脑卒中后吞咽障碍多因素分析及对预后的影响

Multivariate Analysis of Dysphagia after Stroke and Prognosis

目的:探讨急性脑卒中患者吞咽障碍的发生因素及对并发肺部感染和卒中患者预后的影响。方法:432例意识清醒,无明显认知功能障碍及听理解障碍的急性脑卒中患者,均经头颅CT和(或)MRI检查证实,并明确卒中的部位、类型、病灶大小及数目,入院时及3～4周对患者神经功能缺损及生活活动能力进行评分。根据吞咽障碍的临床诊断标准分为吞咽正常组及吞咽障碍组,对吞咽障碍组的患者进行洼田饮水试验评估吞咽障碍的程度,根据结果将吞咽障碍程度分为轻、中、重度三个亚组。结果:432例脑卒中患者中,246例有不同程度的吞咽障碍(56.9%)。其中122例脑出血患者中,70例有吞咽障碍(57.4%),310例脑梗死患者中,176例有吞咽障碍(56.8%),二组比较无显著性的差异;吞咽正常患者与吞咽障碍各亚组患者在年龄、性别、病史以及卒中类型的比较无显著性差异,但中、重度吞咽障碍亚组既往有卒中史的患者比例高于吞咽正常组及轻度吞咽障碍组(P<0.05);脑干卒中、大病灶、双侧半球病灶及多发病灶的卒中患者吞咽障碍的发生率明显增高且严重,中度和重度吞咽障碍的脑卒中患者入院时神经功能缺损严重、并发肺部感染显著多于轻度和无吞咽障碍的患者,中度和重度吞咽障碍的脑卒中患者治疗3～4周神经功能缺损评分及Barthel指数无明显的改善,预后不良;Logistic回归分析发现:脑干卒中、大病灶、多发病灶、入院时NIHSS分值高及BI分值低是脑卒中患者发生吞咽障碍的危险因素。结论:脑卒中后吞咽障碍及其严重程度与卒中部位、病变大小、多少及卒中的严重程度有关,脑干卒中和病灶大的卒中患者常合并重度吞咽障碍和并发肺部感染,中、重度吞咽障碍的卒中患者预后差。

Objective:To make the multivariate analysis of dysphagia after Stroke and predict the prognosis in dysphagia patients.Methods:432 conscious patients after Stroke were verified by skull CT and(or)MRI,the stroke locations,types,lesion sizes and numbers were all assessed.The neurological function deficiency and livelihood capacity of patients were evaluated at admission and 3-4 weeks later.According to the clinical diagnostic criteria of dysphagia patients were classified to normal swallowing group and dysphagia group.According to the Kubota water test's results,the patients in dysphagia group were again divided into the mild,moderate and severe subgroups.Results:Of 432 Stroke patients,246 cases(56.9%)had dysphagia with various degree.Among 122 patients with cerebral hemorrhage,the incidence of dysphagia was 57.4%(70 cases),while 310 patients with cerebral infarction was 56.8%(176 cases).The dysphagia incidence of both groups had no significant difference.At the same time there was no significantly difference in age,sex,history of diabetes or hypertension,and stroke types between the normal swallow and the dysphagia groups.However,in moderate and severe dysphagia subgroups the patients with stroke history had higher proportion than those in normal swallow and mild dysphagia groups(P<0.05).The incidence of dysphagia in the patients with brainstem stroke,large lesions,bilateral hemispheric lesions and multiple focus was significantly higher and more severe.The patients with moderate or severe dysphagia had more severe neurological function deficiency at admission and the higher incidence in concurrent lung infection than those in mild and no dysphagia subgroups.At the same time it was indicated that these patients had no significant improvement in scores evaluated by neurological deficit and Barthel index after 3-4 week's treatment and had the poorer prognosis.Logistic regression analysis suggested that brainstem stroke,larger lesions,multiple focus,high NIHSS and low BI scores at admission were the risk factors of dysphagia in patients after stroke.Conclusions:Dysphagia and its severity in patients after stroke are associated with stroke location,lesion size,numbers and the severity of stroke.Patients with brainstem stroke and larger lesions are often combined with severe dysphagia and concurrent lung infection.Patients with the moderate and severe dysphagia have the poorer prognosis.