分水岭脑梗死临床特点及早期复发的相关因素分析
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摘要
目的探讨分水岭脑梗死（CWI）的临床特点及不同责任血管引起梗死类型的差异；并分析引起CWI早期复发的相关因素。
方法收集我院经核磁共振弥散加权成像（MR-DWI）证实的急性CWI患者132例，分析其临床特点，并根据责任血管分为ICA组及MCA组，比较两组梗死类型的差异。并且随访1个月，观察其早期复发情况并对复发的相关因素分析。
结果
1、CWI的梗死类型以内分水岭梗死（ICWI）及皮质后型梗死最常见，分别为87.88%和57.85%。ICA组皮质前型及皮质前型+ICWI+皮质后型较MCA组更多见，两组差异有显著统计学意义（p=0.003及0.027）；MCA组较ICA组更易出现皮质上型及融合性病变，差异有统计学意义（p=0.042及0.036）。
2、大部分CWI患者初次卒中后临床症状相对较轻，NIHSS评分0～4分者为77.34%（99例），5～9分为19.54%（29例），≥10分患者仅为3.12%（4例）。
3、121例CWI患者随访1个月，36例复发及1例死亡，其中1周（4-7天）、2周，1个月的复发比例分别13.22%（16例），为20.66%（25例），29.75%（36例）。在复发患者中，临床症状较前明显加重，其中NIHSS评分≥10分患者比例为27.78%(10例)，预后较差。
4、卒中早期复发（CIR）相关因素分析显示不稳定斑块、基线收缩压、狭窄程度≥90%、积极降压与CIR显著正相关（p=0.032、0.009、0.019及0.038）；扩容及支架置入治疗与CIR显著负相关（p=0.047及0.044）。Logistic回归显示不稳定斑块（OR4.929，95%CI1.491-16.296，p=0.009）、基线收缩压≤140mmHg（OR2.573，95%CI0.928-7.131，p=0.069）、狭窄程度≥90%（OR6.072，95%CI2.115-17.430，p=0.001）及积极降压（OR3.840，95%CI1.418-10.400，p=0.008）是CIR的独立危险因素；而支架置入治疗（OR0.313，95%CI0.057-1.703，p=0.179）及扩容治疗（OR0.255，95%CI0.063～1.024，p=0.054）则为阻止脑梗死复发的有利因素。
5、复发后以CWI、区域性脑梗死为主要梗死类型，分别占50.00%及27.87%。
结论
1.梗死类型以ICWI及皮质后型梗死最常见；皮质前型及皮质前型+ICWI+皮质后型在ICA病变中较常见，其机制与血流动力学紊乱关系更为密切，而MCA病变更易出现皮质上型及融合性病灶，其机制可能与栓塞有关。
2.CWI首次发病一般症状较轻，但1月内复发率高；复发后，临床症状重、致残率高、预后差。
3.不稳定斑块、基线收缩压、狭窄程度≥90%、积极降压治疗是CIR的独立危险因素；支架置入治疗及扩容治疗有助于预防早期复发。
4.临床医生的对CWI早期高复发率及致残率仍存在认识及评估不足；CWI患者入院后应尽快明确病变血管及部位，并针对病因及发病机制进行个体化治疗。
Objective To investigate clinical features and the discrepancy of infarct patterns bydifferent responsible blood vessels and research early recurrence of CWI and its relatedfactors.
Methods The data of132patients of acute CWI confirmed by magnetic resonancediffusion weighted imaging (MR-DWI) were collected in our hospital and to research thecliniacal features. Thoses patients were grouped into the ICA group and the MCA groupaccording to responsibility of blood vessels and then to analyze and compare thediscrepancy of its infarction types.121patients were followed up for1month to observecerebral infarction recurrence and to find out its related factors.
Result
1. The infarction types of internal infarction watershed (ICWI) and posteriorwatershed infarction were most common in CWI and the rate was87.88%and57.85%respectively. Compared to the ICA group,the types of the anterior CWI and anterior CWI+ICWI+posterior CWI were more common in the ICA group,there was significantlystatistic discrepancy between two groups (p=0.003and0.027). But the type of cortexupper and merged lesion were more common in the MCA group, there was significantlystatistic discrepancy(p=0.042and0.036).
2. The symptoms were relatively mild in most patients after the initial stroke,theNIHSS score0～4points accounted for77.34%,5～7points19.54%and≥10points only3.125%.
