and of those with epilepsy showed only a trend of more severe disability and of increase in lesion size in the post-stroke epilepsy group. Delayed seizures and epilepsy after ischaemic stroke are accompanied by an increase in lesion size on CT and by worsening of the disability of the patients. This study does not allow to determine whether this is due to stroke recurrence or due to additional damage as a result of the seizures themselves.