电生理技术应用于卒中康复评估的临床价值

电生理技术具有客观、可量化、无创、易重复的优点,在卒中患者康复评定中具有不可替代的作用。表面肌电图在运动分析和肌肉功能评估中具有很好的应用价值;通过脑电图可以了解脑功能状况;诱发电位能够反映患者的运动、感觉和认知状态;经颅多普勒可用于检测卒中患者康复前后脑血流的变化。本文对电生理技术应用于卒中患者功能障碍评定、康复效果评估以及康复治疗方案制定中的临床价值及最新进展进行综述。     

Mapping cortical hand motor representation using TMS: A method to assess brain plasticity and a surrogate marker for recovery of function after stroke?

ObjectiveStroke is associated with reorganization within motor areas of both hemispheres. Mapping the cortical hand motor representation using transcranial magnetic stimulation may help to understand the relationship between motor cortex reorganization and motor recovery of the affected hand after stroke.MethodsA standardized review of the pertinent literature was performed.ResultsWe identified 20 trials, which analyzed the relationship between the extent and/or location of cortical hand motor representation using transcranial magnetic stimulation and motor function and recovery of the affected hand. Several correlations were found between cortical reorganization and measures of hand motor impairment and recovery.ConclusionA better understanding of the relationships between the extent and location of cortical hand motor representation and the motor impairment and motor recovery of the affected hand after stroke may contribute to a targeted use of non-invasive brain stimulation protocols. In the future motor mapping may help to guide brain stimulation techniques to the most effective motor area in an affected individual.     

Manual Aspiration Thrombectomy Using Penumbra Catheter in Patients with Acute M2 Occlusion : A Single-Center Analysis

ObjectiveThe efficacy and safety of manual aspiration thrombectomy using Penumbra in an acute occlusion of large intracranial arteries has been proven in many previous studies. Our study aimed to retrospectively assess the efficacy and safety of manual aspiration thrombectomy using Penumbra in patients with small vessel occlusions (M2 segment of the MCA).MethodsWe conducted a retrospective review of 32 patients who underwent manual aspiration thrombectomy using the Penumbra 4 MAX Reperfusion Catheter for treatment of an M2 occlusion between January 2013 and November 2014. We evaluated immediate angiographic results and clinical outcomes through review of patient electronic medical records.ResultsThere were slightly more men in this study (M : F=18 : 14) and the median age was 72.5 (age range : 41–90). The rate of successful recanalization (TICI grade ≥2b) was 84% (27/32). NIHSS at discharge and favorable clinical outcomes at 3 months were significantly improved than baseline. Median initial NIHSS score was 10 (range : 4–25) and was 4 (range : 0–14) at discharge. Favorable clinical outcomes (mRS score ≤2 at 3 months) were seen in 25 out of 32 patients (78%). There were no procedure-related symptomatic intracerebral hemorrhages. One patient expired after discharge due to a cardiac problem.ConclusionManual aspiration thrombectomy might be safe and is capable of achieving a high rate of successful recanalization and favorable clinical outcomes in patients with distal cerebral vessel occlusion (M2).     

Stroke volume measurements with first-pass dynamic positron emission tomography: Comparison with cardiovascular magnetic resonance

