腔隙性脑梗死后血管性痴呆的进程评价 新的血管性事件将加速血管性认知障碍的衰退程度

Evaluation of the development of vascular dementia following lacunar infarctions:New vascular events may speed up the deterioration of vascular cognitive disorder

目的:观察与腔隙性脑梗死相关的血管性痴呆患者的病程,以及随访过程中经历血管事件后对认知、行为和日常生活能力的影响。方法:选择1999-01/2004-06上海华东医院神经内科收治的腔隙性脑梗死后血管性痴呆患者72例进行随访,其中男54例,女18例,平均年龄(73±7)岁。均给予肠溶阿司匹林(75mg/次,1次/d)、石杉碱甲(商品名:双益平,0.05mg/片,2片/次,2次/d)及吡拉西坦(商品名:脑复康,0.4g/片,2片/次,3次/d)口服。门诊随访。患者随访开始时间不一致,1999年至2001年均有入组,随访周期约4个月/次,平均随访时间(24.25±6.01)个月。随访的血管事件包括新近发生的脑和心脏血管性发作。所有患者都接受CT或MRI检查及简易精神状态检查(检查认知缺损程度,满分为30分,低于26分为认知功能受损)、神经精神调查(检查行为能力,共分10个领域,每个领域根据其出现的频率计1～4分,根据严重程度计1～3分,将每项的频率得分乘以严重程度得分后相加,得分越高疾病越严重)、日常生活能力(共20项,每项依据严重程度计1～4分,总分20分为正常,>20分即有不同程度下降)指标评估。同时根据是否经历血管事件分为两组进行各量表评分比较。结果:72例患者全部进入结果分析。①患者随访期末简易精神状态量表得分较随访前显著降低,神经精神调查和日常生活能力评分均较随访前升高(22.3±4.6,32.1±18.3,43.7±9.6);(25.3±5.2,19.4±13.9,32.6±8.3),(t=5.67～14.86,P<0.01)。②发生血管事件组比未发生血管事件组的简易精神状态检查、神经精神调查和日常生活能力评分恶化迅速(数据均为变化值)(-2.24±1.4,11.60±14.3,9.88±12.5);(-1.03±1.7,2.35±15.6,2.04±7.3),(t=2.94～7.38,P<0.01)。③认知和行为恶化与血管事件的发生高度相关(r=0.920,P<0.01);认知改变与行为改变成显著正相关(r=0.793,P<0.01)。结论:腔隙性脑梗死后血管性痴呆患者认知、行为和日常生活能力均出现恶化,且新的血管性事件加重病情,所以早期干预显得尤其重要。其中认知改变与行为改变高度相关,可能与特异性的额叶-皮质下环路的破坏有关,提示腔隙性脑梗死后血管性痴呆中同样的皮质下病理改变造成了认知和行为两种类型的损害。

AIM： To evaluate the cognitive and behavioral course in patients with probable YaD-L, and the affection when they suffered new vascular events during follow-up.METHODS： Totally 72 patients with vascular dementia after lacunae cerebral infarction were selected from Neurological Department of Shanghai Huadong Hospital from January 1999 to June 2004. Among them, there were 54 males and 18 females with the average age of （73±7） years. All patients were given aspirin （75 mg/time, once per day）, huperzine A （0.05 mg/pill,2 pillsonce, twice per day） and piracetam （0.4 g/pill, 2 pills/time, 3 times per day）.The follow-up was lasted from 1999 to 2001 with 4 months as a cycle and the average time was （24.25±6.01） months. The vascular events included the new vascular episode of brain and heart during the follow up.All patients were tested with CT or MRI, MMSE, NPI and ADL. And according to who did or did not undergo additional vascular episodes, all patients were randomized into 2 groups.RESULTS： Totally 72 cases entered the final analysis. ①Scores of MMSE were decreased as compared with those before follow up, but those of NPI and ADL were increased after the follow up [（22.3±4.6, 32.1±18.3,43.7±9.6）; （25.3±5.2, 19.4±13.9, 32.6±8.3）, （t=5.67-14.86, P 〈 0.01）].②Scores of MMSE, NPI and ADL in vascular-event occurrence group were deteriorated obviously as compared with those in vascular-event unoccurrence group [（-2.24±1.4, 11.60±14.3, 9.88±12.5）; （-1.03±1.7, 2.35±15.6,2.04±7.3）, （t=2.94-7.38, P 〈 0.01）].③ Cognition and behavior deterioration were related with the level of vascular-event occurrence （r=0.920, P〈0.01）, and cognitive changes were obviously positive related with behavior changes （r=0.793, P 〈 0.01）.CONCLUSION： YaD-L is characterized by cognitive and behavioral decline. The rate of decline is determined mainly by the occurrence of new vascular episodes. The underlying pathological processes affecting the brain and the severity of the cognitive and the behavioral impairments.