缺血性卒中的中医证型与全脑血管造影所见血管病变特点的相关性研究
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摘要
脑卒中是威胁人类生命最常见的神经系统疾病,是我国成人死亡的第二位致死疾病,具有发病率、死亡率、致残率、复发率高等特点。尤以缺血性脑卒中的危害最常见。尽管缺血性脑卒中多为非致命性,但是致残率很高,严重危害人类的健康和生存质量。根据世界卫生组织(WHO)报道,1999年,全世界因中风死亡的人数达到554万,其中2／3发生在欠发达国家。缺血性卒中的形成机制尚未完全阐明,但有研究表明,缺血性脑卒中的发生、发展与颅内外血管狭窄关系密切,认为颅内外大动脉狭窄和闭塞是重要因素之一,颅内、外动脉不稳定粥样斑块脱落造成的血管事件也可直接导致缺血性卒中,而严重的颅内、外血管狭窄本身也可使患者易于因血流动力学变化而出现梗死或脑缺血的表现。在以往的治疗中只注重对症治疗,而忽视对病因的诊断及处理,从而导致缺血性卒中的高复发率。随着各种神经血管影像诊断技术和介入治疗技术的发展,目前,认为全脑血管造影(DSA)是诊断血管狭窄与闭塞的金标准。DSA检查能直观表现血管走行、血流状态,准确测量血管内径,明确患者狭窄的部位、程度、侧支循环的形成情况等。大大提高了诊断的准确性,对完善诊断及下一步的治疗提供直观的信息。DSA技术的应用,明显提高了脑部血管疾病检出率,对临床选择治疗方案起关键的指导作用。
本课题通过对缺血性卒中患者进行全脑血管造影所见血管病变特点进行观察和血管狭窄的统计,意在探讨血管病变特点与缺血性卒中的中医证型的相关性,为缺血性卒中的中医辨证分型的微观化提供了有利依据,从而进一步指导临床对缺血性卒中开展有效地中医辨证施治。同时通过一系列相关研究,再次证实了有关缺血性卒中与血管狭窄的程度和部位的相关研究。
方法：参照国家中医药管理局脑病急症科研协作组起草制订的《中风病诊断疗效评定标准》(试行1995年)和1995年中华医学会第四届全国脑血管会议修订的诊断标准《各类脑血管疾病诊断要点》。将120例缺血性卒中患者,共分七个证型,痰热腑实型8例、风痰瘀阻型35例、痰湿蒙神型11例、风痰火亢型20例、气虚血瘀型16例、风火上扰型18例、阴虚风动型12例。通过全脑血管造影术明确了120例患者血管病变的部位和程度。所有数据均在计算机上采用SPSS进行数据的录入、管理和统计。X2检验(计数资料)。检验水准。取0.05,采用双侧检验。
结果：
1 120例缺血性卒中患者,中医证型所占比例由大到小依次为：风痰瘀阻>风痰火亢>风火上扰>气虚血瘀>阴虚风动>痰湿蒙神>痰热腑实。
2 120例缺血性卒中患者,中医证型与前、后循环的梗死有显著的统计学意义,p<0.05(0.005)。
3 120例缺血性卒中患者血管病变支数所占比例由大到小依次为：单支病变>多支病变>双支病变。
4 120例缺血性卒中患者血管病变部位与血管狭窄程度有显著统计学意义,p<0.05。
5 120例缺血性卒中患者中医证型与前、后循环系统病变血管分布没有显著统计学差异,P>0.05。
6各中医证型人均受累血管支数所占比例由大到小依次为：阴虚风动>痰热腑实>风痰瘀阻>痰湿蒙神>风火上扰>气虚血瘀>风痰火亢。
结论：
1风火上扰型的缺血性卒中患者多数出现后循环梗死,气虚血瘀型和痰热腑实型的缺血性卒中患者多数出现前循环梗死。
2前循环病变发生缺血性卒中时血管狭窄程度多数较轻,即相对血管狭窄严重的患者较少,而后循环系统恰好相反。
3缺血性卒中患者中医证型与病变血管分布没有显著统计学差异。可能是由于样本量较小,检验效能不足所致。但我们可看出,痰热腑实型缺血性卒中血管病变多发生在前循环。
4缺血性卒中患者中医证型与血管狭窄程度之间无显著统计学差异,但我们可看出,痰热腑实型的血管病变多处于轻度-中度狭窄,而气虚血瘀型的血管病变多处于重度-闭塞之间。
Stroke, is the most familiar nervous system disease of threatening human health, which is the second causing death the disease in adults in our country, with the high incidence of a disease, high death rate, high rate of cause to incomplete, and high recur rate Particularly, Cerebral Infarction (CI) is the most frequently. Though CI is not truculence, it threatens human health and exist the quantity, seriously, with the high rate of cause to incomplete according to the World Health Organization (WHO) report, in 1999, the number of death from suffering stroke is 5,540,000 in whole world, among them 2/3 take place to developing country. Formation mechanism of CI has not yet clarify completely, but the research enunciations, the occurrence, development of CI has closes with blood vessel narrow outside and inside of skull, thinking it is one of the important factors that main artery stricture and obstruct outside and inside of skull, the unsteady artery atherosclerosis block breaks off outside and inside of skull, which causes CI directly. it is easy to appear CI or lack of blood because of the blood stream dynamics changes, When blood vessel is narrow outside and inside of skull.In the former treatment, only paying attention to curing disease, but neglecting to diagnosis and handle of the cause of disease, which causing high recur rate of CI. With development of the technique in every kind of nerve blood vessel image and intervention cure, at present, digital subtraction angiography (DSA) is being as the gold standard in diagnosing blood vessel narrow and occlusive. The check of DSA can observes blood vessel frankly, blood state, and accurately measure diameter of blood vessel, and definitude the narrow part and the narrow degree of blood vessel and the growth state of the branch circulation, which increases consumedly diagnostic accuracy, and offers the information of the view to perfect diagnoses and the next treatment. digital subtraction angiography (DSA) has increased the rate of masculine of The brain blood vessel obviously, offered good terrace for intervention cure.