Background  The assessment of forward stroke volume (SV) using dynamic, first-pass cardiac positron emission tomography (PET) was shown to be feasible in a limited number of studies with small numbers of subjects. The aim of this study was to compare first-pass derived SV with cardiovascular magnetic resonance imaging (CMR)-obtained values in a larger population of subjects. Methods and Results  Fifty-nine subjects with varying degrees of cardiac function were studied. Stroke volume was assessed using oxygen-15-labeled water (H₂ ¹⁵O) dynamic first-pass PET for both the right ventricle (RV) and left ventricle (LV), and compared with the findings of aorta velocity-encoded phase-contrast CMR. The PET-estimated SV was higher for the RV than for the LV (133±34 vs 116±31 mL, P<.01, ±SD), and both were higher compared with values obtained by CMR (81±20 mL, both P<.01,±SD). Although significant, the correlations between PET and CMR were moderate for both the RV (r=0.37, P<.01) and the LV (r=0.40, P<.01,±SD). Bland-Altman analysis revealed a progressive overestimation with increasing SV measured in either ventricle. Conclusions  First-pass dynamic H₂ ¹⁵O PET for the assessment of forward SV is feasible, although values are progressively overestimated with increasing SV, particularly when the RV is used, and correlations with aorta velocity-encoded phase-contrast CMR are moderate. These findings are probably protocol-dependent and warrant further study before the use of first-pass dynamic H₂ ¹⁵O PET in clinical or research settings can be advocated.     

In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention

ObjectiveAlthough the benefits of carotid endarterectomy (CEA) for treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether the optimal timing will vary with preoperative stroke severity has remained unclear. Therefore, we assessed the effect of stroke severity and timing of the intervention on the postoperative outcomes for patients who had undergone CEA for stroke.MethodsWe identified all patients in the Vascular Quality Initiative who had undergone CEA from 2012 to 2020 for prior stroke. The patients were stratified using the preoperative modified Rankin scale score (mRS score, 0-5) and time to CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, 91-180 days). After univariate comparisons, the patients were stratified into the following mRS cohorts for further analysis: 0 to 1, 2, 3 to 4, and 5. The primary outcome was in-hospital stroke/death.ResultsWe identified 15,601 patients, of whom 30% had had an mRS score of 0, 34% an mRS score of 1, 17% an mRS score of 2, 11% an mRS score of 3, 8% an mRS score of 4, and 1% an mRS score of 5. Overall, 9.3% of the patients had undergone CEA within ≤2 days, 46% within 3 to 14 days, 36% in 15 to 90 days, and 8.4% within 90 to 180 days. A decreasing mRS score and an increasing time to CEA were associated with lower rates of perioperative stroke/death (P_trend < .01). After risk adjustment, with CEA at 3 to 14 days as the comparator group, the mRS score 0 to 1 group had had a higher incidence of stroke/death after CEA within ≤2 days (3.6% vs 2.0%; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.7). The mRS score 2 group had had a similar incidence of stroke/death after CEA within ≤2 days (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.6-2.3) but a lower incidence after CEA at 15 to 90 days (2.1% vs 3.9%; OR 0.5; 95% CI, 0.3-0.96). The mRS score 3 to 4 group had had a higher incidence of stroke/death after CEA within ≤2 days (8.0% vs 3.8%; OR, 2.4; 95% CI, 1.5-3.9) but a similar incidence of stroke/death after CEA at 15 to 90 days (3.0% vs 3.8%; OR, 0.8; 95% CI, 0.5-1.3). For the mRS score 5 group, the stroke/death rates were ≥6.5% across all the time to CEA groups. However, the low sample size limited meaningful comparisons.ConclusionsPatients with minimal disability after stroke (mRS score, 0-1) seemed to benefit from CEA within 3 to 14 days. However, those with severe disability (mRS score 5) have a very high risk from CEA at any time point given the poor outcomes. In contrast to the current guidelines, patients with mild disability (mRS score 2) could benefit from delaying CEA to 15 to 90 days, and those with moderate disability (mRS score 3-4) might benefit from CEA within 3 to 90 days given the acceptable in-hospital outcomes. These data should be considered within the context of the clinical situation in the weeks after index event to determine the net benefit of delayed CEA.     

