TIA与TIA形式的脑梗死的相关因素分析
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摘要
目的：分析TIA及TIA形式的脑梗死临床特点，探索其临床相关因素。
方法：回顾性分析吉林大学白求恩第二临床医院2010年1月至2012年2月期间神经内科收治的83例初步诊断为TIA并在症状首发后24小时内行常规MRI及DWI检查的患者，发病1周内行颈部动脉血管彩超、TCD和（或）头颈部CTA。记录一般危险因素、临床特征、相关检查结果及发病后7天内的临床转归。根据DWI结果分为DWI+组及DWI-组，DWI+组为DWI显示与TIA症状和体征相关的高信号责任病灶组，即为TIA形式的脑梗死组；DWI-组为DWI扫描未见高信号病灶组。确定DWI阳性率。比较DWI+组及DWI-组危险因素、临床特征及相关检查结果的差别。分析2组患者动脉粥样硬化斑块的部位、性质、数量及颅内外血管狭窄的部位、程度。所有数据采用spss13.0进行统计学处理。
结果：（1）DWI阳性率为36.1%，DWI+组30例，其中累及颈内动脉系统24例、椎-基底动脉系统6例；DWI-组53例，其中累及颈内动脉系统26例、椎-基底动脉系统27例，2组间差异有统计学意义（χ2=7.65,p=0.006）。（2）DWI+组与DWI-组相比，在年龄、性别、高血压、缺血性心脏病病史、糖尿病、心房纤颤、缺血性脑血管病病史、吸烟史、血脂及纤维蛋白原水平等方面均无统计学差异。（3）DWI+组与DWI-组相比在运动障碍、构音障碍、感觉障碍、中枢性面瘫、偏盲、单眼或双眼一过性视物不清、晕厥、复视、眩晕、共济失调、发作性跌倒、耳鸣、症状持续时间≥30分钟、DWI检查前TIA发作次数等方面均无统计学差异。（4）DWI阳性与动脉粥样硬化相关（P=0.03），与颈部动脉动脉粥样硬化斑块数目相关（P=0.04），与颈部动脉粥样硬化斑块的类型不相关（P=0.23），与颅内及颈部动脉血管中、重度狭窄程度不相关（血管彩超统计结果：P=0.99；头颈部CTA结果：P=0.41），与病变血管分布不相关（血管彩超统计结果：P=0.51，头颈部CTA结果：P=0.40）），与颈部动脉粥样硬化斑块的分布不相关。（5）TIA症状首发后7天内，30.0%DWI+组患者TIA症状反复发作或表现为临床症状持续存在，高于DWI-组（22.6%）。DWI+组中，16.7%TIA反复发作，13.3%表现为临床症状持续存在；DWI-组中，22.6%TIA反复发作，病人进展为脑梗死，两组在临床转归上有统计学差异（P=0.006）。
结论：（1）临床表现为TIA的病例大于1/3急性期DWI检查可发现阳性病灶，即已经形成了脑梗死，颈内动脉系统多于椎-基底动脉系统。（2）DWI+组与DWI-组比较在一般危险因素、临床特征等方面未见明显的统计学差异。（3）DWI阳性与动脉粥样硬化相关，动脉粥样硬化斑块数量越多，DWI阳性的可能性越大，与血管狭窄程度、动脉粥样硬化斑块的性质及病变血管分布无关。（4）DWI+对临床症状表现为TIA的病人预后具有提示作用，与是否形成临床症状持续的脑梗死具有相关性，DWI+的病人7天内更易进展。（5）传统TIA的概念不再是区分是否发生缺血性损伤的标准，更准确的标准依赖包括DWI在内的MRI检查，DWI检查对症状表现为TIA的病人必不可少。
Objective:The purpose of this study was to analyze clinical featuresbetween transient ischemic attacks and cerebral infarction displaying transientischemic attacks，to explore the relative clinical factors.