Our study, by digital subtraction angiography (DSA) to CI sufferers, it can be observed blood vessel configuration characteristics and the part of pathological changes, by which to observe and stat blood vessel narrow, to investigate the dependability between blood vessel configuration characteristics and different patterns of CI syndromes in traditional-Chinese medicine, to provide evidence for the subdivision of differentiation of symptoms and signs for classification of syndrome of CI in traditional-Chinese medicine, So the clinical determination of treatment based on differentiation of symptoms and signs can be better guaranteed. At the same time, a series of study again approves that these relevant studys of CI and blood vessel narrow degree and the part between domestic and international.
Method:According to the national Chinese medicine management bureau brain disease and acute disease scientific research cooperation draft out and make《stroke disease diagnosis curative effect and assessed standard》(try in 1995) and ((Treating Practice and standards revised)) by C.M.A (Chinese medical association) in its fourth national CVD(Cardiovascular Disease) academic conference in 1995. we divided 120 cases of patients with CI into, divided into seven certificates type:Phlegm-Heat and Fu-organ Constipation 8 case,Wind Phlegm and Blood-Stasis 35 case, Phlegm wet and trouble consciousness 11 case, Wind Phlegm and fire up stirring 20 case, Deficiency of Vital Energy and Blood Stasis 16 cases, up stirring of Wind-Fire 18 cases, and stirring of wind due to deficiency of YIN 12 cases respectively. Passing the DSA, it definitudes the part and degree of 1 pathological changes in 120 sufferers.
All data is inputted into computer, managed and processed by SPSS. X2-test (numeration data). Two-sided test(Size of test a=0.05) is applied.
Result:
1 120 cases of patients with CI, the comparison of Chinese medicine certificate type from big to small:Wind Phlegm and Blood-Stasis> Wind Phlegm and fire up stirring> up stirring of Wind-Fire> Deficiency of Vital Energy and Blood Stasis> stirring of wind due to deficiency of YIN> Phlegm wet and trouble consciousness> Phlegm-Heat and Fu-organ Constipation.
2 120 cases of patients with CI, CI of former and after circlation has statistics sense distinctly with Chinese medicine certificate type. p<0.05 (0.005)
3 120 cases of patients with CI, the comparison of pathological changes number from big to small:Single pathological changes> several pathological changes> double pathological changes.
4 120 cases of patients with CI, the part of pathological changes and the degree of blood vessel straitness has statistics sense distinctly.p<0.05.
5 120 cases of patients with CI, the vascularity type of former and after circlation has not statistics sense distinctly Chinese medicine certificate type. P>0.05.
6 Amony Chinese medicine certificate type, the comparison of the number of implicates blood vessel from big to small:stirring of wind due to deficiency of YIN> Phlegm-Heat and Fu-organ Constipation> Wind Phlegm and Blood-Stasis> Phlegm wet and trouble consciousness> up stirring of Wind-Fire> Deficiency of Vital Energy and Blood Stasis> Wind Phlegm and fire up stirring.
