急性缺血性卒中患者血管性认知障碍及其亚型的相关因素分析

摘要/Abstract

摘要：

目的探讨急性缺血性卒中患者血管性认知障碍（vascular cognitive impairment，VCI）及其亚型非痴呆性血管性认知障碍（VCI -no dementia，VCIND）与血管性痴呆（vascular dementia，VaD）发生的主要相关因素。方法选择2014年6月至2015年6月就诊于天津医科大学总医院神经内科的491例急性缺血性卒中患者为研究对象，应用前期已建立的血管性认知障碍数据库记录患者的一般人口学信息、病史、体格检查、血管危险因素、生化及影像检查信息，对患者进行美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）评分、Essen评分及低分子肝素治疗急性卒中试验（the Trial of Org 10172 in Acute Stroke Treatment，TOAST）分型，于发病（10±2）d进行蒙特利尔认知量表（Montreal Cognitive Assessment，MoCA）、临床痴呆量表（Clinical Dementia Rating，CDR）、日常生活能力量表（Activities of Daily Living，ADL）评分，依据血管性认知障碍诊治指南中VCI的诊断及分类诊断标准将患者分为认知正常组（no cognitive impairment，NCI）和VCI组，VCI组包括VCIND组和VaD组，分析上述各项因素的组间差异及相关性。结果 491例急性缺血性卒中患者中VCI占69.86%，其中包括37.68%的VCI ND和32.18%的VaD 患者。①VCI 组低受教育程度（P ＜0.001）、糖尿病（P =0.005）、心脏病（P =0.045）、卒中家族史（P =0.005）、幕上病变（P＜0.001）的比例及卒中次数（P =0.014）、D-二聚体水平（P =0.001）、Essen 评分（P =0.024）、NIHSS评分（P＜0.001）显著高于NCI组，女性（P =0.004）、幕下病变（P＜0.001）的比例及受教育年（P＜0.001）显著低于NCI组，差异均有显著性；Logistic回归分析显示低受教育程度、糖尿病、幕上病变和高D-二聚体水平是VCI的独立危险因素。②与VCIND组比较，VaD组患者既往卒中史（P =0.013）、TOAST分型中大动脉粥样硬化型梗死（P＜0.001）的比例及卒中次数（P =0.001）、Essen评分（P =0.032）、神经功能缺损程度（P =0.005）显著高于VCIND组，TOAST分型中小动脉闭塞型梗死（P ＜0.001）、幕下病变（P＜0.001）的比例显著低于VCIND组，差异均有显著性；Logistic回归分析显示卒中次数、神经功能缺损程度、大动脉粥样硬化型梗死是VaD的独立危险因素，而幕下病变患者发生VaD 的风险明显小于幕上病变患者。结论 VCI及其亚型的影响因素不同，与NCI比较，低受教育程度、糖尿病、幕上病变和高D-二聚体水平是VCI的独立危险因素；与VCIND比较，卒中次数、严重的神经功能缺损、TOAST分型中大动脉粥样硬化型梗死是VaD的独立危险因素。

文章导读： 本研究显示急性缺血性卒中患者血管性认知障碍及其亚型的危险因素不同，并从卒中病因、复发、生化检查等多方面进行了分析，不同阶段需不同角度针对性的干预。

关键词: 血管性认知障碍; 缺血性卒中; 非痴呆性血管性认知障碍; 血管性痴呆; 危险因素

Abstract:

Objective To investigate the major correlation factors of vascular cognitive impairment (VCI) and its subtypes including VCI-no dementia (VCIND) and vascular dementia (VaD). Methods A total of 491 patients with acute ischemic stroke admitted in Neurology Department of Tianjin Medical University General Hospital during June 2014 to June 2015 were recruited in this study. General demographic information, medical history, physical examination, vascular risk