Females are less likely to receive best medical therapy for stroke prevention before and after carotid revascularization than males

BackgroundCurrent professional guidelines recommend best medical therapy (BMT) with statin agents and antiplatelet therapy for primary and secondary stroke prevention in patients with carotid artery stenosis. We aimed to assess the association of patient sex with preoperative BMT in patients undergoing carotid revascularization.MethodsWe performed a retrospective review of Vascular Quality Initiative patients who underwent carotid endarterectomy or carotid artery stenting between January 2003 and February 2022. Multivariable logistic regression models were used to assess the association of patient sex with preoperative BMT after adjusting for sociodemographic, comorbidity, and disease severity characteristics. In-hospital outcomes were assessed by sex and preoperative BMT status.ResultsOf 214,008 patients who underwent carotid revascularization, 38.7% (n = 82,855) were female and 61.3% (n = 131,153) were male. Overall, 77.2% (n = 63,922) of females were on preoperative BMT, compared with 80.4% (n = 105,375) of males (P < .001). After adjusting for baseline differences, females had 11% lower odds of being on BMT compared with males (adjusted odds ratio, 0.89; 95% confidence interval, 0.86-0.91). Postoperatively, females had 18% lower odds of being prescribed BMT than males (adjusted odds ratio, 0.82; 95% confidence interval, 0.79-0.84). In-hospital stroke (1.20% vs 1.51%), death (0.37% vs 0.66%), and stroke/death (1.46% vs 1.98%) were all significantly lower for patients on BMT (all P < .001).ConclusionsThere is a significant discrepancy in the proportion of females versus males receiving preoperative BMT for stroke prevention before carotid artery revascularization. In-hospital outcomes are worse in patients without BMT, highlighting the importance of raising awareness and implementing targeted interventions to improve preoperative adherence to stroke prevention guidelines.     

每搏输出量变异度监测不同潮气量通气时全麻患者血容量变化的准确性

目的 评价每搏输出量变异度(SVV)监测不同潮气量通气时全麻患者血容量变化的准确性.方法 择期行胃肠手术的全麻患者50例,年龄31～59岁,ASAⅠ或Ⅱ级,随机分为2组:常规潮气量组(C组,n=20)和小潮气量组(L组,n=30).C组潮气量(VT)8 ml/kg,呼吸频率(RR)12次/min,呼气末正压力0,吸入氧浓度80%,氧流量2 L/min,行间歇正压通气;L组VT 6 ml/kg,RR16次/min,余同c组.气管插管后10 min,两组均以0.3 ml·kg-1·min-1的速率静脉输注6%羟乙基淀粉130/0.4氯化钠注射液7 ml/kg,输注后开始手术.于输注前(T1)和输注后10 min(T2)时记录MAP、HR、CVP、体循环血管阻力(SVR)、SVV和每搏指数(SI),并计算其变化率.绘制各项血液动力学指标监测血容量变化的ROC曲线.结果 ROC曲线结果 分析显示:以SI变化率≥25%为监测血容量变化的标准时,SVV的诊断周值为9.5%,C组SVV>9.5%监测血容量变化的灵敏度为100%,特异度为57.1%;L组SVV>9.5%监测血容量变化的灵敏度为91.3%,特异度为71.4%.ROC曲线下面积显示:两组SVV监测血容量变化的准确性高于MAP、HR、CVP、SVR.结论 在常规潮气量(8 ml/kg)和小潮气量(6 ml/kg)/机械通气时,SVV均可准确地监测全麻患者血容量变化.     