Conclusion:
1 120 cases of patients with CI,the patients with CI of up stirring of Wind-Fire have come up CI of the after circlation, the patients with CI of Deficiency of Vital Energy and Blood Stasis and Phlegm-Heat and Fu-organ Constipation have come up CI of the former circlation.
2 When CI of the former circlation, the degree of blood vessel pathological change is lighter, the after circlation is opposite.
3 120 cases of patients with CI, the Chinese medicine certificate type and the part of pathological changes blood vessel has not statisticses difference. May be because the number of sample is smaller, examine is not enough effect. But we can see, the patients with CI of Phlegm-Heat and Fu-organ Constipation has come up blood vessel pathological change in the former circlation mostly.
4 120 cases of patients with CI, the Chinese medicine certificate type and the degree of blood vessel stratness have not statisticses difference, but we can see, pathological changes blood vessel of Phlegm-Heat and Fu-organ Constipation lecate between light degree and hit degree,pathological changes blood vessel of Deficiency of Vital Energy and Blood Stasis lecate between weight degree and close.
本课题通过对缺血性卒中患者进行全脑血管造影所见血管病变特点进行观察和血管狭窄的统计,意在探讨血管病变特点与缺血性卒中的中医证型的相关性,为缺血性卒中的中医辨证分型的微观化提供了有利依据,从而进一步指导临床对缺血性卒中开展有效地中医辨证施治。同时通过一系列相关研究,再次证实了有关缺血性卒中与血管狭窄的程度和部位的相关研究。
方法：参照国家中医药管理局脑病急症科研协作组起草制订的《中风病诊断疗效评定标准》(试行1995年)和1995年中华医学会第四届全国脑血管会议修订的诊断标准《各类脑血管疾病诊断要点》。将120例缺血性卒中患者,共分七个证型,痰热腑实型8例、风痰瘀阻型35例、痰湿蒙神型11例、风痰火亢型20例、气虚血瘀型16例、风火上扰型18例、阴虚风动型12例。通过全脑血管造影术明确了120例患者血管病变的部位和程度。所有数据均在计算机上采用SPSS进行数据的录入、管理和统计。X2检验(计数资料)。检验水准。取0.05,采用双侧检验。
结果：
1 120例缺血性卒中患者,中医证型所占比例由大到小依次为：风痰瘀阻>风痰火亢>风火上扰>气虚血瘀>阴虚风动>痰湿蒙神>痰热腑实。
2 120例缺血性卒中患者,中医证型与前、后循环的梗死有显著的统计学意义,p<0.05(0.005)。
3 120例缺血性卒中患者血管病变支数所占比例由大到小依次为：单支病变>多支病变>双支病变。
4 120例缺血性卒中患者血管病变部位与血管狭窄程度有显著统计学意义,p<0.05。
5 120例缺血性卒中患者中医证型与前、后循环系统病变血管分布没有显著统计学差异,P>0.05。
6各中医证型人均受累血管支数所占比例由大到小依次为：阴虚风动>痰热腑实>风痰瘀阻>痰湿蒙神>风火上扰>气虚血瘀>风痰火亢。
结论：
1风火上扰型的缺血性卒中患者多数出现后循环梗死,气虚血瘀型和痰热腑实型的缺血性卒中患者多数出现前循环梗死。
2前循环病变发生缺血性卒中时血管狭窄程度多数较轻,即相对血管狭窄严重的患者较少,而后循环系统恰好相反。
3缺血性卒中患者中医证型与病变血管分布没有显著统计学差异。可能是由于样本量较小,检验效能不足所致。但我们可看出,痰热腑实型缺血性卒中血管病变多发生在前循环。
4缺血性卒中患者中医证型与血管狭窄程度之间无显著统计学差异,但我们可看出,痰热腑实型的血管病变多处于轻度-中度狭窄,而气虚血瘀型的血管病变多处于重度-闭塞之间。
Stroke, is the most familiar nervous system disease of threatening human health, which is the second causing death the disease in adults in our country, with the high incidence of a disease, high death rate, high rate of cause to incomplete, and high recur rate Particularly, Cerebral Infarction (CI) is the most frequently. Though CI is not truculence, it threatens human health and exist the quantity, seriously, with the high rate of cause to incomplete according to the World Health Organization (WHO) report, in 1999, the number of death from suffering stroke is 5,540,000 in whole world, among them 2/3 take place to developing country. Formation mechanism of CI has not yet clarify completely, but the research enunciations, the occurrence, development of CI has closes with blood vessel narrow outside and inside of skull, thinking it is one of the important factors that main artery stricture and obstruct outside and inside of skull, the unsteady artery atherosclerosis block breaks off outside and inside of skull, which causes CI directly. it is easy to appear CI or lack of blood because of the blood stream dynamics changes, When blood vessel is narrow outside and inside of skull.In the former treatment, only paying attention to curing disease, but neglecting to diagnosis and handle of the cause of disease, which causing high recur rate of CI. With development of the technique in every kind of nerve blood vessel image and intervention cure, at present, digital subtraction angiography (DSA) is being as the gold standard in diagnosing blood vessel narrow and occlusive. The check of DSA can observes blood vessel frankly, blood state, and accurately measure diameter of blood vessel, and definitude the narrow part and the narrow degree of blood vessel and the growth state of the branch circulation, which increases consumedly diagnostic accuracy, and offers the information of the view to perfect diagnoses and the next treatment. digital subtraction angiography (DSA) has increased the rate of masculine of The brain blood vessel obviously, offered good terrace for intervention cure.
