急性动脉粥样硬化型脑梗死患者的脑血管储备功能及其在近期预后的应用价值研究

Cerebrovascular reserve in patients with acute atherosclerotic cerebral infarction and its application value in the short-term prognosis

目的探讨急性动脉粥样硬化型脑梗死患者脑血管储备功能（CVR）状况及其与患者近期预后的关系。方法选取2016年12月至2017年12月发病72 h内收治于合肥市第一人民医院神经内科的单侧急性动脉粥样硬化型脑梗死患者（试验组）106例，NIHSS评分中位数（四分位数）为4（2，5）分。并按照头颅DWI结果将试验组划分为病灶侧106例，非病灶侧106例。另选取同期来我院健康体检者40名为对照组。采用经颅多普勒超声结合CO2吸入试验测定试验组和对照组的脑血流速度变化率（CBFV）及搏动指数变化率，以CBFV≥10%为脑血流储备正常，〈10%为脑血流储备受损，并比较试验组病灶侧、试验组非病灶侧、对照组3组间的CBFV及搏动指数变化率的差异。应用头颅MRA检测试验组Willis环评估脑结构储备功能并进行分型。采用单因素分析评估糖尿病、高血压、低密度脂蛋白胆固醇（LDL）、高密度脂蛋白胆固醇（HDL）、吸烟及饮酒史等对脑血流储备的影响，并对NIHSS评分、梗死部位及体积与CVR进行相关性分析。试验组均采用药物治疗，3个月后随访并通过改良Rankin量表评估预后情况。采用多因素Logistic回归分析性别、HDL、LDL、糖尿病、高血压、吸烟史、饮酒史、脑血流储备是否正常、NIHSS评分、脑结构储备、梗死部位、年龄等对预后的影响。结果动脉粥样硬化型脑梗死患者病灶侧CBFV增加率为5.94% （2.18%，10.49%），搏动指数增加率为10.77% （2.21%, 22.62%），二者均低于对照组[CBFV增加率：11.54% （5.01%，17.96%） ，Z＝2.547，P〈0.05；搏动指数增加率：48.36% （33.93%，64.51%），Z＝6.604，P〈0.01]。有无糖尿病史在脑血流储备正常组和受损组中的分布不同，分别为2/14和43.48%（40/92），差异有统计学意义（χ2＝4.328，P〈0.05）。试验组脑结构储备分别与梗死体积和NIHSS评分呈正相关，秩相关系数分别为0.219和0.238（P〈0.05）。脑血流储备正常组较受损组预后良好，其CBFV正常患者的比例为18.84%（13/69），预后良好但CBFV下降的患者的比例为81.16%（56/69），预后不良但CBFV正常患者的比例为2.70%（1/37），预后不良且CBFV下降的患者的比例为97.30%（36/37），差异有统计学意义（χ2＝4.155，P〈0.05）。脑结构储备分组中Ⅰ、Ⅲ型患者预后良好占比分别为37.68%（26/69）、5.80%（4/69），Ⅱ型、Ⅳ型预后良好占比分别为43.48（30/69）、13.04（9/69），差异有统计学意义（χ2＝8.456，P〈0.05）。多因素Logistic回归分析结果显示，NIHSS评分、年龄及脑结构储备是试验组预后不良的危险因素，脑血流储备正常是预后良好的保护因素。结论急性动脉粥样硬化型脑梗死患者的CVR显著降低，CVR可作为患者3个月预后的评价指标。

ObjectiveTo assess the cerebrovascular reserve（CVR）and the relationship of CVR with the short-term prognosis in patients with acute atherosclerotic cerebral infarction.MethodsA total of 106 patients with unilateral acute （within 72 h） atherosclerotic cerebral infarction （trial group） were selected from December 2016 to December 2017 in the Department of Neurology of the First People′s Hospital of Hefei, which were divided into two groups including the lesion group （106 cases） and the non-lesion group （106 cases）. The median score of NIHSS in patients was 4（2, 5）. The control group included 40 healthy controls. The cerebral blood flow reserve and pulsatility index were measured by transcranial Doppler combined with CO2 inhalation test in both the trial group and the control group. According to the rate of change of cerebral blood flow velocity （CBFV）, all subjects were divided into two groups including the normal group and the impaired cerebral blood flow reserve group. The changes of CBFV were compared in the control group and the trial group, which was divided into two groups including the group with lesion side and the group with non-lesion side. To evaluate the brain structure reserve the circle of Willis in the trial group was assessed by MRA. According to the integrity of the circle of Willis anterior and posterior circulation all subjects were divided into four groups （type Ⅰ, type Ⅱ, type Ⅲ and type Ⅳ）. The effect of the factors, such as diabetes, hypertension, low density lipoprotein（LDL）, high density lipoprotein （HDL）, smoking, and drinking history, on cerebral blood flow reserve was measured by single-factor analysis. The correlation of NIHSS scores, infarct size and volume with CVR was also measured. All patients in the trial group were treated with drugs and were followed-up for three months. The modified Rankin Scale （mRS） was used to evaluate the prognosis of the patients. It means poor prognosis if the value of mRS was more than three. The effects of factors, such as sex, HDL, LDL, diabetes, hypertension, smoking history, drinking history, cerebral blood flow reserve, NIHSS scores, brain structure reserve, infarct location, age, on the prognosis were measured by multivariate Logistic regression.ResultsThe increase rate of CBFV in the lesion-side of patients with atherosclerotic cerebral infarction was 5.94% （2.18%, 10.49%）, and the increase rate of pulsatility index was 10.77% （2.21%, 22.62%）, which were both lower than the control group （CBFV： 11.54% （5.01%, 17.96%）, Z=2.547, P〈0.05）; pulsatility index： 48.36% （33.93%, 64.51%）, Z=6.604, P〈0.01）. There was significant difference （χ2=4.328, P〈0.05） in the distribution of diabetes, which was 2/14 in the normal group and 43.48% （40/92） in the impaired cerebral blood flow reserve group. And in the trial group the brain structural reserve was positively correlated to the infarct volume and the NIHSS score, and the rank correlation coefficient was 0.219 and 0.238 respectively （P〈0.05）. The prognosis of cerebral blood flow reserve in the normal group was better than the impaired group （χ2=4.155, P〈0.05）, for example, the proportion of patients with good prognosis and normal CBFV was 18.84% （13/69）, the proportion of patients with good prognosis but decreased CBFV was 81.16% （56/69）, the proportion of patients with poor prognosis but normal CBFV was 2.70% （1/37）, the proportion of patients with poor prognosis and decreased CBFV was 97.30% （36/37）. The proportion of patients with type Ⅰ and type Ⅲ of the brain structure reserve was 37.68% （26/69） and 5.80% （4/69） respectively, whose prognosis was better （χ2=8.456, P〈0.05） than patients with type Ⅱ and type Ⅳ, whose proportion was 43.48% （30/69） and 13.04% （9/69）. Multivariate Logistic regression analysis showed that NIHSS score, age, and brain structural reserve were risk factors for poor prognosis in the trial group. Normal cerebral blood flow reserve was a protective factor for good prognosis.ConclusionsCVR in patients with acute atherosclerotic cerebral infarction is significantly reduced. CVR can be used as an index to evaluate the prognosis of patients who were followed-up for three months.