孤立性丘脑梗死后认知障碍的影响因素分析

Analysis of factors influencing cognitive impairment associated with isolated thalamic infarction

目的分析孤立性丘脑梗死后认知障碍发生的影响因素。方法回顾性连续纳入安徽医科大学附属安庆医院国家脑卒中高级中心2018年1月至2020年12月收治的急性孤立性丘脑梗死患者124例,所有患者发病3个月后予以蒙特利尔认知评估(MoCA)量表评分,校正教育程度因素后,MoCA<26分为认知障碍,纳入认知障碍组(32例),MoCA≥26分为非认知障碍,纳入非认知障碍组(92例)。单因素分析两组患者的一般及临床资料[性别、年龄、文化教育程度(文盲、小学、中学、大学)及既往史如高血压病、糖尿病、高脂血症、高尿酸血症、高同型半胱氨酸(Hcy)血症、心脏病、卒中病史,以及美国国立卫生研究院卒中量表(NIHSS)评分等],将P<0.05的因素纳入多因素Logistic回归分析中,分析影响孤立性丘脑梗死发病3个月后发生认知障碍的相关危险因素,并绘制森林图,以诺莫图、受试者工作特征(ROC)曲线评估联合因素对梗死后认知障碍发生的预测效果。结果与非认知障碍组比较,认知障碍组患者在年龄[(66±11)岁比(62±11)岁]、高Hcy血症[34.4%(11/32)比9.8%(9/92)]、发病时间[10.0(5.5,24.0)h比24.0(7.0,72.0)h]、入院NIHSS评分[3(1,4)分比1(1,2)分]、丘脑梗死部位[前部、外侧部、内侧部、后部分别为:9.4%(3/32)、53.1%(17/32)、25.0%(8/32)、12.5%(4/32)比4.3%(4/92)、71.7%(66/92)、10.4%(6/92)、14.8%(16/92)]、后循环大血管狭窄程度[无或轻度、中度、重度或闭塞分别为:56.3%(18/32)、9.4%(3/32)、34.4%(11/32)比80.4%(74/92)、12.0%(11/92)、7.6%(7/92)]等方面差异均有统计学意义(均P<0.05)。多因素Logistic回归分析结果显示,高Hcy血症(OR=4.175,95%CI:1.189~14.655,P=0.026)、后循环大血管重度狭窄或闭塞(OR=6.084,95%CI:1.463~25.308,P=0.013)、丘脑内侧部梗死(OR=4.789,95%CI:1.109~20.676,P=0.036)是孤立性丘脑梗死后认知障碍发生的独立危险因素。三者联合预测孤立性丘脑梗死后发生认知障碍的敏感度为68.8%,特异度为78.3%,ROC曲线下面积为0.777(95%CI:0.676~0.878,P<0.01)。结论高Hcy血症、丘脑梗死部位差异、后循环大血管狭窄程度等是孤立性丘脑梗死发病3个月后认知障碍发生的相关影响因素。

Objective To analyze the risk factors of cognitive impairment after isolated thalamic infarction.Methods From January 2018 to December 2020,a total of 124 patients with isolated thalamic infarction admitted in National Stroke Advanced Center,Anqing Hospital Affiliated to Anhui Medical University were retrospectively included.The Montreal cognitive assessment(MoCA)scale was used to assess the cognition of patients with isolated thalamic infarction at 3 months.After adjusting by education level,the cognitive impairment was defined as MoCA<26(32 cases),and the non-cognitive impairment was defined as MoCA≥26(92 cases).Clinical data at admission were compared between the two groups.Univariate analysis was performed for general and clinical data(gender,age,educational level[illiteracy,primary school,middle school,university]and previous medical history,such as hypertension,diabetes mellitus,hyperlipidemia,hyperuricemia,hyperhomocysteine[Hcy],history of heart disease,history of stroke,and the National Institutes of Health Stroke Scale[NIHSS]scores).Variables with P<0.05 were further included in the multivariate Logistic regression analysis to assess the risk factors of cognitive impairment after isolated thalamic infarction at 3 months.Forest map,nomogram,and receiver operating characteristic(ROC)curve were used jointly to assess the combined predictive effect of these factors.Results Compared with non-cognitive impairment group,the differences in age([66±11]years vs.[62±11]years),Hcy(34.4%[11/32]vs.9.8%[9/92]),onset time of thalamic infarction(10.0[5.5,24.0]h vs.24.0[7.0,72.0]h),admission NIHSS score(3[1,4]vs.1[1,2]),thalamic infarct site(anterior,lateral,medial,posterior were respectively 9.4%[3/32],53.1%[17/32],25.0%[8/32],and 12.5%[4/32]vs.4.3%[4/92],71.7%[66/92],10.4%[6/92]and 14.8%[16/92]),the degree of posterior circulation large vessel stenosis(non or mild,moderate,severe or occlusion were respectively 56.3%[18/32],9.4%[3/32],34.4%[11/32]vs.80.4%[74/92],12.0%[11/92],7.6%[7/92])and other aspects had statistical significance(all P<0.05).The multivariate Logistic regression analysis indicated that Hcy(OR,4.175,95%CI 1.189-14.655,P=0.026),severe stenosis or occlusion of large vessels in the posterior circulation(OR,6.084,95%CI 1.463-25.308,P=0.013),and thalamic medial infarction(OR,4.789,95%CI 1.109-20.676,P=0.036)were independent risk factors of cognitive impairment after isolated thalamic infarction at 3 months.The combination of the three predicted the occurrence of cognitive impairment after isolated thalamic infarction with a sensitivity of 68.8%,a specificity of 78.3%,and an area under the ROC curve of 0.777(95%CI 0.676-0.878,P<0.01).Conclusion Hcy,thalamic infarct site and degree of posterior circulation macrovascular stenosis are influencing factors of cognitive impairment after isolated thalamic infarction at 3 months.