Our study, by digital subtraction angiography (DSA) to CI sufferers, it can be observed blood vessel configuration characteristics and the part of pathological changes, by which to observe and stat blood vessel narrow, to investigate the dependability between blood vessel configuration characteristics and different patterns of CI syndromes in traditional-Chinese medicine, to provide evidence for the subdivision of differentiation of symptoms and signs for classification of syndrome of CI in traditional-Chinese medicine, So the clinical determination of treatment based on differentiation of symptoms and signs can be better guaranteed. At the same time, a series of study again approves that these relevant studys of CI and blood vessel narrow degree and the part between domestic and international.
Method:According to the national Chinese medicine management bureau brain disease and acute disease scientific research cooperation draft out and make《stroke disease diagnosis curative effect and assessed standard》(try in 1995) and ((Treating Practice and standards revised)) by C.M.A (Chinese medical association) in its fourth national CVD(Cardiovascular Disease) academic conference in 1995. we divided 120 cases of patients with CI into, divided into seven certificates type:Phlegm-Heat and Fu-organ Constipation 8 case,Wind Phlegm and Blood-Stasis 35 case, Phlegm wet and trouble consciousness 11 case, Wind Phlegm and fire up stirring 20 case, Deficiency of Vital Energy and Blood Stasis 16 cases, up stirring of Wind-Fire 18 cases, and stirring of wind due to deficiency of YIN 12 cases respectively. Passing the DSA, it definitudes the part and degree of 1 pathological changes in 120 sufferers.
All data is inputted into computer, managed and processed by SPSS. X2-test (numeration data). Two-sided test(Size of test a=0.05) is applied.
Result:
1 120 cases of patients with CI, the comparison of Chinese medicine certificate type from big to small:Wind Phlegm and Blood-Stasis> Wind Phlegm and fire up stirring> up stirring of Wind-Fire> Deficiency of Vital Energy and Blood Stasis> stirring of wind due to deficiency of YIN> Phlegm wet and trouble consciousness> Phlegm-Heat and Fu-organ Constipation.
2 120 cases of patients with CI, CI of former and after circlation has statistics sense distinctly with Chinese medicine certificate type. p<0.05 (0.005)
3 120 cases of patients with CI, the comparison of pathological changes number from big to small:Single pathological changes> several pathological changes> double pathological changes.
4 120 cases of patients with CI, the part of pathological changes and the degree of blood vessel straitness has statistics sense distinctly.p<0.05.
5 120 cases of patients with CI, the vascularity type of former and after circlation has not statistics sense distinctly Chinese medicine certificate type. P>0.05.
6 Amony Chinese medicine certificate type, the comparison of the number of implicates blood vessel from big to small:stirring of wind due to deficiency of YIN> Phlegm-Heat and Fu-organ Constipation> Wind Phlegm and Blood-Stasis> Phlegm wet and trouble consciousness> up stirring of Wind-Fire> Deficiency of Vital Energy and Blood Stasis> Wind Phlegm and fire up stirring.
Conclusion:
1 120 cases of patients with CI,the patients with CI of up stirring of Wind-Fire have come up CI of the after circlation, the patients with CI of Deficiency of Vital Energy and Blood Stasis and Phlegm-Heat and Fu-organ Constipation have come up CI of the former circlation.
2 When CI of the former circlation, the degree of blood vessel pathological change is lighter, the after circlation is opposite.
