非手术指征颈动脉斑块患者缺血性脑卒中的危险因素分析
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摘要
目的:探讨颈动脉狭窄≤50%的颈动脉斑块患者的MRI斑块特征及临床因素与发生缺血性脑卒中的关系。方法:选取2014年9月—2016年2月超声筛选颈动脉狭窄≤50%的颈动脉斑块患者43例,所有患者行核磁共振黑血成像检查,分析MRI斑块特征及其他危险因素与缺血性脑卒中的关系。结果:43例患者的颈动脉斑块狭窄程度5%～50%,随访时间1.9～19.4个月。随访期间发现脑梗死患者共4例。单因素与多因素Logistic回归分析结果显示,仅MRI的斑块内出血与缺血性脑卒中的发生有明显关系(OR=297.797,95%CI=2.638～33620,P=0.018),而其他斑块特征及临床因素均无明显关系(均P>0.05)。Kaplan-Meier生存分析显示,有斑块内出血者较无斑块内出血者的中位无脑卒中时间明显缩短(14.3个月vs. 18.6个月,P=0.001);有冠心病者较无冠心病者的中位无脑卒中时间也明显缩短(12.1个月vs. 18.7个月,P=0.029);Cox回归分析显示,斑块内出血(HR=18.2,95%CI=2.7～123.3,P=0.003)及冠心病(HR=27.4,95%CI=1.6～464.3,P=0.022)是缺血性脑卒中发生的独立危险因素。结论:在颈动脉狭窄≤50%的颈动脉斑块患者中,斑块内出血与冠心病是缺血性卒中的发生密切相关。
Objective: To investigate the relations of carotid plaque characteristics of MRI and clinical factors with ischemic stroke in patients with carotid artery stenosis≤50%. Methods: From September 2014 to February 2016, a total of 43 patients with carotid artery stenosis ≤50% were selected by ultrasound screening. All patients underwent the black-blood MRI examination. The relations of the plaque MRI characteristics and other risk factors with ischemic stroke were analyzed.Results: In the 43 patients, the degree of carotid artery stenosis ranged from 5% to 50%, and the follow-up time ranged from 1.9 to 19.4 months. During the follow-up period, ipsilateral ischemic stroke occurred in 4 patients. The results of univariate and multivariate Logistic regression analysis showed that only the intra-plaque hemorrhage(IPH) was significantly associated with ischemic stroke(OR=297.797, 95% CI=2.638–33620, P=0.018), while other MRI features and clinical factors were irrelevant to ischemic stroke(all P>0.05). Kaplan-Meier survival analysis showed that the mean ischemic stroke-free time in patients with IPH was significantly shorter than that in patients without IPH(14.3 months vs. 18.6 months, P=0.001), and in patients with coronary heart disease(CHD) was significantly shorter than that in patients without CHD(12.1 months vs. 18.7 months, P=0.029); Cox regression analysis showed that IPH(HR=18.2, 95% CI=2.7–123.3, P=0.003) and CHD(HR=27.4; 95% CI=1.6–464.3; P=0.022) were independent risk factors for ischemic stroke.Conclusion: In patients with carotid artery stenosis ≤50%, IPH and CHD are closely associated with the occurrence of ischemic stroke.
Objective: To investigate the relations of carotid plaque characteristics of MRI and clinical factors with ischemic stroke in patients with carotid artery stenosis≤50%. Methods: From September 2014 to February 2016, a total of 43 patients with carotid artery stenosis ≤50% were selected by ultrasound screening. All patients underwent the black-blood MRI examination. The relations of the plaque MRI characteristics and other risk factors with ischemic stroke were analyzed.Results: In the 43 patients, the degree of carotid artery stenosis ranged from 5% to 50%, and the follow-up time ranged from 1.9 to 19.4 months. During the follow-up period, ipsilateral ischemic stroke occurred in 4 patients. The results of univariate and multivariate Logistic regression analysis showed that only the intra-plaque hemorrhage(IPH) was significantly associated with ischemic stroke(OR=297.797, 95% CI=2.638–33620, P=0.018), while other MRI features and clinical factors were irrelevant to ischemic stroke(all P>0.05). Kaplan-Meier survival analysis showed that the mean ischemic stroke-free time in patients with IPH was significantly shorter than that in patients without IPH(14.3 months vs. 18.6 months, P=0.001), and in patients with coronary heart disease(CHD) was significantly shorter than that in patients without CHD(12.1 months vs. 18.7 months, P=0.029); Cox regression analysis showed that IPH(HR=18.2, 95% CI=2.7–123.3, P=0.003) and CHD(HR=27.4; 95% CI=1.6–464.3; P=0.022) were independent risk factors for ischemic stroke.Conclusion: In patients with carotid artery stenosis ≤50%, IPH and CHD are closely associated with the occurrence of ischemic stroke.