Methods:A retrospeetive analysis was performed on83patients entered inneurology department of our hospital during2010.1-2012.2who were clinicallydiagnosed as TIA.all patients underwent MRI and DWI scan<24hours aftersymptoms onset. TCD and neck arterial color dopplar ultrasound or(and) CTAwere performed within1week after symptoms onset.A detailed history of TIApatients was investigated record clinical data and results of every assistedexamination.We separate the TIA patienis to two parts：with or without DWIabnormalities,to identify the positive rate of DWI abnormalities.We comparedthe risk factors,clinical symptoms,likely etiology,assisted examinations andprognosis(7days) of the two part TIA patients. Compare the distribution,degreeof intra and extra-cranial artery stenosis,analyze the distribution,type ofatheromatous plaque.Statistical analysis were performed with the spssstatistical package(13.0),Quantitative data was analyzed by independent-sample t-test,chi-square test or rank sum test.The results were regarded assignificance when p＜0.05.
Results:(1)30out of83TIA patients (36.1%) revealed focal abno-rmalities on DWI;24out of50cases with carotid system TIA (48.0%) werefound acute ischemic lesions on DWI;6out of33cases with vertebrobasilarsystemTIA18.2%) were found acute ischemic lesions on DWI. There wasdifference between the two groups (χ2=7.65， p=0.006).（2） The risk factors:age,sex,blood pressure,history of ischemic heart disease, diabetesmellitus,atrial fibrillation,history of ischemic cerebrovascular disease,smoke,hyperlip-emia, fibrinogen,do not relate to the positive rate of DWI.(3) Theclinical features:the duration of symptoms,limb weakness, speech impairment,sensory disturbance, facial paralysis, hemianopsia, syncope, iplopia,dizziness,dystaxia, onset fall, tinnitus and the frequency of TIA before examination ofDWI do not relate to the positive rate of DWI.(4)The large arteryatherosclerosis is relate to the positive rate of DWI(p=0.03).The number ofatheromatous plaque in large artery atherosclerosis is relate to the positive rateof DWI(p=0.04).The type of atheromatous plaque is not relate to the positiverate of DWI(p=0.23).The intracranial and cervical angiostegnosis are not relateto the positive rate of DWI(color Doppler sonography:p=0.99,CTA:p=0.41).The distribution of atheromatous plaque in intracranial and cervical large arteryis not relate to the positive rate of DWI.(5) Within7days after TIAoutbreaks,The prognosis of DWI+(30.0%) is higher than DWI-(22.6)，there are5(16.7%) patients display repetitious TIA in DWI+,4(13.3%) patientsdeveloping into persisting clinical symptoms;however, there are12(22.6%)patients display repetitious TIA in DWI-,there is no patients developing intopersisting clinical symptoms,the type of ischemic cerebrovascular diseasewithin7days after TIA outbreaking displays statistical significance(p=0.006).