3 120 cases of patients with CI, the Chinese medicine certificate type and the part of pathological changes blood vessel has not statisticses difference. May be because the number of sample is smaller, examine is not enough effect. But we can see, the patients with CI of Phlegm-Heat and Fu-organ Constipation has come up blood vessel pathological change in the former circlation mostly.
4 120 cases of patients with CI, the Chinese medicine certificate type and the degree of blood vessel stratness have not statisticses difference, but we can see, pathological changes blood vessel of Phlegm-Heat and Fu-organ Constipation lecate between light degree and hit degree,pathological changes blood vessel of Deficiency of Vital Energy and Blood Stasis lecate between weight degree and close.
引文
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[28]黄明, 朱凤水,李慎茂,等170例短暂性脑缺血发作患者的脑血管造影结果分析[J]1中国脑血管病杂志,2005,2(10)：449-453.
[29]冯来会1全脑血管造影在短暂性脑缺血发作患者病因诊断中的价值[J]1WorldHealth Digest,2008,5 (3):90-92.
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[1]feigin v1.lawes CMM.Bennett DA et al.Stroke epidemiology:a review of population-hased studies of incidence, prevalence, and case-futality in the late 20th Century.Lancet Neurot.2003, 2(1):43-53
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[11]asner SE, Chimowitz M1, Lynn MJ, et al. Predictors of ischemic stroke In the territory of asymptomatic intracranial arterial stenosis. Cireulation JT-Cireulation,2006,113(4):555— —63.
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[1]feigin v1.lawes CMM.Bennett DA et al.Stroke epidemiology:a review of population-hased studies of incidence, prevalence, and case-futality in the late 20th Century.Lancet Neurot.2003, 2(1):43-53
[2]M J KLAG, Z WU, et al. Stroke in the People's Republic of China. Ⅱ. Meta-analysis of hypertension and risk of stroke[J]. Stroke,1995,26(12):2228-2232.
[3]CHENG X M, D K ZIEGLER Y H LAI, et aL Stroke in China,1986 through 1990[J]. Stroke, 1995.26(11):1990-1994.
[4]HAUMER M.R AHMADI, E MINAR. Pefi-interventional drug therapy in PTA of supra-aortic blood vessels. Radiologe,2000,40(12):1172-1182.
[5]刑成名.缺血性脑血管病.北京：人民卫生出版社,2003：1-2
[6]James F Toole[美]著,龙洁主译,北京：中国协和医科大学出版社2004：1
[7]马廉亭.介入神经外科学.武汉：湖北科学技术出版社,2003：53.
[8]Katz DA, Marks MP, NaPel SA, et al. Circle ofWillis:evaluation with spiral CT angiograPhy, MR angiograPhy, and conventional angiograPhy. Radiology JT-Radiology,1995, 195(2):445-9.
[9]GallegoJ, Martinez—VilaE. Asymptomatic cerebrovaseular disease and systemic diagnosis in stroke, athero thrombosis as a disease of the vaseular tree. CerebrovascDisTJ-Cerebrovaseular diseases(Basel, Switzerland),2005,20(12):1.10.
[10]FusterV, Moreno PR. Athero thrombosis as a systemie,often silent, disease. Nat ClinPraet Cardio vase MedJT-Nature clinical Practice. Cardio vascular medieine,2005,2(9):431.
[11]asner SE, Chimowitz M1, Lynn MJ, et al. Predictors of ischemic stroke In the territory of asymptomatic intracranial arterial stenosis. Cireulation JT-Cireulation,2006,113(4):555— —63.
[12]Turkenburg JL, Otayen JA, Olen WL. Role of carotid sonography as a first examination in the evaluation of patients with transient ischemic attacks and strokes:benefit in relation to age[J]. J Clin Ultrasound,1999,27:65.
[13]王永炎、沈绍功主编.今日中医内科.[M].人民卫生出版社.2000：1-97；
[14]国家中医药管理局脑病急症协作组.中风病诊断与疗效评定标准[S].北京中医药大学学报,1996,19(1)：55
[15]全国第四届脑血管病学术会议.各类脑血管疾病诊断要点[J].中华神经科杂志.1996,29(6)：379.
[16]姜卫剑,王拥军,戴建平.缺血性脑血管病血管内治疗手册.北京：人民卫生出版社,2004：20-40.
[17]王桂红,王拥军,姜卫剑,等.缺血件脑血管病患者脑动脉狭窄的分布及特征[J].中 华老年心脑血管病杂志.2003,10(5)：315—317.
[18]North Americall Symplomatic carotid Endanerectomy Trial collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high grade stenosis[J]. N Engl J Med, 1991,325(7):445—453.
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