引文
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[2]赵冬.我国人群脑卒中发病率、死亡率的流行病学研究[J].中华流行病学杂志,2003,24(3):236-239.doi:10.3760/j.issn:0254-6450.2003.03.020.Zhao D.Epidemiologic study of morbidity and mortality of stroke in Chinese population[J].Chinese Journal of Epidemiology,2003,24(3):236-239.doi:10.3760/j.issn:0254-6450.2003.03.020.
[3]North American Symptomatic Carotid Endarterectomy Trial Collaborators1,Barnett HJM,Taylor DW,et al.Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis[J].N Engl J Med,1991,325(7):445-453.doi:10.1056/NEJM199108153250701.
[4]缪东培,吕磊,殷宇刚,等.老年人颈动脉粥样硬化与缺血性脑梗死关系的初步分析[J].国际脑血管病杂志,2008,16(1):17-20.doi:10.3760/cma.j.issn.1673-4165.2008.01.005.Miao DP,Lu L,Yin YG,et al.Relationship between carotid artery athorosclerosis and ischemic cerebral infarction in the elderly a preliminary analysis[J].International Journal of Cerebrovascular Diseases,2008,16(1):17-20.doi:10.3760/cma.j.issn.1673-4165.2008.01.005.
[5]谢坚,章成国,邵燕.血脂、颈动脉粥样硬化与缺血性脑血管病的关系[J].中华脑血管病杂志:电子版,2008,2(4):250-253.doi:10.3969/j.issn.1672-9248.2008.04.001.Xie J,Zhang CG,Shao Y.Relationship between lipid,carotid artherosclerosis and ischemic cerebrovascular disease[J].Chinese Journal of Cerebrovascular Diseases:Electronic Edition,2008,2(4):250-253.doi:10.3969/j.issn.1672-9248.2008.04.001.
[6]曹茂红,柯开富,周冉冉,等.脑梗死患者颈动脉斑块与相关因素分析[J].中华老年心脑血管病杂志,2011,13(1):62-64.doi:10.3969/j.issn.1009-0126.2011.01.021.Cao MH,Ke KF,Zhou RR,et al.Analysis of carotic plaque and correlative factors in patients with cerebral infarction[J].Chinese Journal of Geriatric Heart Brain and Vessel Diseases,2011,13(1):62-64.doi:10.3969/j.issn.1009-0126.2011.01.021.
[7]Rerkasem K,Rothwell PM.Temporal trends in the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis:an updated systematic review[J].Eur J Vasc Endovasc Surg,2009,37(5):504-511.doi:10.1016/j.ejvs.2009.01.011.
[8]Alqadri SL,Qureshi AI.Treatment of symptomatic carotid stenosis:carotid stent placement versus endarterectomy[J].Curr Atheroscler Rep,2013,15(8):345.doi:10.1007/s11883-013-0345-5.
[9]Brott TG,Hobson RW 2nd,Howard G,et al.Stenting versus endarterectomy for treatment of carotid-artery stenosis[J].N Engl JMed,2010,363(1):11-23.doi:10.1056/NEJMoa0912321.
[10]Ricotta JJ,Aburahma A,Ascher E,et al.Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease[J].J Vasc Surg,2011,54(3):832-836.doi:10.1016/j.jvs.2011.07.004.
[11]Brinjikji W,Huston J 3rd,Rabinstein AA,et al.Contemporary carotid imaging:from degree of stenosis to plaque vulnerability[J].J Neurosurg,2016,124(1):27-42.doi:10.3171/2015.1.JNS142452.
[12]Cremonesi A,Castriota F,Secco GG,et al.Carotid artery stenting:an update[J].Eur Heart J,2015,36(1):13-21.doi:10.1093/eurheartj/ehu446.
[13]孙岩,张十一,刘洋,等.颅外段颈动脉狭窄的手术治疗[J].中国普通外科杂志,2011,20(12):1383-1385.Sun Y,Zhang SY,Liu Y,et al.Surgical treatment of extracranial carotid stenosis[J].Chinese Journal of General Surgery,2011,20(12):1383-1385.
[14]李红英.颈动脉易损斑块MRI表现与缺血性脑卒中的风险预测[J].磁共振成像,2016,7(1):16-19.doi:10.12015/issn.1674-8034.2016.01.004.Li HY.MRI appearances of carotid vulnerable plaques and prediction of the risk of ischemic stroke[J].Chinese Journal of Magnetic Resonance Imaging,2016,7(1):16-19.doi:10.12015/issn.1674-8034.2016.01.004.
