大脑中动脉重度狭窄进程的影响因素分析

Influencing factors of the process of severe middle cerebral artery stenosis

目的：通过经颅多普勒超声（TCD）动态观察单侧大脑中动脉（MCA）重度狭窄患者的血流动力学参数变化，对影响狭窄进程的相关因素进行分析。方法回顾性连续纳入经TCD筛查并经CT血管成像（CTA）或DSA证实单侧MCA重度狭窄的患者133例，根据MCA血流动力学参数变化，分为进展组43例和非进展组90例，并记录分析患者年龄、性别、脑血管病主要危险因素、临床症状、临床用药及药物依从性对狭窄进程的影响。结果（1）脑血管病危险因素检出率比较：进展组有吸烟史的患者[72.1％（31例）]明显高于非进展组[51.1％（46例），P＝0.022]；进展组患者吸烟时间长于非进展组[（28±12）年比（21±10）年，P＝0.011]。（2）MCA血流动力学参数比较：首诊时MCA狭窄远段搏动指数进展组低于非进展组（0.66±0.10比0.70±0.13，t ＝-2．096，P＝0.038），结点时MCA狭窄远段搏动指数进展组中狭窄程度进展患者低于非进展组患者（0.61±0.15比0.74±0.15），差异有统计学意义（t＝-2.718，P＝0.008）。结点时，进展组中10例狭窄程度进展患者MCA狭窄段收缩期峰值流速高于非进展组[（299±23）cm/s比（244±50）cm/s，t ＝3.437，P＝0.001]，而33例闭塞患者的MCA收缩期峰值流速明显低于非进展组[（56±18）cm/s比（244±50）cm/s，t＝-20.905，P＝0.000]。（3）规律性用药：规律性服用他汀类药物（阿托伐他汀）的患者进展组明显低于非进展组[2.3％（1例）比54.4％（49例），χ2＝33.690，P＜0.01]。（4）随访期间短暂性脑缺血发作和卒中再发率进展组明显高于非进展组[27.9％（12例）比6.7％（6例），32.6％（14例）比2.2％（2例）；均P＜0.01]。（5）多元 Logistic回归分析，吸烟者（OR ＝4.403，95％CI：1.094～14.017）、脑血管事件再发（OR＝10.648，95％CI：2.530～41.261）及非规律性服用他汀类药（OR＝5.675，95％CI：1.631～152.740）均与 MCA重度狭窄程度的进展密切相关。结论 TCD随访评价MCA重度狭窄的血流动力学变化，可以作为临床评估转归的重要依据。戒烟及规律性服用他汀类药物治疗有助于延缓MCA狭窄程度的进展。

Objectives To dynamically observe the changes of hemodynamic parameters in patients with severe stenosis of unilateral middle cerebral artery （MCA）by transcranial Doppler ultrasound （TCD） andtoevaluateandanalyzetherelatedfactorsforinfluencingthestenoticprocess.Methods Atotalof 113 consecutive patients with severe stenosis of unilateral MCA screened by TCD and confirmed by computed tomography angiography （CTA）and digital subtraction angiography （DSA）were enrolled retrospectively. They were divided into either a progressive group （n =43 ）or a non-progressive group （n=90）according to the variation of MCA hemodynamic parameters. The effects of age,sex,major risk factors for cerebrovascular disease,clinical symptoms,clinical medication,and drug compliance on the stenotic process were documented and analyzed. Results （1）The comparison of detection rate of the risk factors for cerebrovascular disease：The patients with a history of smoking （72. 1%[n=31]）in the progressive group was significantly higher than that （51. 1%[n=46]）in the non-progressive group （P=0.022）. The period of smoking of the patients in the progressive group were longer than that in the non-progressive group （28 ± 12 years vs. 21 ± 10 years,P=0. 011）. （2）Comparison of MCA hemodynamic parameters：The distal pulsatility indexes of MCA stenosis at the first diagnosis in the progressive group were all lower than those in the non-progressive group （0. 66 ± 0. 10 vs. 0. 70 ± 0. 13;t= -2. 096,P=0. 038）,and the distal pulsatility indexes of MCA stenosis at the end point in the patients of the progressive group were lower than those in the non-progressive group （0. 61 ± 0. 15 vs. 0. 74 ± 0. 15）. There were significant differences （t=-2. 718,P= 0. 008）. The peak systolic velocity （PSV）of the progressive MCA stenotic segments at the end point in 10 patients of the progressive group was higher than that in the non-progressive group （299 ± 23 cm/s vs. 244 ± 50 cm/s,t=3. 437;P=0. 001）,while PSV of MCA in 33 patients with occlusion in the progressive group were significantly lower than those in the non-progressive group （56 ± 18 cm/s vs. 244 ± 50 cm/s,t= -20. 905;P=0. 000）. （3）The regular medication：The patients using statins （atorvastatin calcium）were significantly lower than those of the non-progressive group （2. 3%[n=1] vs. 54. 4%[n=49],χ2 =33. 690;P〈0. 01）. （4）During the follow up period,the recurrence rates of transient ischemic attack and stroke of the progressive group were significantly higher than those of the non-progressive group （27. 9%[n=12]vs. 6. 7%[n=6],32. 6%[n=14]vs. 2. 2%[n=2];all P〈0.01）. （5）Multivariate Logistic regression analysis showed that smokers （OR,4. 403,95%CI 1. 094-14.017）,cerebrovascular event recurrence （OR,10. 648,95%CI 2. 530 -41. 261）,and irregularly taking statins （OR,5. 675,95%CI 1. 631-152. 740）were all closely associated with the progress of severe MCA stenosis.Conclusion Evaluation of the hemodynamic changes of severe MCA stenosis with TCD follow up study can be used as an important basis for clinical assessment of the outcomes. Stop smoking and regularly taking statins may help to delay the progress of MCA stenosis.