住院患者不明原因栓塞性卒中诊治现状研究

Current Status of Diagnosis and Treatment of Embolic Stroke of Undetermined Source

目的了解目前中国不明原因栓塞性卒中(embolic stroke of undetermined source,ESUS)诊治现状。方法回顾性分析2011年1月-2012年12月在北京大学第三医院神经内科住院的缺血性卒中患者,将住院及随访期间未完善24 h心电监测(Holter)但已完成其他评估并符合ESUS标准者,定义为可疑ESUS(suspected ESUS,sESUS),将完善了包括24 h心电监测等在内全部评估并符合ESUS诊断标准者,定义为"确定ESUS"(definite ESUS,dESUS),以上均划分为ESUS组;其他卒中亚型为非ESUS组。比较两组间一般情况、危险因素及临床特点;并随访ESUS组患者二级预防及复发情况。结果研究共纳入缺血性卒中患者900例,按照住院资料诊断d ESUS 9例(1.0%),sESUS 95例(10.6%),合计104例(11.6%);非ESUS组796例。ESUS患者活动中起病85例(81.7%)、病情波动58例(55.8%)、入院时美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分2.0(0,4.0)分,非ESUS组分别是538例(67.6%),245例(30.8%)和3.0(1.3,5.0)分,差异均有显著性(P分别为0.010、<0.001、<0.001)。对ESUS组患者急性期及二级预防抗栓药物使用的调查发现,随访d ESUS患者均为抗血小板治疗,其中6例出现1年内缺血性卒中复发;sESUS患者也全部为抗血小板治疗,其中10例出现1年内缺血性卒中复发。结论目前ESUS在缺血性卒中患者中比例较高,与非ESUS患者相比,其病情波动较大,神经功能缺损较轻。对该类患者应该加强24 h心电图的监测以助查找病因。

Objective To investigate the current status of diagnosis and treatment of embolic stroke of undetermined source （ESUS） in patients hospitalized for ischemic stroke in China. Methods A retrospective review of clinical data of inpatients for ischemic stroke in Peking University Third Hospital between Jan 2011 and Dec 2012 was conducted. Patients who did not receive 24-hour Holter monitoring, yet had completed the other evaluations and met ESUS diagnostic criteria of ESUS International Working Group were defined as ＂suspected ESUS＂（sESUS）, while those who completed all relative evaluations （including 24-hour Holter monitoring） and met the diagnostic criteria of ESUS were defined as ＂definite ESUS＂ （dESUS）. All the above patients were enrolled into ESUS group, and the other subtypes of stroke as control. The baseline charateristics, risk factors and clinical features were compared between the two groups. Secondary prevention and stroke recurrence of these ESUS patients （including sESUS and dESUS） after discharge were followed up. Results Finally, 900 patients with ischemic stroke were enrolled in this study, of which 9 dESUS （1.0%） and 95 sESUS （10.6%）, the 104 ESUS patients accounted for 11.6% （104/900） of all subjects,and the remaining 796 patients were divided into non-ESUS group. Clinical features of two groups as follows： 85 onset during physical activities （81.7%）, 58 ones with fluctuating symptoms （55.8%） and the mean score of National Institutes of Health Stroke Scale （NIHSS） was 2.0 （0, 4.0） in ESUS group;the corresponding in control group was 538 （67.6%） , 245 （30.8%） and 3.0 （1.3, 5.0）, respectively;there was significant difference in any of the three between two groups （P=0.010, P〈0.001, P〈0.001, respectively）. Analyzing the usage of antithrombotic drugs in acute phase and after discharge in ESUS patients, we found that all ESUS patients had taken antiplatelet agents, and 6 dESUS and 10 sESUS patients experienced recurrent stroke during the first year after discharge. Conclusion Patients diagnosed as ESUS is very common in patients with ischemic stroke. Comparing with non-ESUS patients, there were more fluctuating symptoms and less neurologic deficit in ESUS ones. 24-hour Holter monitoring in ESUS patients is necessary and very helpful for determing the cause of stroke.