factors, laboratory and image data recorded in our previously established VCI database were used to assess. The National Institutes of Health Stroke Scale (NIHSS) scores, mechanism of ischemic stroke (the Trial of Org 10 172 in Acute Stroke Treatment, TOAST), Essen scores, Montreal Cognitive Assessment (MoCA), Clinical Dementia Rating (CDR), and Activities of Daily Living (ADL) after (10±2) days of stroke. Recruited patients were divided into VCI group and no cognitive impairment (NCI) group according to the Guide for Diagnosis and Treatment of VCI. Patients with VCI comprised of those with VCIND and VaD. Inter-group differences and correlations of factors mentioned above were analyzed. Results Among 491 cases of patients with acute ischemic stroke, VCI accounted for 69.86% which was composed of 37.68% of VCIND and 32.18% of VaD. (1) Comparing to NCI group, patients with VCI were more likely to have higher low-educational status (P <0.001), diabetes (P =0.005), heart disease (P =0.045), family history of stroke (P =0.005), supratentorial stroke (P <0.001), stroke frequency (P =0.014), higher Essen scores (P =0.024), stroke severity (NIHSS) scores (P <0.001) and D-Dimer level (P =0.001), lower proportion of female (P =0.004) and subtentorial stroke (P <0.001), and less education year (P <0.001), which had significant differences. Logistic regression analysis showed that lower educational status, diabetes, supratentorial stroke, higher D-Dimer level were independent risk factors for VCI. (2) In VaD group, the proportion of prior stroke (P =0.013), TOAST subtype large artery atherosclerotic cerebral infarction (P <0.001) and stroke frequency (P =0.001), Essen scores (P =0.032), stroke severity (NIHSS) scores (P =0.005) were significantly higher than those in VCIND group. Frequency of small-vessel occlusion (lacune) and infratentorial stroke (P <0.001) and proportation of subtentorial stroke (P <0.001) in VCIND were lower than VaD group, which had significant differences. Logistic regression analysis showed that stroke frequency, stroke severity (NIHSS) scores and large artery atherosclerotic cerebral infarction were independent risk factors for VaD. The risk of VaD in patients with infratentorial stroke was obviously lower than supratentorial stroke patients. Conclusion Compared to NCI group, the influential factors for VCI and its subtypes differ. Low educational status, diabetes, supratentorial stroke, higher D-Dimer level were independent risk factors for VCI. Compared to VCIND group, stroke frequency, stroke severity (NIHSS) scores and large artery atherosclerotic cerebral infarction were found to be the risk factors of VaD.

Key words: Vascular cognitive impairment; Ischemic stroke; Vascular cognitive impairment-no dementia; Vascular dementia; Risk factors

曾瑞，李春芳，刘蕾，杜宁，张轩，陈书丽，薛蓉. 急性缺血性卒中患者血管性认知障碍及其亚型的相关因素分析[J]. 中国卒中杂志, 2016, 11(04): 255-261.

ZENG Rui, LI Chun-Fang, LIU Lei, et al.. Correlation Factors Analysis of Vascular Cognitive Impairment and Its Subtypes of Acute Ischemic Stroke Patients[J]. Chinese Journal of Stroke, 2016, 11(04): 255-261.

参考文献

1 中华医学会神经病学分会痴呆与认知障碍学组写作

组. 血管性认知障碍诊治指南[J]. 中华神经科杂志，

2011，44：142-147.

2 Moorhouse P，Rockwood K. Vascular cognitive

impai rme nt：cu r rent concept s and cl ini cal

developments[J]. Lancet Neurol，2008，7：246-255.

3 吴逊. 全国第四届脑血管病学术会议纪要[J]. 卒中与

神经疾病，1997，4：51-55.

4 Mellon L，Brewer L，Hall P，et al. Cognitive impairment

six months after ischaemic stroke：a profile from the

ASPIRE-S study[J]. BMC Neurol，2015，15：31.

5 Qu Y，Zhuo L，Li N，et al. Prevalence of post-stroke

cognitive impairment in China：A communitybased，

cross-sectional study[J]. PLoS One，2015，10：

e122864.

6 Kh e d r EM，Hamed SA，El -She r e ef HK，e t

al. Cognitive impairment after cerebrovascular

stroke：Relationship to vascular risk factors[J].

Neuropsychiatr Dis Treat，2009，5：103-116.

7 Sachdev PS，Brodaty H，Valenzuela MJ，et al.

Clinical determinants of dementia and mild cognitive

impairment following ischaemic stroke：The Sydney

Stroke Study[J]. Dement Geriatr Cogn Disord，2006，

21：275-283.

8 Chaudhari TS，Verma R，Garg RK，et al. Clinicoradiological

predictors of vascular cognitive

impai rment (VCI ) in pat ient s with st roke：A

prospective observational study[J]. J Neurol Sci，2014，

340：150-158.

9 Ighodaro ET，Abner EL，Fardo DW，et al. Risk

factors and global cognitive status related to brain

arteriolosclerosis in elderly individuals[J]. J Cereb

Blood Flow metab，2016. [Epub ahead of print].

10 Tu Q，Ding B，Yang X，et al. The current situation on

vascular cognitive impairment after ischemic stroke in

Changsha[J]. Arch Gerontol Geriatr，2014，58：236-247.

11 Wardlaw JM，Smith C，Dichgans M. Mechanisms of

sporadic cerebral small vessel disease：insights from

neuroimaging[J]. Lancet Neurol，2013，12：483-497.

12 Gong L，Liu XY，Fang M. Recent progress on small

vessel disease with cognitive impairment[J]. Int J Clin

Exp Med，2015，8：7701-7709.

13 Psychogios K，Stathopoulos P，Takis K，et al. The

pathophysiological mechanism is an independent

predictor of long-term outcome in stroke patients with

large vessel atherosclerosis[J]. J Stroke Cerebrovasc

Dis，2015，24：2580-2587.

14 孟霞，王伊龙，赵性泉，等. Essen评分在TIA、缺血性

小卒中与大卒中患者中预测效度的比较[J]. 中国卒中

杂志，2014：486-492.

15 Ince B，Bayram C，Harmanci H，et al. Hemostatic

marker s i n ischemic st roke of undetermined

etiology[J]. Thromb Res，1999，96：169-174.

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