延髓不同部位梗死的临床特征分析

Clinical analysis of different parts of medullary infarction

目的探讨延髓不同部位梗死灶的临床、影像学、病因学以及预后之间的区别。方法连续纳入自2017年7月至2022年7月于天津市环湖医院住院的延髓梗死的患者。收集患者人口学资料、临床及影像学资料,对患者进行3个月随访并对结果进行分析。结果共纳入256例延髓梗死患者。外侧延髓梗死∶内侧延髓梗死=1.4∶1。外侧延髓梗死最常见的临床表现为头晕(84.7%,127/150),内侧延髓梗死最常见的临床表现为运动障碍(83.0%,88/106)。外侧延髓梗死主要分布于延髓中段(42.7%,64/150),内侧延髓梗死主要分布于延髓上段(60.4%,64/106),差异有统计学意义(χ^(2)=47.53,P<0.001)。发病机制均以大动脉粥样硬化为主,在外侧和内侧延髓梗死分别占57.3%(86/150)和56.6%(60/106)。早期神经功能恶化更多出现在内侧延髓梗死中(25.5%,27/106),外侧延髓梗死较少(7.3%,11/150),差异有统计学意义(χ^(2)=16.17,P<0.001)。出院时预后不良的患者在外侧延髓梗死和内侧延髓梗死中分别占24.0%(36/150)和45.3%(48/106),差异有统计学意义(χ^(2)=12.76,P<0.001);90 d随访时预后不良的患者分别为12.7%(19/150)和33.0%(35/106),差异也有统计学意义(χ^(2)=15.48,P<0.001)。住院期间共有10例(4.0%,10/256)患者发生呼吸衰竭,外侧延髓梗死7例(4.7%,7/150);内侧延髓梗死3例(2.8%,3/106),3例中均为双侧内侧延髓梗死。早期神经功能恶化(OR=3.38,95%CI 1.25~9.10,P=0.016)、发病机制为大动脉粥样硬化(相较于小动脉闭塞)(OR=3.08,95%CI 1.13~8.37,P=0.028)是内侧延髓梗死预后不良的独立危险因素;年龄(OR=1.01,95%CI 1.01~1.17,P=0.026)、早期神经功能恶化(OR=20.19,95%CI 2.63~155.06,P=0.004)是外侧延髓梗死预后不良的独立危险因素。结论外侧延髓梗死和内侧延髓梗死在病因上具有相似性,在临床表现、早期神经功能恶化、预后不良上均有明显差异,在临床工作中对延髓梗死进行进一步内外侧分型及进一步分类对诊断、治疗和预后评估具有重要意义。

Objective To investigate the clinical,imaging,etiological and prognostic features of patients with infarctions in different locations of the medulla oblongata.Methods Patients with acute medullary infarction hospitalized at Tianjin Huanhu Hospital from July 2017 to July 2022 were included.The risk factors,clinical manifestation,stroke mechanism and 90-day prognosis of these patients were analyzed retrospectively.Results Among the 256 patients enrolled,150(58.6%)had lateral medullary infarction(LMI),106(41.4%)had medial medullary infarction(MMI).The most frequent clinical manifestation of patients with LMI was dizziness(84.7%,127/150).And motor disorders(83.0%,88/106)was the most frequent clinical manifestation of patients with MMI.LMI lesions were mostly located in the middle(42.7%,64/150)and MMI lesions were mostly located in the upper(60.4%,64/106)medulla oblongata,with statistically significant difference(χ^(2)=47.53,P<0.001).Large artery atherosclerosis(LAA)was the main stroke mechanism in LMI and MMI[57.3%(86/150)vs 56.6%(60/106)].Early neurological deterioration was more common in MMI(25.5%,27/106)and less common in LMI(7.3%,11/150),with statistically significant difference(χ^(2)=16.17,P<0.001).At discharge,more patients with MMI showed poor prognosis in short term[45.3%(48/106)vs 24.0%(36/150),with statistically significant difference(χ^(2)=12.76,P<0.001)]and even long term at 90-day follow-up[33.0%(35/106)vs 12.7%(19/150),also with statistically significant difference(χ^(2)=15.48,P<0.001)]than those with LMI.A total of 10 patients(4.0%,10/256)developed respiratory failure during hospitalization,including 7 patients with LMI(4.7%,7/150)and 3 patients with bilateral MMI(2.8%,3/106).Early neurological deterioration(OR=3.38,95%CI 1.25-9.10,P=0.016)and LAA(compared with small artery occlusion)(OR=3.08,95%CI 1.13-8.37,P=0.028)were independent risk factors for poor prognosis in MMI.Age(OR=1.01,95%CI 1.01-1.17,P=0.026)and early neurological deterioration(OR=20.19,95%CI=2.63-155.06,P=0.004)were independently correlated with poor outcome in LMI.Conclusions LMI and MMI had similar etiology and significant differences in clinical manifestations,early neurological deterioration and prognosis.Further classification of medullary infarction was of great significance for diagnosis,treatment and prognosis evaluation.