Conclusions:(1) More than l/3patients displaying TIA had DWIabnormalities,it has already formed the cerebral infarction,the internal carotidartery system is more than vertebrobasilar arteries system.(2) There is nostatistical significance in the risk factors,clinical symptoms between DWI+andDWI-.(3) The large artery atherosclerosis is relate to positive of DWI, the moreatheromatous plaque,the more positive frequency of DWI,The type ofatheromatous plaque,the intracranial and cervical angiostegnosis,thedistribution of atheromatous plaque in intracranial and cervical large artery are no relate to DWI+.(4) Imformations from DWI were useful in estimatingprognosis,it relates to the type of ischemic cerebrovascular disease.The patientof DWI+are more likely to develop into persisting clinical symptoms within7days.(5) Traditional definition can not distinguish whether ot not happenhistologic damage,more accurate examination depends on MRI including DWI.There is no relation in the risk factors,clinical symptoms between DWI+andDWI-.The examination of DWI is essential for TIA patients
方法：回顾性分析吉林大学白求恩第二临床医院2010年1月至2012年2月期间神经内科收治的83例初步诊断为TIA并在症状首发后24小时内行常规MRI及DWI检查的患者，发病1周内行颈部动脉血管彩超、TCD和（或）头颈部CTA。记录一般危险因素、临床特征、相关检查结果及发病后7天内的临床转归。根据DWI结果分为DWI+组及DWI-组，DWI+组为DWI显示与TIA症状和体征相关的高信号责任病灶组，即为TIA形式的脑梗死组；DWI-组为DWI扫描未见高信号病灶组。确定DWI阳性率。比较DWI+组及DWI-组危险因素、临床特征及相关检查结果的差别。分析2组患者动脉粥样硬化斑块的部位、性质、数量及颅内外血管狭窄的部位、程度。所有数据采用spss13.0进行统计学处理。
结果：（1）DWI阳性率为36.1%，DWI+组30例，其中累及颈内动脉系统24例、椎-基底动脉系统6例；DWI-组53例，其中累及颈内动脉系统26例、椎-基底动脉系统27例，2组间差异有统计学意义（χ2=7.65,p=0.006）。（2）DWI+组与DWI-组相比，在年龄、性别、高血压、缺血性心脏病病史、糖尿病、心房纤颤、缺血性脑血管病病史、吸烟史、血脂及纤维蛋白原水平等方面均无统计学差异。（3）DWI+组与DWI-组相比在运动障碍、构音障碍、感觉障碍、中枢性面瘫、偏盲、单眼或双眼一过性视物不清、晕厥、复视、眩晕、共济失调、发作性跌倒、耳鸣、症状持续时间≥30分钟、DWI检查前TIA发作次数等方面均无统计学差异。（4）DWI阳性与动脉粥样硬化相关（P=0.03），与颈部动脉动脉粥样硬化斑块数目相关（P=0.04），与颈部动脉粥样硬化斑块的类型不相关（P=0.23），与颅内及颈部动脉血管中、重度狭窄程度不相关（血管彩超统计结果：P=0.99；头颈部CTA结果：P=0.41），与病变血管分布不相关（血管彩超统计结果：P=0.51，头颈部CTA结果：P=0.40）），与颈部动脉粥样硬化斑块的分布不相关。（5）TIA症状首发后7天内，30.0%DWI+组患者TIA症状反复发作或表现为临床症状持续存在，高于DWI-组（22.6%）。DWI+组中，16.7%TIA反复发作，13.3%表现为临床症状持续存在；DWI-组中，22.6%TIA反复发作，病人进展为脑梗死，两组在临床转归上有统计学差异（P=0.006）。
结论：（1）临床表现为TIA的病例大于1/3急性期DWI检查可发现阳性病灶，即已经形成了脑梗死，颈内动脉系统多于椎-基底动脉系统。（2）DWI+组与DWI-组比较在一般危险因素、临床特征等方面未见明显的统计学差异。（3）DWI阳性与动脉粥样硬化相关，动脉粥样硬化斑块数量越多，DWI阳性的可能性越大，与血管狭窄程度、动脉粥样硬化斑块的性质及病变血管分布无关。（4）DWI+对临床症状表现为TIA的病人预后具有提示作用，与是否形成临床症状持续的脑梗死具有相关性，DWI+的病人7天内更易进展。（5）传统TIA的概念不再是区分是否发生缺血性损伤的标准，更准确的标准依赖包括DWI在内的MRI检查，DWI检查对症状表现为TIA的病人必不可少。
Objective:The purpose of this study was to analyze clinical featuresbetween transient ischemic attacks and cerebral infarction displaying transientischemic attacks，to explore the relative clinical factors.
Methods:A retrospeetive analysis was performed on83patients entered inneurology department of our hospital during2010.1-2012.2who were clinicallydiagnosed as TIA.all patients underwent MRI and DWI scan<24hours aftersymptoms onset. TCD and neck arterial color dopplar ultrasound or(and) CTAwere performed within1week after symptoms onset.A detailed history of TIApatients was investigated record clinical data and results of every assistedexamination.We separate the TIA patienis to two parts：with or without DWIabnormalities,to identify the positive rate of DWI abnormalities.We comparedthe risk factors,clinical symptoms,likely etiology,assisted examinations andprognosis(7days) of the two part TIA patients. Compare the distribution,degreeof intra and extra-cranial artery stenosis,analyze the distribution,type ofatheromatous plaque.Statistical analysis were performed with the spssstatistical package(13.0),Quantitative data was analyzed by independent-sample t-test,chi-square test or rank sum test.The results were regarded assignificance when p＜0.05.
