脑卒中后抑郁患者P300及相关临床因素研究

目的：脑卒中后抑郁（post—strokedepression，PSD）是脑卒中患者发病后常见的并发症，由于缺乏客观的检测指标和判断标准，往往被漏诊。本课题采用前瞻性研究，通过对PSD发生率、相关因素、影像学特点、认知功能缺损及其事件相关电位（P300）的改变，并与脑卒中非抑郁患者（N—PSD）进行对比，探讨PSD可能的发病机制、相关的危险因素及预测因素、P300在早期诊断的应用价值，以达到临床早期诊断及治疗的目的。方法：从2007年3月至2008年3月间入住我院神经内科能够完成随访，符合课题要求的首发急性脑卒中患者96例，其中脑梗死82例，脑出血12例，蛛网膜下腔出血2例，所有患者均经脑CT及MRI证实，并记录病灶部位分布，96例患者经过综合治疗，病情好转后出院，出院后每月随访一次，连续12个月。采用中国精神分类方案第3版（CCMD-3）抑郁状态的诊断标准将其分为抑郁组（PSD组，36例）和非抑郁组（N—PSD组，60例）。统计PSD组发病时间及临床表现，并选取年龄、性别、文化程度、吸烟史、酗酒史、慢性病史、负性生活事件、病灶部位分布等可能的危险因素在PSD组和N—PSD组间进行单因素分析，以有显著差别的指标进行多元Logistic逐步回归分析来确定其影响程度。随访时对两组患者采用简易智力量表（MMSE）评分和事件相关电位（P300）检查进行认知功能评测，并分析比较两组患者P300潜伏期、波幅差异及MMSE评分的变化。统计学处理应用SPSS13．0软件对资料进行分析。计量资料采用t检验，计数资料采用χ^2检验，单因素分析阳性参数采用Logistic（Forward：Wdald法）逐步回归分析来确定其影响程度，相关分析采用Spearman相关，检验水准为α=0．05。结果：1、一般资料：在96例脑卒中患者中，36例发生抑郁，其发病率为37．50％（36／96），其中轻度抑郁21例（58．33％）；中度抑郁12例（33．33％），重度抑郁3例（8．33％）。PSD组与N—PSD组患者年龄、性别、吸烟、文化程度比较无显著性差异（P〉0．05）。两组酗酒史、近期有负性生活事件、慢性病史比较均有显著性差异（P〈0．05），对PSD组与N—PSD组间单因素分析有差别的指标（酗酒史、慢性病史、近期有负性生活事件）进行多元Logistic回归分析，结果显示以上三个因素均进入议程，发生PSD的OR值分别为3．516、3．047和3．987，P〈0．05。2、临床表现和发病时间：大部分PSD患者均有兴趣丧失、无愉快感、精力减退或疲乏感、自我评价过低、自责，或有内疚感，少数严重患者有想死的念头或有自杀、自伤行为。病程分布以卒中后3～6个月发生PSD最多见（19例，52．78％）。3、病变部位：96例脑卒中患者中，病灶位于左侧27例，位于右侧45例，多发24例；病灶位于左侧半球合并PSD率最高（59．26％），右侧次之（33．33％），多发病灶抑郁率（20．83％）最低（P=0．013）。4、MMSE评分：PSD组MMSE平均评分为（20．14±3．01）分，N—PSD组为（22．77±3．77）分，两者比较差异有显著性（P〈0．05），PSD患者发生认知功能受损的比例（41．67％）明显高于N—PSD组（20．00％，P=0．022）。5、P300检查：PSD组P300检查30例出现异常（83．33％），平均潜伏期（383．14±13．20）ms，平均波幅（6．14±3．29）μV；N—PSD组检查9例出现异常（15％）平均潜伏期（342．70±15．38）ms，平均波幅（16．50±3．28）μN，两组比较差异有显著性（P〈0．05）。6、比较PSD组P300潜伏期及波幅与MMSE评分的相关性发现：P300潜伏期与MMSE评分均呈负相关关系（r=-0．881，P〈0．001），P300波幅与MMSE评分呈正相关关系（r=0．863，P〈0．001）。结论：1、PSD是脑卒中后的一种常见并发症，其发生率为37．50％左右，多发生在脑卒中后3～6个月之间，以轻度抑郁多见。2、PSD的发病可能与病灶位于左侧半球、近期出现负性生活事件、酗酒、慢性病有关。3、PSD患者常伴有认知功能受损。4、P300可为早期诊断PSD提供重要依据。