3.121patiens were followed up for1month,36patients recurred and1patient wasdead,The proportion of recurrence was13.22%,20.66%,29.75%within1week,2weeksand1month respectively. The clinical symptoms aggratated obviously in these patients andthe rate of NIHSS score≥10points patients was26.92%,the prognosis is very poor.
4.The analysis of related factors of stroke early recurrence showed that unstableplaque,baseline systolic blood pressure,degree of stenosis≥90%,active antihypertensivetreatment and CIR were significantly positively correlative (p=0.032、0.009、0.019and 0.038respectively). The treatment of expansion blood volume, stent treatment and CIRwere significantly negatively correlative (p=0.047and0.044). Logistic regression diplayedthat the unstable plaque (OR4.929，95%CI1.491-16.296，p=0.009), baseline systolic bloodpressure≤140mmHg (OR2.573，95%CI0.928-7.131，p=0.069), the degree of stenosis≥90%(OR6.072，95%CI2.115-17.430，p=0.001) and antihypertensive therapy (OR3.840，95%CI1.418-10.400，p=0.008) were independent risk factors of CIR. The treatment ofexpansion blood volume（OR0.255，95%CI0.063～1.024，p=0.054） and stent treatment（OR=0.046，95%CI0.005-0.402，p=0.005）did a favorable factor to prevent CIR.
5．Regional infarct and CWI were the main infarction types after recurrence,accounting for46.15%and26.92%respectively.
conclusion
1.The ICWI and posterior CWI are most common patterns of CWI. Anterior CWI andanterior CWI+ICWI+posterior CWI are more common in ICA lesions and that meanshemodynamic compromise may play a important role. The MCA lesion are prone to cortexupper and merged lesion and its mechanisms are more prone to embolism on thefoundation of hemodynamic compromise.
2. The clinical symptoms are relatively mild in most of the CWI patients after theinitial strok, but it is easy to recure in1month.After recurrence, the symptoms turn seriousand there is a high rate of morbidity and a poor prognosis.
3. The stable plaque, baseline systolic blood pressure, degree of stenosis≥90%andactive antihypertensive treatment are independent risk factors of CIR. The treatment ofexpansion blood volume and stent treatment do a favorable factor to prevent CIR.
4．Many clinicians are still lack of knowledge and assessment about the high rate ofrecurrence and morbidity of CWI.We should make clear to responsible blood vessel andthe site of CWI as soon as possible and give their individualized treatment respectivelyaccording to the etiology and mechanism.
方法收集我院经核磁共振弥散加权成像（MR-DWI）证实的急性CWI患者132例，分析其临床特点，并根据责任血管分为ICA组及MCA组，比较两组梗死类型的差异。并且随访1个月，观察其早期复发情况并对复发的相关因素分析。
结果
1、CWI的梗死类型以内分水岭梗死（ICWI）及皮质后型梗死最常见，分别为87.88%和57.85%。ICA组皮质前型及皮质前型+ICWI+皮质后型较MCA组更多见，两组差异有显著统计学意义（p=0.003及0.027）；MCA组较ICA组更易出现皮质上型及融合性病变，差异有统计学意义（p=0.042及0.036）。
2、大部分CWI患者初次卒中后临床症状相对较轻，NIHSS评分0～4分者为77.34%（99例），5～9分为19.54%（29例），≥10分患者仅为3.12%（4例）。
3、121例CWI患者随访1个月，36例复发及1例死亡，其中1周（4-7天）、2周，1个月的复发比例分别13.22%（16例），为20.66%（25例），29.75%（36例）。在复发患者中，临床症状较前明显加重，其中NIHSS评分≥10分患者比例为27.78%(10例)，预后较差。
4、卒中早期复发（CIR）相关因素分析显示不稳定斑块、基线收缩压、狭窄程度≥90%、积极降压与CIR显著正相关（p=0.032、0.009、0.019及0.038）；扩容及支架置入治疗与CIR显著负相关（p=0.047及0.044）。Logistic回归显示不稳定斑块（OR4.929，95%CI1.491-16.296，p=0.009）、基线收缩压≤140mmHg（OR2.573，95%CI0.928-7.131，p=0.069）、狭窄程度≥90%（OR6.072，95%CI2.115-17.430，p=0.001）及积极降压（OR3.840，95%CI1.418-10.400，p=0.008）是CIR的独立危险因素；而支架置入治疗（OR0.313，95%CI0.057-1.703，p=0.179）及扩容治疗（OR0.255，95%CI0.063～1.024，p=0.054）则为阻止脑梗死复发的有利因素。
5、复发后以CWI、区域性脑梗死为主要梗死类型，分别占50.00%及27.87%。
结论
1.梗死类型以ICWI及皮质后型梗死最常见；皮质前型及皮质前型+ICWI+皮质后型在ICA病变中较常见，其机制与血流动力学紊乱关系更为密切，而MCA病变更易出现皮质上型及融合性病灶，其机制可能与栓塞有关。
2.CWI首次发病一般症状较轻，但1月内复发率高；复发后，临床症状重、致残率高、预后差。
3.不稳定斑块、基线收缩压、狭窄程度≥90%、积极降压治疗是CIR的独立危险因素；支架置入治疗及扩容治疗有助于预防早期复发。
4.临床医生的对CWI早期高复发率及致残率仍存在认识及评估不足；CWI患者入院后应尽快明确病变血管及部位，并针对病因及发病机制进行个体化治疗。
Objective To investigate clinical features and the discrepancy of infarct patterns bydifferent responsible blood vessels and research early recurrence of CWI and its relatedfactors.
