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隐匿性脑梗死和多血管床病变相关性研究

2019-03-15 02:29:38

柯博熙 陆蓉 陈秋月

[摘要] 目的 研究隐匿性脑梗死(SCI)和多血管床病变(PolyVD)的相关性,为识别脑梗死高危人群提供依据。 方法 纳入2015年2月~2016年6月入住台州市中心医院神经内科的患者,95例被确诊为首次隐匿性脑梗死的患者作为脑梗死组,95例同期头晕、头痛而经头颅MRI证实无梗死灶者作为对照组。检测外周动脉区(颈动脉、锁骨下动脉、下肢动脉)及冠状动脉、颅内动脉,比较各个区域血管床病变情况。 结果 两组患者在性别、年龄、烟酒史及高血压病史、糖尿病史、冠心病史、血脂基线水平等方面差异无统计学意义(P>0.05)。检测外周血管区(颈动脉、锁骨下动脉、下肢动脉)及冠状动脉、颅内动脉,相应动脉病变检出率,脑梗死组分别为65.3%、24.2%、33.7%,21.1%、32.6%,对照组分别为49.5%、17.9%、25.3%、15.8%、24.2%,其中脑梗死组颈动脉斑块检出率高于对照组,差异有统计学意义(χ2=4.842,P=0.028)。两组病变血管检出条数率分别为35.4%、27.4%,脑梗死组高于对照组,差异有统计学差异(χ2=8.689,P=0.003)。外周动脉、冠状动脉、颅内动脉的三个区域,两组1个区域发生动脉粥样硬化病变分别是37.9%、72.6%,存在2个区域血管病变分别为47.4%、22.1%,存在3个区域血管病变分别为14.7%、5.3%,两组病变区域比较,差异有统计学意义(Z=4.761,P=0.000<0.01)。兩组PolyVD发生率分别为62.1%、27.4%,差异有统计学意义(χ2=23.183,P=0.000<0.01)。 结论 PolyVD和SCI存在相关性,是脑卒中的危险因素,病变血管越多,导致卒中的风险大。

[关键词] 脑梗死;多血管床;外周动脉;冠状动脉

[中图分类号] R743.3;R766 [文献标识码] A [文章编号] 1673-9701(2016)33-0008-04

[Abstract] Objective To study the correlation between silent cerebral infarction(SCI) and polyvascular disease(PolyVD), and to provide evidence for identifying high risk population of cerebral infarction. Methods From February 2015 to June 2016, patients admitted to Department of Neurology, the Central Hospital of Taizhou City were enrolled in this study. Among them, 95 patients who were diagnosed as first SCI were enrolled in the cerebral infarction group, 95 patients with dizziness and headache while had no cerebral infarction confirmed by head MRI were enrolled in the control group. Peripheral arterial areas(carotid artery, subclavian artery, lower extremity artery), coronary artery and intracranial artery were examined, the vascular bed lesions were compared in each region. Results There were no significant differences in sex, age, history of alcohol and tobacco, hypertension, diabetes mellitus, coronary heart disease and blood lipid baseline level between the two groups(P>0.05). The detection rate of cerebral arteries was 65.3%, 24.2%, 33.7%, 21.1% and 32.6% respectively in the peripheral arterial areas (carotid artery, subclavian artery, lower extremity artery), coronary artery and intracranial artery,while the control group was 49.5%, 17.9%, 25.3%, 15.8%, 24.2% respectively, in which, the carotid plaque detected was significantly higher in the cerebral infarction group than that in the control group, the difference was statistically significant(χ2=4.842, P=0.028). The ratio of the number of blood vessels detected in the two groups were 35.4% and 27.4%, respectively, which was higher in the cerebral infarction group than the control group, the difference between the two groups was statistically significant(χ2=8.689, P=0.003). The incidence of one atherosclerotic lesion occured in the three regions of peripheral artery, coronary artery and intracranial artery between the two groups was 37.9% and 72.6%, while the incidence of two lesions occurred was 47.4% and 22.1%, respectively, the incidence of three lesions occurred was 14.7% and 5.3%, respectively, showed statistically significant differences between the two groups(Z=4.761, P=0.000<0.01). The incidence of PolyVD in the two groups was 62.1% and 27.4%, respectively. There was significant difference between the two groups(χ2=23.183, P=0.000<0.01). Conclusion There is a correlation between PolyVD and SCI, and it is an risk factor for stroke. The more vascular lesions, the greater the risk of stroke.

