急性脑梗死CISS与TOAST病因分型探讨

Investigation of CISS and TOAST subclassification methods in acute cerebral infarction

目的 探讨中国缺血性卒中亚型（chinese ischemic stroke subclassification,CISS）和TOAST（trial of org10172 in acute stroke treatment,TOAST）分型在急性脑梗死（acute cerebral infarction,ACI）中的病因分布差异.方法 连续收集2011-07~2011-12于广西壮族自治区人民医院神经内科住院治疗的ACI患者,对符合纳入标准的310例ACI患者根据CISS分型及TOAST分型标准进行病因分型比较,同时分析常见危险因素在CISS分型亚型中的分布差异.结果 310例ACI患者,经CISS分型,大动脉粥样硬化141例（45.5%）,其中主动脉弓粥样硬化3例和颅内外大动脉粥样硬化138例;穿支动脉疾病102例（32.9%）,心源性卒中15例（4.8%）,其他病因8例（2.6%）,病因不明44例（14.2%）.138例颅内外大动脉粥样硬化性脑梗死发病病理机制分别为：动脉到动脉栓塞70例（50.4%）,载体动脉（斑块或血栓）阻塞穿支动脉34例（24.5%）,低灌注/栓子清除下降14例（10.1%）,混合型21例（15.1%）.与TOAST分型比较,CISS分型大动脉粥样硬化性比例明显增加,病因不明比例明显减少（P〈0.001）.CISS分型与TOAST分型对心源性卒中和其他病因的诊断一致性很好,对大动脉粥样硬化性、小动脉闭塞/穿支动脉疾病、病因不明性卒中诊断的一致性中等.吸烟、饮酒、高尿酸血症和高纤维蛋白原血症在各亚型分布中比例差异无统计学意义（P〉0.05）;高血压病和脂代谢紊乱在大动脉粥样硬化、穿支动脉疾病及病因不明亚型中比例明显高于心源性卒中组（P〈0.05）,高血压病和脂代谢紊乱在这三个亚型间比较差异无统计学意义（P〉0.05）;穿支动脉疾病合并糖尿病比例（43.1%）均大于大动脉粥样硬化、心源性卒中及病因不明者（P〈0.05）;大动脉粥样硬化合并高同型半胱氨酸血症比例明显高于穿支动脉疾病、心源性卒中及病因不明者（P〈0.05）.结论 CISS分型更符合脑梗死的病因分型和病理机制,提高了病因诊断的准确性,可以为脑梗死急性期干预及二级预防提供个体化的指导.

Objective To discuss the etiology distribution of acute cerebral infarction （ACI） by two subclassification methods, China ischemic stroke subclassification （CISS） and Trial of Org 10172 in Acute Stroke Treatment （TOAST）. Methods We consecutively included 310 in - hospital patients with ACI in the Neurology Department of the Guangxi Zhuang Autonomous Region People＇s Hospital from July 1, 2011 to December 31, 2011. All patients were subclassified according to CISS criteria and the TAOST criteria, and the relationship between various CISS subtypes and common risk factors were analyzed. Results Among 310 ACI patients, there were 141 （45. 5% ） patients of large artery atherosclerosis （LAA） including 3 aortic arch atherosclerosis and 138 intra- cranial and extra- cranial large arteries atherosclerosis, 102 （ 32.9% ） patients of penetrating artery disease （PAD） ,44 （ 14.2% ） patients of undetermined etiology （ UE）, 15 （4.8%） patients of cardiac stroke, 8 （2.6%） patients of other ACI cases caused by intra - cranial and extra - cranial large arteries atherosclerosis included 70 （50.4%） patients of artery to artery embolization,34 （24.5%） cases of parent artery （plaque or thrombus） occluding penetrating artery, ld （10.1% ） cases of hypoperfusion/impaired emboli clearance and 21 （ 15.1% ） cases of multiple causes. The main artery atherosclerosis proportion was increased significantly, and the proportion of unknown etiology was significantly reduced by CISS criteria compared to TOAST criteria（P 〈 0.001 ）. The consistency of cardiogenic stroke and undetermined etiology by CISS and TOAST classification was very good, but the consistency of large artery atherosclerosis and penetrating artery disease/small - vessel occlusion and undetermined etiology by the two methods was medium. Smoking, drinking, high uric acid hematic disease and hyperfibrinogenemia in the subtypes distribution was not statistically different （P 〉 0.05）. Hypertension,lipid metabolism disorders in LAA, PAD and UE were significantly higher than those in the CS group, with a statistically significant difference （P 〈 0.05）. Diabetes mellitus was more common in PAD （43.1% ） than in LAA, cardiac stroke and UE（P 〈 0.05）. High homocysteine in LAA was significantly higher than that of PAD, CE and UE group （P 〈 0.05）. Conclusion The CISS criteria improves the diagnostic accuracy of the etiology and the pathological causes of ACI, which provides an individualized guidance for the intervention and secondary prevention of these diseases.