脑白质疏松和陈旧性腔隙性脑梗死对首发缺血性卒中患者预后的影响

摘要/Abstract

摘要：

目的探讨脑白质疏松和陈旧性腔隙性脑梗死对于首发缺血性卒中患者预后的影响。方法连续选取791例7 d以内首次发病的非心源性缺血性卒中患者。收集患者的人口学信息和脑血管病的危险因素，评价患者的头颅磁共振成像包括脑白质疏松的严重程度、无症状性腔隙性脑梗死的数量、缺血性卒中的病因分型以及急性梗死灶的分布特征，通过多因素Logistic回归分析脑白质疏松和陈旧性腔隙性脑梗死与缺血性卒中患者预后相关的危险因素。结果分别有14例（1.8%）、38例（4.8%）患者在缺血性卒中发病1年内死亡、缺血性卒中或短暂性脑缺血发作（transient ischemic attack，TIA）复发。多元Logistic回归发现：存在陈旧性腔隙性脑梗死、有皮层新发脑梗死灶、入院后未给予抗血小板药物、出院时未服用他汀药物是缺血性卒中患者1年内死亡的危险因素；而脑白质疏松对于缺血性卒中患者1年内的死亡无显著影响。冠状动脉粥样硬化性心脏病、入院美国国立卫生研究院卒中量表（National Institute of Health stroke scale，NIHSS）评分<4 分、新发梗死灶的责任脑动脉闭塞或狭窄程度≥70%、出院时未给予抗血小板药物是缺血性卒中患者1年内缺血性卒中或TIA复发的危险因素；而脑白质疏松和陈旧性腔隙性脑梗死对于缺血性卒中患者1年内缺血性卒中或TIA的复发无显著影响。结论陈旧性腔隙性脑梗死是缺血性卒中患者1年内死亡的危险因素。而脑白质疏松和陈旧性腔隙性脑梗死对于缺血性卒中患者1年内缺血性卒中或TIA的复发无显著影响。

文章导读： 本研究发现陈旧性腔隙性脑梗死是缺血性卒中患者1年内死亡的危险因素。而脑白质疏松和陈旧性腔隙性脑梗死对于缺血性卒中患者1年内缺血性卒中或短暂性脑缺血发作的复发无显著影响。

关键词: 脑白质疏松; 陈旧性腔隙性脑梗死; 缺血性卒中; 危险因素

Abstract:

Objective To investigate the relationship between cerebral small vessel disease and the outcome of ischemic stroke. Methods Overall, 791 patients within 7 days of their first-ever non-cardiogenicischemic stroke were enrolled consecutively. Demographic information, vascular risk factors were recorded. We evaluated cranial magnetic resonance imaging includingseverity of leukoaraiosis, number of silent lacunar infarction(SLI), etiologic subtype of ischemic stroke, and topographic patterns of acute cerebral infarcts. Factors associated with the outcome of ischemic stroke were analyzed. Results A total of 14 patients (1.8%) died, and 38 patients (4.8%) developed recurrence of ischemic stroke or transient ischemic attack(TIA) in one year after stroke onset. In multivariable logistic regression analysis, presence of SLI, and presence of acute cortical cerebral infarction, without antithromboticsat admission, without statins at discharge were predictors of death in one year, while leukoaraiosis had no influence on death in one year.Coronary heart disease,admission National Institute of Health stroke scale <4, responsible artery stenosis ≥70%, and without antithrombotics at discharge were risk factors associated with recurrence of ischemic stroke or TIA in 1 year, while leukoaraiosisand SLI had no impacts on recurrence of ischemic stroke or TIA in 1 year.Conclusion Presence of SLI werepredictors of death at one year after stroke. However, leukoaraiosis and SLI had no influence on the recurrence of ischemic stroke or TIA in 1 year.

Key words: Leukoaraiosis; Silent lacunar infarction; Ischemic stroke; Risk factors

张长青，王伊龙，王春雪，赵性泉，王拥军. 脑白质疏松和陈旧性腔隙性脑梗死对首发缺血性卒中患者预后的影响[J]. 中国卒中杂志, 2015, 10(11): 923-929.