Results:(1)30out of83TIA patients (36.1%) revealed focal abno-rmalities on DWI;24out of50cases with carotid system TIA (48.0%) werefound acute ischemic lesions on DWI;6out of33cases with vertebrobasilarsystemTIA18.2%) were found acute ischemic lesions on DWI. There wasdifference between the two groups (χ2=7.65， p=0.006).（2） The risk factors:age,sex,blood pressure,history of ischemic heart disease, diabetesmellitus,atrial fibrillation,history of ischemic cerebrovascular disease,smoke,hyperlip-emia, fibrinogen,do not relate to the positive rate of DWI.(3) Theclinical features:the duration of symptoms,limb weakness, speech impairment,sensory disturbance, facial paralysis, hemianopsia, syncope, iplopia,dizziness,dystaxia, onset fall, tinnitus and the frequency of TIA before examination ofDWI do not relate to the positive rate of DWI.(4)The large arteryatherosclerosis is relate to the positive rate of DWI(p=0.03).The number ofatheromatous plaque in large artery atherosclerosis is relate to the positive rateof DWI(p=0.04).The type of atheromatous plaque is not relate to the positiverate of DWI(p=0.23).The intracranial and cervical angiostegnosis are not relateto the positive rate of DWI(color Doppler sonography:p=0.99,CTA:p=0.41).The distribution of atheromatous plaque in intracranial and cervical large arteryis not relate to the positive rate of DWI.(5) Within7days after TIAoutbreaks,The prognosis of DWI+(30.0%) is higher than DWI-(22.6)，there are5(16.7%) patients display repetitious TIA in DWI+,4(13.3%) patientsdeveloping into persisting clinical symptoms;however, there are12(22.6%)patients display repetitious TIA in DWI-,there is no patients developing intopersisting clinical symptoms,the type of ischemic cerebrovascular diseasewithin7days after TIA outbreaking displays statistical significance(p=0.006).
Conclusions:(1) More than l/3patients displaying TIA had DWIabnormalities,it has already formed the cerebral infarction,the internal carotidartery system is more than vertebrobasilar arteries system.(2) There is nostatistical significance in the risk factors,clinical symptoms between DWI+andDWI-.(3) The large artery atherosclerosis is relate to positive of DWI, the moreatheromatous plaque,the more positive frequency of DWI,The type ofatheromatous plaque,the intracranial and cervical angiostegnosis,thedistribution of atheromatous plaque in intracranial and cervical large artery are no relate to DWI+.(4) Imformations from DWI were useful in estimatingprognosis,it relates to the type of ischemic cerebrovascular disease.The patientof DWI+are more likely to develop into persisting clinical symptoms within7days.(5) Traditional definition can not distinguish whether ot not happenhistologic damage,more accurate examination depends on MRI including DWI.There is no relation in the risk factors,clinical symptoms between DWI+andDWI-.The examination of DWI is essential for TIA patients
引文
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[16] Fisher MC.Intermittent cerebral ischemia.In:Wright IS,Millikan CH.Cerebral vascular disease.New York,NY:Grune&Stratton,1958:81-97.
[17] Siekert RG,Whisnant JP,eds.Cerebral vascular diseases:fourth conference
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[21] Evans GW,Howard G,Murros KE,et al.Cerebral infarctionverified bycranial computed tomography and prognosis forsurvival following trans-ient ischemic attack.Stroke.1991;22(4):431-436.
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[24]王宝军,李美琳,王建利,等.弥散成像和血液灌注成像核磁共振诊断急性缺血性脑血管病的意义.中华神经内科杂志.1999;32(5):265-268.
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[34] Mauriello A,Sangiorgi G,Palmieri G,et al.Hyper fibrinogenemia isassociated with specific histocytological composition and complications ofatherosclerotic carotid plaques in patients affected by transient ischemicattacks.Circulation,2000,101(7):744.
[35]吴卫文,徐军.血脂及纤维蛋白原水平与短暂性脑缺血发作的关系.中国临床医学.2008;15(4),478-9.
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[40] Nandalur KR,Baskurt E,Hagspiel KD,et al.Calcified caroti athero-sclerotic plaque is associated less with ischemic symptoms than isnoncalcified plaque on MDCT.AJR.2005;184(1):295-298.
[41] Tong Tong,Yao Zhenwei,Feng Xiaoyuan.Combined diffusion-andperfusion-weighted imaging: a new way for the assessment of hemispherictransient ischemic attack patients.Neurosci.2011;29(1):63-9.
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[44] Ay H,Koroshetz WJ,Benner T,et al.Transient Ischemic with Infaction:AUnigue Syndrome[J].Ann Neurol.2005;57:679-686.
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[1]赵冬.我国人群脑卒中发病率和死亡率的流行病学研究.中华流行病学杂志.2003;24(3):236-239.