[Key words] Cerebral infarction; Polyvascular; Peripheral artery; Coronary artery

脑血管病已居我国疾病死亡率首位,脑梗死具有高发病率、高死亡率和高致残率[1]。其中,隐匿性脑梗死(silent cerebral infarction,SCI)或称无症状性脑梗死,是指经头颅磁共振成像(MRI)等检查发现脑梗死,而在临床上无明显相应的神经系统缺损症状和体征,或表现轻微容易被忽视,列在2015年脑血管病分类中。SCI是非致残性卒中,如何针对病因精准有效干预,尤其是多血管床病变(polyvascular disease,PolyVD),成为新的研究课题。动脉粥样硬化是全身性疾病,是脑梗死发生、发展的重要病因,被认为是预测脑卒中发生的主要危险因素[2]。PolyVD指临床确认的2~3处动脉区域,主要表现为脑血管病(cerebrovascular disease,CVD)、冠心病(coronary artery disease,CAD)、外周动脉疾病(peripheral arterial disease,PAD)[3]。本研究探討SCI和PolyVD是否相关,为预测脑梗死高危人群提供依据。

1 资料与方法

1.1一般资料

脑梗死组:纳入2015年2月~2016年6月入住台州市中心医院神经内科患者,95例为首次确诊SCI患者,通过头颅MRI确诊。纳入标准:依据全国第4届脑血管会议提出的脑梗死的诊断标准[4]。排除标准:①出血性脑梗死;②动脉炎致脑梗死;③有明确栓子来源如心房颤动、风湿性心脏病、脂肪栓塞等所致脑梗死;④血液成分改变导致的脑梗死;⑤ 肿瘤、全身免疫性疾病;⑥有脑卒中史。对照组:纳入95例同期头晕头痛而经头颅MRI证实无梗死灶者。试验方案经伦理学委员会批准,研究对象签署知情同意书。

1.2观察指标

所有入选患者均行头颅MRI+MRA/或CTA,颈动脉(包括椎动脉)、锁骨下动脉、下肢动脉彩超,冠脉CTA(心电图、心超异常患者),心电图,心超,TCD及肝肾功能、心肌酶、血糖、血脂等检查。详细记录入组患者的临床资料,包括年龄、性别、高血压病、糖尿病、冠心病、吸烟、饮酒史等资料。

1.3仪器与方法

(1)颈动脉、下肢动脉彩超采用GE logic E9多普勒血流显像仪,锁骨下动脉采用德国DWL Doppler-BoX经颅多普勒血流分析仪,颅内动脉、冠状动脉通过GE1.5 TMR、宝石HD750CT(64)检测。检查内容包括血管形态、内膜厚度、斑块回声性质、管腔狭窄程度等。局限性内中膜厚度≥1.5 mm并突入管腔定义为动脉硬化斑块形成,血管狭窄率≥50%定义为血管狭窄。

(2)患者入院后取静脉血送检总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、血常规、凝血功能、心肌酶谱、血糖、肝肾功能等。检验仪器为西门子进口全自动化仪。

1.4 统计学方法

采用SPSS 23.0软件对数据进行统计分析,满足正态性的计量资料用均数±标准差(x±s)表示,比较采用独立样本t检验;不满足正态性的采用Mann-Whitney U检验;计数资料比较采用χ2检验,P<0.05表示差异有统计学意义。

2 结果

2.1 两组基线资料比较

两组各纳入95例,一般资料如表1所示,两组患者在性别、年龄、烟酒史及高血压病史、糖尿病史、冠心病史、血脂基线水平方面差异无统计学意义(P>0.05)。无症状性脑梗死组中,前循环系统68例(占71.6%)、后循环系统27例(占28.4%)。

2.2两组动脉斑块检出率及分布比较

检测外周血管区(颈动脉、锁骨下动脉、下肢动脉)及冠状动脉、颅内动脉,脑梗死组动脉病变检出率分别为65.3%、24.2%、33.7%,21.1%、32.6%(n/95),高于对照组动脉病变检出率相对应的49.5%、17.9%、25.3%、15.8%、24.2%(n/95),脑梗死组颈动脉斑块检出率高于对照组,差异有统计学意义(χ2=4.842,P=0.028)。脑梗死组血管病变检出条数率高于对照组:35.4%(168/475) vs 27.4%(126/475),差异有统计学意义(χ2=8.689,P=0.003),(表2)。同时,脑梗死组合并PAD高于对照组,24.6% vs 18.5%(P<0.05)。

2.3 两组多血管床病变区域比较

脑梗死组和对照组影像学检查发现,存在CVD或PAD或CAD其中1个区域发生动脉粥样硬化病变分别是37.9%、72.6%,两组存在2个区域血管动脉粥样硬化病变为47.4%、22.1%,两组存在3个区域血管动脉粥样硬化病变为14.7%、5.3%。两组血管床病变区域比较,差异有统计学意义(Z=4.761,P=0.000<0.01),可以认为脑梗死组存在PolyVD高于对照组。见表3。