CT影像学对血管性痴呆患者的诊断价值

目的 探讨CT影像学对血管性痴呆患者的诊断价值。方法 选取本院2018年1月～2019年10月期间接诊的78例经CT影像学检查确诊为血管性痴呆的患者作为观察组,选取同期的78例非痴呆性脑卒中患者作为对照组,同样接受CT影像学检查,使用简易智力状态检查量表(MMSE)和日常生活能力评定量表(ADL)对比两组患者认知功能和生活自理能力,对比两组患者CT影像学检查表现及两组患者的脑萎缩率。结果 观察组患者的MMSE评分和ADL评分分别为(21.65±1.45)分和(40.25±5.36)分,对照组患者的MMSE评分和ADL评分分别为(27.20±1.66)分和(60.78±3.26)分,观察组评分明显低于对照组,差异有统计学意义(P0.05);两组患者的CT影像学表现结果表明,观察组患者的脑梗死面积比对照组大,部分患者在脑出血后出现梗死,病变的位置以皮质和皮质下为主,双侧和左侧为主要倾向;观察组患者的脑萎缩率达到83.33%,明显高于对照组的12.82%,差异有统计学意义(P0.05)。结论 CT影像学检查可以清晰且准确的反映出血管性痴呆患者的病灶位置和脑萎缩情况等,临床诊断价值较高,是一种高效、可靠的血管性痴呆检查方法,值得推广并应用。     

FLAIR血管高信号征在大脑中动脉供血区急性脑梗死中的临床价值

目的探讨磁共振液体衰减反转恢复(FLAIR)序列高信号血管征(HVS)在评估大脑中动脉供血区急性脑梗死患者病情严重程度及预后中的应用价值。方法回顾性分析大脑中动脉供血区急性脑梗死的患者共52例。根据T2 FLAIR图像上血管高信号征是否存在分为有血管高信号征组和无血管高信号组。比较两组患者弥散序列(DWI)上梗死体积大小、入院时及治疗10天后NIHSS评分、早期神经功能恢复情况及基本临床资料。结果大脑中动脉供血区急性缺血性脑梗死患者52例中无远端HVS组35例(67%)和远端HVS组17例(33%)中,梗死体积大小分别为(89.74±28.82)和(73.15±26.37),入院时NIHSS评分分别为16(6~27)分及10(2~21)分,入院10天NIHSS评分分别为13(6-26)和8(0~19)分,无远端HVS组与远端HVS组差异存在统计学意义(P<0.05)。梗死侧大脑中动脉狭窄程度分为轻度狭窄、明显狭窄、闭塞,HVS组的发生率分别为19例(42%)、11例(73%),16例(89%)。HVS组中大脑中动脉严重狭窄或闭塞者27例,占HVS阳性组77%,血管高信号征阴性组中大脑中动脉严重狭窄或闭塞者5例,占HVS阴性组29%,两组之间存在显著差异(P<0.05)。结论 T2 FLAIR序列HVS是大脑中动脉供血区急性脑缺血性梗死重要的影像学征象。有远端HVS的患者急性梗死灶体积较小,NIHSS评分较低,临床预后较好。责任血管狭窄程度越严重,HVS的出现率越高。大脑中动脉区HVS联合MRA有利于临床评估脑梗死的病变范围、血管病变的大致位置、血管的狭窄程度,可指导临床进行早期干预,改善患者的预后。     

以脑梗死为表现的特鲁索综合征1例临床特点及文献复习

特鲁索综合征是恶性肿瘤伴血液高凝状态引起的血栓栓塞并发症,青岛大学附属医院2020年10月收治1例以脑梗死为表现的特鲁索综合征患者。本例为胰腺恶性肿瘤患者,入院第2天出现口角歪斜、言语含糊,颅脑磁共振成像(MRI)检查显示脑实质内见多发DWI高信号,增强显示脑实质内未见异常强化,考虑为特鲁索综合征。检索中国知网、万方和PubMed数据库2011年1月至2021年6月的相关文献,共检索到以脑梗死为表现且资料比较完整的特鲁索综合征者76例,加上本例共77例。其中男性36例、女性41例,中位年龄63岁,最常见肿瘤类型为肺腺癌(24例,31.2%)。D-二聚体水平为(17.3±12.8)mg/L,颅脑CT或MRI检查提示双侧多发病变者57例(74.0%),56例行抗凝治疗。68例随访资料显示中位生存时间为90 d,log-rank法分析1年总生存率为32.6%。提示,对D-二聚体水平显著升高、多血管受累的脑梗死患者,需考虑恶性肿瘤的并发症。