cTTE+隐源性卒中患者临床特征及影像学分析

Clinical characteristics and imaging analysis of cTTE positive cryptogenic stroke patients

目的研究右心声学造影(contrast transthoracic echocardiography,cTTE)阳性(cTTE+)的隐源性脑卒中(cryptogenetic stroke,CS)患者临床特征、磁共振影像学表现,以期发现cTTE+患者特定临床特征,有助于对CS的病因学诊断。方法回顾性收集2020年8月至2022年5月在国科大宁波华美医院被诊断为CS并行右心声学造影检查的108例患者的临床和影像资料,按照cTTE结果分为cTTE+组与右心声学造影阴性(cTTE-)组,对比分析两组的年龄、性别、脑血管病危险因素(高血压病、糖尿病、心脏病、吸烟史、饮酒史等)、发病症状、NIHSS评分、入院时mRS评分、左心房大小、弥散加权成像(DWI)上脑梗死灶的梗死类型(数量、位置、大小)等之间的差异,分析不同级别的右向左分流在DWI上的梗死病灶的差异。结果(1)108例CS患者中cTTE+的阳性率为39.8%,其中男30例(69.8%),女13例(30.2%),年龄(52.8±17.5)岁;右向左分流1级分流21例,2级分流12例,3级分流10例。cTTE+组共发现4例心外分流,有2例经手术证实为肺小动静脉瘘。(2)两组患者中,cTTE+组青壮年比率更高(P=0.021),发病时非特异性症状发生率更高(P=0.008),cTTE-组以典型神经功能缺损症状为主,吸烟个人史的比率更高(P=0.012),差异均有统计学意义。(3)cTTE+组脑梗死病灶累及多血管区域的比例(44.2%)显著高于cTTE-组(15.4%,P=0.004),且多表现为多血管支配的多发梗死灶,同时cTTE+组脑梗死病灶更多分布于椎基底动脉系统(P=0.021),较少分布于右侧颈内动脉系统(P=0.045);而cTTE-组卒中梗死病灶最大直径更多分布于[1cm,3cm],差异均有统计学意义(P<0.05)。随着右向左分流级别的增加,<1 cm病变的比率有增加的趋势,但无明显统计学差异。结论(1)<50岁的发病症状以非特异性症状为主的CS患者,影像学表现常以后循环为优势的多血管多发病灶为特征,发病机制需考虑与右向左分流相关。(2)cTTE检测右向左分流对CS的病因诊断有补充价值,可以发现部分隐匿的不易察觉的心外分流,提示CS患者需积极进行cTTE筛查,有助于明确病因并指导卒中预防治疗方案的选择。

Objective To analyze the clinicial features magnetic resonance imaging manifestations of contrast transthoracic echocardiography(cTTE)on patients cryptogenic stroke,in order to discover the specific clinical characteristics of patients with cTTE+and contribute to the etiological diagnosis of CS.Methods The clinical and imaging data of 108 patients who were diagnosed with CS in Ningbo Huamei Hospital from August 2020 to May 2022 were retrospectively collected.According to the cTTE results,they were classified intotwo groups:cTTE+group and cTTE-group.Then the age of onset,gender,risk factors of cerebrovascular disease(hypertension,diabetes,heart disease,smoking history,drinking history,etc.),symptoms,NIHSS score,mRS score,left atrium size,infarct types(number,location,size)of cerebral infarction on diffusion weighted imaging(DWI)of the two groups were compared and analyzed.The differences of infarct lesions on DWI with different grades of right-to-left shunt were analyzed.Results(1)The cTTE+positive rate among 108 ptients with CS was 39.8%,including 30 males(69.8%)and 13 females(30.2%),aged(52.8±17.5)years.Right-to-left shunt was found in 21 patients with grade 1,12 with grade 2,and 10 with grade 3.In the positive group,4 cases of extracardiac shunt were found,and 2 cases of pulmonary arteriovenous fistula were confirmed by operation.(2)Among the two groups of patients,the cTTE+group had a higher ratio of young adults(P=0.021)and a higher incidence of non-specific symptoms at onset(P=0.008),while the negative group had a higher ratio of core symptoms and personal history of smoking(P=0.012),with statistically significant differences.(3)The proportion of multi-vessel area involved in the cTTE+group was significantly higher than that in the cTTE-group(P=0.004),Meanwhile,more cerebral infarction lesions were distributed in the vertebrobasilar artery system(P=0.021),Less in the right internal carotid artery system(P=0.045);and the maximum diameter of stroke infarct lesions in the cTTE-group was more distributed in[1cm,3cm],with statistical significance(P<0.05).With the increase of right-to-left shunt grade,the proportion of lesions<1 cm showed an increasing trend,but there was no significant statistical difference.Conclusion(1)Non-specific symptom onset of CS mainly occurs in multi-vessel distribution areas under 50 years old,and the pathogenesis should be considered to be related to right-to-left shunt.(2)The detection of right-to-left shunt by cTTE is of supplementary value to the etiological diagnosis of CS,which can detect some hidden and undetectable extracardial shunt,suggesting that CS patients should actively undergo cTTE screening,which is helpful to define the etiology and guide the selection of stroke prevention and treatment plan.