2.4 两组多血管床病变发生率比较

根据PolyVD定义,两组PolyVD发生率分别为62.1%(59/95)、27.4%(26/95),差异具有高度统计学意义(χ2=23.183,P=0.000<0.01),可以认为脑梗死组的PolyVD发生率显著高于对照组。

3 讨论

脑卒中病因一直是研究重点,从著名的TOAST分型,到最新的中国缺血性卒中亚型(CISS分型),大动脉粥样硬化均是主要类型[5]。在伴有脑血管、冠状动脉血管疾病史,或周围动脉疾病患者,高水平的LDL-C等导致动脉硬化使主要心血管事件风险增加[6]。动脉粥样硬化血栓是导致脑梗死、冠心病及外周动脉疾病发生的直接原因[7]。Maeda H等[8]研究认为微血管内皮功能障碍也与PolyVD的存在显著相关。国外大量流行病学研究证实,动脉粥样硬化患者存在多血管床损伤现象。而PolyVD和发病最高的脑心梗死的关系,成为研究重点。SCI作为非致残性卒中,因临床症状、体征不明显,容易被忽视,诊断依赖于头颅MRI弥散成像(DWI)。国外的研究表明,SCI的诊断率仅占脑梗死的18%[9],是一个很大的患者群体。

本研究取95例SCI患者作为脑梗死组,取同期95例非脑梗死患者作为对照组,研究SCI和PolyVD的相关性。两组一般资料的基线水平差异无统计学意义,共检测PAD、CAD、CVD主要的血管,发现脑梗死组的病变血管占检测血管的比例(35.4%)高于对照组(26.5%),差异具有统计学意义(χ2=8.689,P=0.003)。全球性大样本多中心的REACH研究,发现40%的脑血管病患者合并冠心病或外周动脉疾病[10],和本研究得出47.4% SCI患者合并其他血管区病变的结论基本相仿。Bhatt DL等[11]随访4年发现PolyVD可增加缺血事件再发风险,并得出PolyVD是缺血再发的强独立的预测因素,本研究两组PolyVD发生率分别为62.1%、27.4%,差异具有统计学意义(χ2=23.183,P=0.000<0.01),可以认为脑梗死组的PolyVD发生率显著高于对照组,存在相关性。Lee WH等[12]台湾回顾性队列研究显示,血管床病变部分越多,卒中风险越高。本研究对脑梗死组和对照组PolyVD区域的比较,发现两组存在2个区域血管动脉粥样硬化病变为47.4%、22.1%,两組存在3个区域血管动脉粥样硬化病变为14.7%、5.3%,差异具有统计学意义(Z=4.761,P<0.01),可认为脑梗死组存在PolyVD高于对照组,且越多血管区域病变,发生脑卒中风险越大。Subherwal S等[13]进行大型队列分析发现,PAD的缺血性事件风险显著增加,本研究也发现脑梗死组伴PAD高于对照组(24.6% vs 18.5%,P<0.05)。2013年美国心脏病学会将卒中、冠心病及外周动脉疾病等归于一个大的概念:动脉粥样硬化性心脏病(ASCVD)[14]。Yang X等[15]研究有效工具对中国人口进行10年ASCVD风险预测,将有助于改善心血管疾病的初级预防和管理。另有国外的研究,PolyVD合并患有心肌梗死(包括NSTEMI和STEMI),静息踝臂指数(ABI)是一个简单有用的测量工具,能预测这些患者的广泛的动脉粥样硬化[16],建议下肢动脉疾病患者均应检查ABI。颈动脉斑块和脑梗死关系密切[17],另外有研究[18]认为,颈动脉内中膜增厚与早期慢性肾病有关,肾脏功能障碍的早期检测是非常重要的动脉粥样硬化疾病的危险分层。van Kruijsdijk RC等[19]研究,有明显的血管疾病如脑卒中患者,在心血管疾病和癌症的死亡率风险增加。Abtan J等[20]研究,心肌梗死后患者随访4年,再发缺血性风险包括脑卒中逐渐增加,强调制定有价值的二级预防策略,以尽量减少心脑血管再发风险。

基于以上研究,本文得出这样结论:PolyVD和SCI存在相关性,是脑卒中的危险因素,对于脑卒中的发生有重要作用,并且病变血管越多导致卒中的风险越大。对脑血管病一级、二级预防患者,临床医生需关注PolyVD,有助于为脑卒中高危人群的识别提供依据,控制SCI复发风险。

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(收稿日期:2016-08-20)

标签: 动脉 研究进展 统计学

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