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[4] Adeoye O,Heitsch L,Moomaw CJ,et al.How Much Would PerformingDiffusion-Weighted Imaging for All Transient Ischemic Attacks IncreaseMRI Utilization?.Stroke,2010;41(10):2218-2222.
[5] Adam Wallis,Tim Saunders.Imaging transient ischaemic attack withdiffuseon weighted magnetic resonance imaging.BMJ,2010,340:1113-5.
[6] Purroy F,Begué R,Gil MI,et al.Patterns of diffusion-weighted magneticresonance imaging associated with etiology improve the accuracy ofprognosis after transient ischaemic attack.Eur J Neurol.2011,18(1):121-8.
[7] Prabhakaran S,Lee VH.Does diffusion-weighted imaging in transientischemic attack patients improve accuracy of diagnosis,prognosis,or both?.Stroke,2009,40:408.
[8] Prabhakaran S,Chong JY,Sacco RL.Impact of abnormal diffusion-weightedimaging results on short-term outcome following transient ischemic attack.Arch Neurol.2007;64:1105–1109.
[9] Calvet D,Lamy C,Touze E,et al.Management and outcome of patients withtransient ischemic attack admitted to a stroke unit.Cerebrovasc Dis2007;24:80-85.
[10] Crisostomo RA,Garcia MM,Tong DC.Detection of diffusion weightedMRI abnormalities in patients with transient ischemic attack:correlationwith clinical characteristics.Stroke,2003;34:932.
[11] Josephson SA,Bryant SO,Mak HK,et al.Evaluation of carotid stenosisusing CT angiography in the initial evaluation of stroke and TIA.Neurology,2004;63(3):457-460.
[12]赵玉霞,刘运芳,张梅,等.声学密度定量技术检测动脉粥样斑块的临床研究.中国超声医学杂志.2002;8(10):762-764.
[13]Brain silver著.戴永萍,刘春风译.颈动脉超声.国外医学脑血管疾病分册,2005,13(2):157.
[14]张致身.人体血管解剖与临床第二版.北京:科技文献出版社,2004;99-183.
[15] Beneficial effect of carotid endarterectomy in symptomatic patients withhigh grade carotid stenosis North American Symptomatic Carotid Endarte-rectomy Trial Collaorators.N Engl J Med,1991;325(7):445-453.
[16] Fisher MC.Intermittent cerebral ischemia.In:Wright IS,Millikan CH.Cerebral vascular disease.New York,NY:Grune&Stratton,1958:81-97.
[17] Siekert RG,Whisnant JP,eds.Cerebral vascular diseases:fourth conference
[C].New York:Grune&Stratton,1965.
[18] Ad Hoc Committee on Cerebrovascular Diseases.Aclassification andoutline of cerebrovascular diseases.II.Stroke.1975;6(5):564-616.
[19] Kidwell CS,Alger JR,Di Salle F,et al.Diffusion MRI in patients withtransient ischemic attacks.Stroke.1999;30(6):1174-1180.
[20] Rovira A,Rovira Gols A,Pedraza S,et al.Diffusion weighted MR imagingin the acute phase of transient ischemic attacks.AJNR Am J Neuroradiol2002,23(1):77-83.
[21] Evans GW,Howard G,Murros KE,et al.Cerebral infarctionverified bycranial computed tomography and prognosis forsurvival following trans-ient ischemic attack.Stroke.1991;22(4):431-436.
[22] Albers GW,Caplan LR,Easton JD,et al.Transient ischemic attack proposalfor a new definition.N Engl J Med.2002;347(21):1713-1716.
[23] Easton JD,Saver JL,Albers GW,et al.Definition and evaluation of transientischemic attack:a scientific statement for healthcare professionals from theAmerican Heart Association/American Stroke Association Stroke Council;Council on Cardiovascular Surgery and Anesthesia;Council on Card-iovascular Radiology and Intervention;Council on Cardiovascular Nursing;and the Interdisciplinary Council on Peripheral Vascular Disease.TheAmerican Academy of Neurology affirms the value of this statement as aneducational tool for neurologist.Stroke.2009;40(6):2276-2293.
[24]王宝军,李美琳,王建利,等.弥散成像和血液灌注成像核磁共振诊断急性缺血性脑血管病的意义.中华神经内科杂志.1999;32(5):265-268.