ZHANG Chang-Qing, WANG Yi-Long, WANG Chun-Xue, et al.. Relationship between Cerebral Small Vessel Disease and Outcome of Ischemic Stroke[J]. Chinese Journal of Stroke, 2015, 10(11): 923-929.

参考文献

1 Gioia LC, Tollard E, Dubuc V, et al. Silent ischemic

lesions in young adults with first stroke are associated

with recurrent stroke[J]. Neurology, 2012, 79:1208-1214.

2 Putaala J, Haapaniemi E, Kurkinen M, et al. Silent

brain infarcts, leukoaraiosis, and long-term prognosis

in young ischemic stroke patients[J]. Neurology, 2011,

76:1742-1749.

3 Weber R, Weimar C, Wanke I, et al. Risk of recurrent

stroke in patients with silent brain infarction in the

Prevention Regimen for Effectively Avoiding Second

Strokes (PRoFESS) imaging substudy[J]. Stroke, 2012,

43:350-355.

4 Rouhl RP, van Oostenbrugge RJ, Knottnerus IL, et al.

Virchow-Robin spaces relate to cerebral small vessel

disease severity[J]. J Neurol, 2008, 255:692-696.

5 Zhu YC, Dufouil C, Tzourio C, et al. Silent brain

infarcts:a review of MRI diagnostic criteria[J]. Stroke,

2011, 42:1140-1145.

6 Fazekas F, Chawluk JB, Alavi A, et al. MR signal

abnormalities at 1.5T in Alzheimer's dementia

and normal aging[J]. AJR Am J Roentgenol, 1987,

149:351-356.

7 Zhang C, Li Z, Wang Y, et al. Risk factors of cerebral

microbleeds in strictly deep or lobar brain regions

differed[J]. J Stroke Cerebrovasc Dis, 2015, 24:24-30.

8 Ay H, Furie KL, Singhal A, et al. An evidence-based

causative classification system for acute ischemic

stroke[J]. Ann Neurol, 2005, 58:688-697.

9 D'Amore C, Paciaroni M. Border-zone and watershed

infarctions[J]. Front Neurol Neurosci, 2012, 30:181-184.

10 Momjian-Mayor I, Baron JC. The pathophysiology

of watershed infarction in internal carotid artery

disease:review of cerebral perfusion studies[J]. Stroke,

2005, 36:567-577.

11 Szabo K, Kern R, Gass A, et al. Acute stroke patterns

in patients with internal carotid artery disease:a

diffusion-weighted magnetic resonance imaging

study[J]. Stroke, 2001, 32:1323-1329.

12 Ois A, Gomis M, Rodriguez-Campello A, et al.

Factors associated with a high risk of recurrence

in patients with transient ischemic attack or minor

stroke[J]. Stroke, 2008, 39:1717-1721.