THE STUDY OF P300 AND ASSOCIATED CLINICAL FACTORS ON PATIENTS WITH POST-STROKD DEPRESSION

Objective： Post - stroke depression（PSD） is a common complication of patients with stroke. Due to the lack of objective index and criteria of detection, misdiagnosis is quite common. In order to attain the expectant purposes of climical early diagnosis and treatment the incidence of PSD, relevant factors, inaging features, cognititve impairment and event - related potential （ P300 ） changes were studied prospectivly and compared with patients with stroke without Nondepression （N- PSD）, so that explore the associated risk factors, predictable factors of and paeliogenasis PSD. Methods： Ninety six inpatients（ 82 cerebral infarction cases,12 cerebral hemorrhage cases and 2 SAH cases） with first acute stroke from March 2007 to March 2008 were selected for the study . We confirmed all the patients through CT and MRI, and recorded their lesion location and distribution. After treatment by combined therapy, their diseases got improved, all the patients were discharged from hospital, and they were followea up every month until twelve months. All the patients were classified into PSD group （36 cases）and N.- PSD team （60 cases） according to the diagnostic criteria for depression of CCMD - 3. We stated pathogenic time and clinical manifestation of PSD group, and selected possible dangerous factors to make every single factor analysis between PSD and N - PSD group, such as age, sex, educational level, smoking history, excessing drinking history, history of chronic diseases, negative life events and distribution of lesions. Factors of significant differences from above （as independent variables）and PSD （as dependent variable ） were adopted to undergo Logistic regression （Forward： Wald method ）analysis to determine the degree of their effects. When doing following -up visits, we used MMSE and P300 inspection for the two groups of patients to analyze their P300 latency, amplitude differences and MMSE score . Then we applied SPSS13.0 software to analyze these statistical data, and the difference between measurement data was decided by comparing t test or single factor analysis of variance , the difference between the numeration data was assessed by xz text, correlation analysis use spearman correlation. Results： 1, General Information：In 96 patients with stroke , there were depression in 36 cases , the morbidity was 37.50% （36/96） ,including 21 cases with mild depression（58.33% ） , 12 cases with moderate depression （33.33%） ,and 3 cases with severe depression （8.3 3 % ）. Single factor analysis indicated that excessive drinking history, negative life events, chronic diseases history were significantly different between the PSD arid N - PSD group （P 〈 0.05 ） , while age, sex, smoking, education level were without differences （ P 〉 0. 05）. The excessing drimking history, negative life events, chronic diseases history entered the Logistic regression model, the OR value was 3. 516,3. 407and 3. 987 respectively, P 〈 0.05. 2, Clinical manifestations ： Most of patients with PSD have loss of interests, It lack of pleasure, decreased energy or fatigue, low self - evaluation, self - reproach , feelings of guilt . A small number of patients have the idea of death or suicide and self - injurious behaviors . PSD happen often in three to six months after stroke（52.78% ）. 3 ,The location of lesion ： There were 27 cases of lesions in the left brain ,45 cases were in the right brain, and 24 cases were-in the two hemisphere . The incidence of PSD was highest in the left hemisphere （59.26%） ;and the second was in the right side（33.33% ）,the lowest rate was multiple loci in the two hemisphere （20.83%） （P =0.013）. 4 ,The average MMSE score of PSD Group was 20.14 ± 3.01, while N - PSD was 22.77 ± 3.77, and their difference was significant （ P 〈 0.05 ）. PSD group＇s proportion of cognitive impairment （41.67%） was significantly higher than that of N - PSD group （20.00%）, （P =0. 022）. 5, PSD group＇s P300 latency average and amplitude were 383. 14 ± 13. 20ms and 6. 14 ± 3.29μV, while those of N - PSD group were 342.70±15. 38 ms , 16. 50 ± 3. 28μV , There was a significant （ P 〈 0.05 ） difference between the two groups. The P3oo abnormal rate of PSD group was 83.33% （30/36） ,while that of N -PSD group was only 15% （9/60）. 6,PSD group＇s P300 latency and MMSE scores was negative correlation （r = - 0. 881, P 〈 0.001 ）, while P300 amplitude and the MMSE total score showed a positivel correlation （ r = 0.863,P 〈 0.001 ）. Conclusions： 1 ,PSD is a common complication. It happened often in 3 to 6 months ofter stroke Its morbidity was 37.5%, the patients have mostly mild depression. 2 ,PSD may associated with lesions located in left hemisphere of brain , the recent negative life events, alcoholism and chronic diseases. 3 ,The patients with PSD have often cognitive impairment. 4,P300 can be used as an important basis of early diagnosis of PSD.