Methods The data of132patients of acute CWI confirmed by magnetic resonancediffusion weighted imaging (MR-DWI) were collected in our hospital and to research thecliniacal features. Thoses patients were grouped into the ICA group and the MCA groupaccording to responsibility of blood vessels and then to analyze and compare thediscrepancy of its infarction types.121patients were followed up for1month to observecerebral infarction recurrence and to find out its related factors.
Result
1. The infarction types of internal infarction watershed (ICWI) and posteriorwatershed infarction were most common in CWI and the rate was87.88%and57.85%respectively. Compared to the ICA group,the types of the anterior CWI and anterior CWI+ICWI+posterior CWI were more common in the ICA group,there was significantlystatistic discrepancy between two groups (p=0.003and0.027). But the type of cortexupper and merged lesion were more common in the MCA group, there was significantlystatistic discrepancy(p=0.042and0.036).
2. The symptoms were relatively mild in most patients after the initial stroke,theNIHSS score0～4points accounted for77.34%,5～7points19.54%and≥10points only3.125%.
3.121patiens were followed up for1month,36patients recurred and1patient wasdead,The proportion of recurrence was13.22%,20.66%,29.75%within1week,2weeksand1month respectively. The clinical symptoms aggratated obviously in these patients andthe rate of NIHSS score≥10points patients was26.92%,the prognosis is very poor.
4.The analysis of related factors of stroke early recurrence showed that unstableplaque,baseline systolic blood pressure,degree of stenosis≥90%,active antihypertensivetreatment and CIR were significantly positively correlative (p=0.032、0.009、0.019and 0.038respectively). The treatment of expansion blood volume, stent treatment and CIRwere significantly negatively correlative (p=0.047and0.044). Logistic regression diplayedthat the unstable plaque (OR4.929，95%CI1.491-16.296，p=0.009), baseline systolic bloodpressure≤140mmHg (OR2.573，95%CI0.928-7.131，p=0.069), the degree of stenosis≥90%(OR6.072，95%CI2.115-17.430，p=0.001) and antihypertensive therapy (OR3.840，95%CI1.418-10.400，p=0.008) were independent risk factors of CIR. The treatment ofexpansion blood volume（OR0.255，95%CI0.063～1.024，p=0.054） and stent treatment（OR=0.046，95%CI0.005-0.402，p=0.005）did a favorable factor to prevent CIR.
5．Regional infarct and CWI were the main infarction types after recurrence,accounting for46.15%and26.92%respectively.
conclusion
1.The ICWI and posterior CWI are most common patterns of CWI. Anterior CWI andanterior CWI+ICWI+posterior CWI are more common in ICA lesions and that meanshemodynamic compromise may play a important role. The MCA lesion are prone to cortexupper and merged lesion and its mechanisms are more prone to embolism on thefoundation of hemodynamic compromise.
2. The clinical symptoms are relatively mild in most of the CWI patients after theinitial strok, but it is easy to recure in1month.After recurrence, the symptoms turn seriousand there is a high rate of morbidity and a poor prognosis.
3. The stable plaque, baseline systolic blood pressure, degree of stenosis≥90%andactive antihypertensive treatment are independent risk factors of CIR. The treatment ofexpansion blood volume and stent treatment do a favorable factor to prevent CIR.
4．Many clinicians are still lack of knowledge and assessment about the high rate ofrecurrence and morbidity of CWI.We should make clear to responsible blood vessel andthe site of CWI as soon as possible and give their individualized treatment respectivelyaccording to the etiology and mechanism.
引文
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