[25] Warach S,Boska M,Weleh KM.Pitfalls and Potential of clinical diffusion-weighted MR imaging in acute stroke.Stroke.1997;28:481.
[26] Jeffrey L,Kidwell C.Neuroimaging in TIAs.Neurology.2004;62(Suppl6):22-25.
[27] Olivot JM,MlynashM,ThijsVN,et al.Relationships between cerebralperfusion and reversibility of acute diffusion lesions in DEFUSE:Insightsfrom RADAR.Stroke.2009;40:1692-1697.
[28] Kranz PG,Eastwood JD.Does diffusion-weighted imaging represent theischemic core?An evidence-based systematic review.Am JNeuroradiol.2009;30:1206-1209.
[29] Sitburana O,KoroshetzWJ.Magnetic resonance imaging: Implicationinacute ischemic strokemanagement.Current Atherosclerosis Reports.2005;7:305-312.
[30] Ringer TM,Neumann Haefelin T,Sobel RA,et al.Reversal of earlydiffusion-weighted magnetic resonance imaging abnormalities does notnecessarily reflect tissue salvage in experimental cerebral ischemia.Stroke.2001;32:2362-2369.
[31] Redgrave JN,Coutts SB,Schulz UG,et al.Systematic review of associationsbetween the presence of acute ischemic lesions on diffusion-weightedimaging and clinical predictors of early stroke risk after transient ischemicattack.Stroke,2007,38:1482-1488.
[32] Jessica NE,Shelagh B,UrsulaG.Systematic review of associations betweenthe presence ofacute ischemic lesionson diffusion-weighted imaging andclinicalpredictors ofearly stroke risk after transient in transient ischemicattack.Stroke.2007;38:1428-1488.
[33] KimuraK,MinematsuK,WadaK,et.al.Lesions visualized by contrastenhanced magnetic resonance imaging in transient ischemic attacks.NeurolSci.2000;173:103-108.
[34] Mauriello A,Sangiorgi G,Palmieri G,et al.Hyper fibrinogenemia isassociated with specific histocytological composition and complications ofatherosclerotic carotid plaques in patients affected by transient ischemicattacks.Circulation,2000,101(7):744.
[35]吴卫文,徐军.血脂及纤维蛋白原水平与短暂性脑缺血发作的关系.中国临床医学.2008;15(4),478-9.
[36] Lamy C,Oppenheim C,CalvetD,et al.Diffusion-weighted MR imaging intransient ischemic attacks.Eur Radiol.2006;16:1090-1095.
[37] InatomiY,KimuraK.YoneharaT,et al.DWI abnormalities and eliniealeharaeteristics in TIA Patients.Neurology.2O04;62:376-380.
[38] Hollingworth W,Nathens AB,Kanne JP,et al.The diagnosisa ccuracy ofcomputed tomography angiography for traumatic or atherosclerotic lesionsof the carotid and vertebral arteries: a systematic review.Eur JRadiol.2003;48(1):88-102.
[39] Mckinney AM,Casey SO,Teksam M,et al.Carotid bifurcation calcium andcorrelation with percent stenosis of the internal carotid artery on CTangiography.Neuroradiology.2005;47(1):1-9.
[40] Nandalur KR,Baskurt E,Hagspiel KD,et al.Calcified caroti athero-sclerotic plaque is associated less with ischemic symptoms than isnoncalcified plaque on MDCT.AJR.2005;184(1):295-298.
[41] Tong Tong,Yao Zhenwei,Feng Xiaoyuan.Combined diffusion-andperfusion-weighted imaging: a new way for the assessment of hemispherictransient ischemic attack patients.Neurosci.2011;29(1):63-9.
[42] Hjort N,Christensen S,Solling C,et al.Ischemic injury detected by diffusionimaging11minutes after stroke.Ann Neurol2005;58:462–465.
[43] Engelter ST,Wetzel SG,Bonati LH,et al.The clinical signiicance ofdiffusion-weighted MR imaging in stroke and TIA patients.Swiss MedicalWeekly.2008;138(49-50):729-740.
[44] Ay H,Koroshetz WJ,Benner T,et al.Transient Ischemic with Infaction:AUnigue Syndrome[J].Ann Neurol.2005;57:679-686.