13 Conijn MM, Kloppenborg RP, Algra A, et al. Cerebral

small vessel disease and risk of death, ischemic

stroke, and cardiac complications in patients with

atherosclerotic disease:the Second Manifestations of

表4 缺血性卒中患者发病1年内脑梗死或TIA复发相关因素的

多因素Logistic回归结果

变量P值调整后的OR（95%CI）

年龄≥65岁0.826 0.908（0.383～2.152）

男性0.745 1.183（0.429～3.260）

以前或现在吸烟0.925 0.955（0.367～2.484）

大量饮酒0.763 0.781（0.157～3.891）

高血压0.841 0.913（0.374～2.227）

糖尿病0.113 0.502（0.214～1.176）

高脂血症0.583 1.313（0.497～3.470）

冠状动脉粥样硬化性心脏病0.011 3.845（1.356～10.90）

有脑出血病史0.126 5.731（0.611～53.77）

有脑白质疏松0.883 0.882（0.167～4.666）

Fazekas评分≥3分0.981 0.989（0.415～2.358）

有陈旧性腔梗0.532 0.542（0.079～3.710）

陈旧性腔梗的数量分级0.506 1.604（0.398～6.459）

入院NIHSS评分<4分<0.0001 5.757（2.446～13.55）

小动脉闭塞性卒中* 0.640 0.642（0.101～4.105）

梗死灶责任脑动脉闭塞或狭窄程度70% 0.042 5.873（1.065～32.38）

新发梗死灶为多发0.191 2.167（0.680～6.901）

有流域性脑梗死0.070 0.298（0.081～1.103）

有皮层小的梗死灶0.362 2.381（0.369～15.36）

有皮层新发梗死灶0.162 0.271（0.044～-1.685）

有分水岭梗死0.306 2.315（0.464～11.55）

有内分水岭梗死0.225 0.424（0.106～1.698）

有前皮层分水岭梗死0.437 1.592（0.493～5.139）

有后皮层分水岭梗死0.074 0.319（0.091～1.118）

出院时未给予抗血小板药物0.039 3.165（1.058～9.469）

出院时口服他汀药物0.268 0.594（0.237～1.491）

注：*：相对大动脉粥样硬化性卒中。NIHSS：美国国立卫生研究院卒中量表；TIA：短

暂性脑缺血发作；OR ：比值比；CI：可信区间

参考文献

1 Gioia LC, Tollard E, Dubuc V, et al. Silent ischemic

lesions in young adults with first stroke are associated

with recurrent stroke[J]. Neurology, 2012, 79:1208-1214.

2 Putaala J, Haapaniemi E, Kurkinen M, et al. Silent

brain infarcts, leukoaraiosis, and long-term prognosis

in young ischemic stroke patients[J]. Neurology, 2011,

76:1742-1749.

3 Weber R, Weimar C, Wanke I, et al. Risk of recurrent

stroke in patients with silent brain infarction in the

Prevention Regimen for Effectively Avoiding Second

Strokes (PRoFESS) imaging substudy[J]. Stroke, 2012,

43:350-355.

4 Rouhl RP, van Oostenbrugge RJ, Knottnerus IL, et al.

Virchow-Robin spaces relate to cerebral small vessel

disease severity[J]. J Neurol, 2008, 255:692-696.

5 Zhu YC, Dufouil C, Tzourio C, et al. Silent brain

infarcts:a review of MRI diagnostic criteria[J]. Stroke,

2011, 42:1140-1145.

6 Fazekas F, Chawluk JB, Alavi A, et al. MR signal

abnormalities at 1.5T in Alzheimer's dementia

and normal aging[J]. AJR Am J Roentgenol, 1987,

149:351-356.

7 Zhang C, Li Z, Wang Y, et al. Risk factors of cerebral

microbleeds in strictly deep or lobar brain regions

differed[J]. J Stroke Cerebrovasc Dis, 2015, 24:24-30.

8 Ay H, Furie KL, Singhal A, et al. An evidence-based

causative classification system for acute ischemic

stroke[J]. Ann Neurol, 2005, 58:688-697.

9 D'Amore C, Paciaroni M. Border-zone and watershed

infarctions[J]. Front Neurol Neurosci, 2012, 30:181-184.

10 Momjian-Mayor I, Baron JC. The pathophysiology

of watershed infarction in internal carotid artery

disease:review of cerebral perfusion studies[J]. Stroke,

2005, 36:567-577.

11 Szabo K, Kern R, Gass A, et al. Acute stroke patterns

in patients with internal carotid artery disease:a

diffusion-weighted magnetic resonance imaging

study[J]. Stroke, 2001, 32:1323-1329.

12 Ois A, Gomis M, Rodriguez-Campello A, et al.

Factors associated with a high risk of recurrence

in patients with transient ischemic attack or minor

stroke[J]. Stroke, 2008, 39:1717-1721.

13 Conijn MM, Kloppenborg RP, Algra A, et al. Cerebral

small vessel disease and risk of death, ischemic

stroke, and cardiac complications in patients with

atherosclerotic disease:the Second Manifestations of

ART erial disease-Magnetic Resonance (SMART-MR)

study[J]. Stroke, 2011, 42:3105-3109.

14 Ong CT, Sung KC, Sung SF, et al. Impact of silent

infarction on the outcome of stroke patients[J]. J Formos

Med Assoc, 2009, 108:224-230.

15 Jorgensen HS, Nakayama H, Raaschou HO, et al.

Leukoaraiosis in stroke patients. The Copenhagen

Stroke Study[J]. Stroke, 1995, 26:588-592.

16 Podgorska A, Hier DB, Pytlewski A, et al. Leukoaraiosis

and stroke outcome[J]. J Stroke Cerebrovasc Dis,

2002, 11:336-340.

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