[15]Fuster V,Stein B,Ambrose JA,et al.Atherosclerotic plaque rupture and thrombosis.Evolving concepts[J].Circulation,1990,82(3Suppl):II47-59.
[16]Watanabe Y,Nagayama M,Suga T,et al.Characterization of atherosclerotic plaque of carotid arteries with histopathological correlation:vascular wall MR imaging vs.color Doppler ultrasonography(US)[J].J Magn Reson Imaging,2008,28(2):478-485.doi:10.1002/jmri.21250.
[17]Huibers A,de Borst GJ,Bulbulia R,et al.Plaque Echolucency and the Risk of Ischaemic Stroke in Patients with Asymptomatic Carotid Stenosis Within the First Asymptomatic Carotid Surgery Trial(ACST-1)[J].Eur J Vasc Endovasc Surg,2016,51(5):616-621.doi:10.1016/j.ejvs.2015.11.013.
[18]Yi XY,Liao DX,Wang C,et al.Cytochrome P450 Genetic Variants and Their Metabolite Levels Associated with Plaque Stability in Patients with Ischemic Stroke[J].J Atheroscler Thromb,2016,23(3):330-338.doi:10.5551/jat.31120.
[19]Mathiesen EB,B?naa KH,Joakimsen O.Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis:the troms?study[J].Circulation,2001,103(17):2171-2175.
[20]Owolabi MO,Akpa OM,Agunloye AM.Carotid IMT is more associated with stroke than risk calculators[J].Acta Neurol Scand,2016,133(6):442-450.doi:10.1111/ane.12482.
[21]Nakamura T,Tsutsumi Y,Shimizu Y,et al.Ulcerated carotid plaques with ultrasonic echolucency are causatively associated with thromboembolic cerebrovascular events[J].J Stroke Cerebrovasc Dis,2013,22(2):93-99.doi:10.1016/j.jstrokecerebrovasd is.2011.06.015.
[22]Meletta R,Borel N,Stolzmann P,et al.Ex vivo differential phase contrast and magnetic resonance imaging for characterization of human carotid atherosclerotic plaques[J].Int J Cardiovasc Imaging,2015,31(7):1425-1434.doi:10.1007/s10554-015-0706-y.
[23]Altaf N,Daniels L,Morgan PS,et al.Detection of intraplaque hemorrhage by magnetic resonance imaging in symptomatic patients with mild to moderate carotid stenosis predicts recurrent neurological events[J].J Vasc Surg,2008,47(2):337-342.doi:10.1016/j.jvs.2007.09.064.
[24]Takaya N,Yuan C,Chu B,et al.Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events:a prospective assessment with MRI--initial results[J].Stroke,2006,37(3):818-823.DOI:10.1161/01.STR.0000204638.91099.91
[25]林凯,张兆琪,吕飚,等.颈动脉壁易损斑块与再发缺血性脑卒中间隔时间关系的磁共振研究[J].中国医学影像技术,2006,22(3):372-376.doi:10.3321/j.issn:1003-3289.2006.03.015.Lin K,Zhang ZQ,Lu S,et al.Vulnerable lesion correlates to accelerated recurrence of cerebral infarction:carotid MR imaging study[J].Chinese Journal of Medical Imaging Technology,2006,22(3):372-376.doi:10.3321/j.issn:1003-3289.2006.03.015.
[26]王嵇,赵辉林,曹烨,等.磁共振测定颈动脉粥样硬化特征与急性脑梗死的关系[J].放射学实践,2012,27(12):1320-1323.doi:10.3969/j.issn.1000-0313.2012.12.012.Wang J,Zhao HL,Cao Y,et al.Association of carotid atherosclerotic plaque characteristics determined by magnetic resonance imaging with acute ischemic stroke[J].Radiologic Practice,2012,27(12):1320-1323.doi:10.3969/j.issn.1000-0313.2012.12.012.
[27]罗南,刘一,范占明.MRI评估颈动脉粥样硬化斑块成分、类型及其与临床症状的相关性[J].中华临床医师杂志:电子版,2013,7(23):10519-10524.doi:10.3877/cma.j.issn.1674-0785.2013.23.032.Luo N,Liu Y,Fan ZM.To evaluate the composition and typing of carotid artery atherosclerotic plaque and the relationship between plaque morphology and clinical symptoms[J].Chinese Journal of Clinicians:Electronic Edition,2013,7(23):10519-10524.doi:10.3877/cma.j.issn.1674-0785.2013.23.032.
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