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缺血性腦卒中患者頸動(dòng)脈內(nèi)-中膜厚度和斑塊與顱內(nèi)動(dòng)脈粥樣硬化關(guān)系的研究

2013-04-06 02:22白洪忠張雪萍陳顏強(qiáng)
關(guān)鍵詞:胸科單支高脂血癥

白洪忠,張雪萍,李 雯,張 慶,陳顏強(qiáng)*

(1.河北省胸科醫(yī)院醫(yī)務(wù)處,河北石家莊050041;2.河北省胸科醫(yī)院護(hù)理部,河北石家莊050041;3.河北省胸科醫(yī)院影像科,河北石家莊050041;4.河北省胸科醫(yī)院神經(jīng)內(nèi)科,河北石家莊050041)

·論 著·

缺血性腦卒中患者頸動(dòng)脈內(nèi)-中膜厚度和斑塊與顱內(nèi)動(dòng)脈粥樣硬化關(guān)系的研究

白洪忠1,張雪萍2,李 雯3,張 慶4,陳顏強(qiáng)4*

(1.河北省胸科醫(yī)院醫(yī)務(wù)處,河北石家莊050041;2.河北省胸科醫(yī)院護(hù)理部,河北石家莊050041;3.河北省胸科醫(yī)院影像科,河北石家莊050041;4.河北省胸科醫(yī)院神經(jīng)內(nèi)科,河北石家莊050041)

目的研究缺血性腦血管?。╥schemic cerebrovascular disease,ICVD)患者頸動(dòng)脈內(nèi)-中膜厚度(common carotid artery intimamedia thickness,CCA-IMT)和斑塊與顱內(nèi)動(dòng)脈粥樣硬化的關(guān)系。方法對(duì)374例ICVD患者進(jìn)行頸部血管超聲檢查,根據(jù)結(jié)果分為頸動(dòng)脈正常組、CCA-IMT增厚組、頸動(dòng)脈斑塊組,并對(duì)所有患者行顱內(nèi)血管結(jié)構(gòu)檢查,將患者分為顱內(nèi)動(dòng)脈正常組、粥樣硬化組,后者再分為輕度動(dòng)脈粥樣硬化組、單支動(dòng)脈狹窄組、多支動(dòng)脈狹窄組,分析CCA-IMT與顱內(nèi)動(dòng)脈粥樣硬化的關(guān)系。結(jié)果CCA-IMT增厚組患者顱內(nèi)動(dòng)脈粥樣硬化的比率高,頸動(dòng)脈斑塊組患者顱內(nèi)動(dòng)脈粥樣硬化、顱內(nèi)動(dòng)脈狹窄、多支動(dòng)脈狹窄的比率高,年齡、高血壓病、高脂血癥與CCA-IMT增厚有關(guān)。結(jié)論CCA-IMT增厚與顱內(nèi)動(dòng)脈粥樣硬化有關(guān),頸動(dòng)脈斑塊與顱內(nèi)動(dòng)脈狹窄關(guān)系密切,應(yīng)積極控制高血壓病、高脂血癥,預(yù)防CCA-IMT增厚。

腦血管意外;頸動(dòng)脈狹窄;動(dòng)脈粥樣硬化

顱內(nèi)動(dòng)脈粥樣硬化狹窄是亞洲缺血性腦血管?。╥schemic cerebrovascular disease,ICVD)公認(rèn)的常見原因,而西方人顱外頸動(dòng)脈疾病多見,頸動(dòng)脈內(nèi)-中膜厚度(common carotid artery intima media thickness,CCA-IMT)是ICVD的一種危險(xiǎn)因素[1-2]。研究[3]證明,CCA-IMT增厚和顱內(nèi)動(dòng)脈狹窄與ICVD的發(fā)生密切相關(guān),本研究目的在于論證CCAIMT增厚和斑塊與顱內(nèi)動(dòng)脈粥樣硬化的關(guān)系。

1 資料與方法

1.1 一般資料:選擇2010年1月—2012年1月我院神經(jīng)科住院的新發(fā)缺血性卒中患者374例,男性191例(51.1%),女性183例(48.9%),年齡22~92歲,平均(63.89±11.17)歲;其中腦梗死333例,短暫性腦缺血發(fā)作(transient ischemic attack,TIA)41例。發(fā)病7d以內(nèi),均經(jīng)頭顱磁共振成像證實(shí)。排除腦出血、腦腫瘤、顱內(nèi)或全身感染、精神病。374例患者中存在頸動(dòng)脈粥樣硬化者271例(72.4%),其中CCA-IMT>1.10mm~1.13mm者82例(21.9%),CCA-IMT>1.13mm者189例(50.5%),軟斑71例(19.0%);374例患者中顱內(nèi)動(dòng)脈粥樣硬化者296例(79.1%),其中輕度腦動(dòng)脈硬化62例(16.6%),單支動(dòng)脈狹窄80例(21.3%),多支動(dòng)脈狹窄154例(41.2%)。

1.2 頸動(dòng)脈超聲檢查:所有患者均進(jìn)行頸動(dòng)脈超聲檢查,觀察并記錄CCA-IMT,有無(wú)粥樣硬化斑塊及其回聲和表面特征。判別標(biāo)準(zhǔn),CCA-IMT≤1.10mm為正常,>1.10~1.13mm之間為增厚,>1.13mm視為粥樣硬化斑塊。

1.3 顱內(nèi)動(dòng)脈狹窄測(cè)量:所有患者均行頭顱MRA檢查,采用WASID方法判斷顱內(nèi)動(dòng)脈狹窄的程度[4],狹窄率=(1-狹窄直徑/正常直徑)×100%。正常直徑的標(biāo)準(zhǔn)首選動(dòng)脈近端管腔最寬、無(wú)彎曲、正常的節(jié)段;如果動(dòng)脈近端有病變,由動(dòng)脈遠(yuǎn)端管腔最寬、直行的正常節(jié)段代替。如果某條動(dòng)脈多處狹窄,選最重的一處,如果動(dòng)脈嚴(yán)重狹窄出現(xiàn)截?cái)喱F(xiàn)象,狹窄率定為99%。根據(jù)狹窄程度分為正常、輕度動(dòng)脈粥樣硬化(狹窄率≤50%)、單支嚴(yán)重狹窄(狹窄率>50%)、多支嚴(yán)重狹窄。

1.4 研究分組:根據(jù)頸動(dòng)脈超聲結(jié)果將所有患者分為正常組、CCA-IMT增厚組、斑塊組;根據(jù)顱內(nèi)動(dòng)脈粥樣硬化程度不同將患者分為正常組、輕度動(dòng)脈硬化組、單支嚴(yán)重狹窄組、多支嚴(yán)重狹窄組。

1.5 統(tǒng)計(jì)學(xué)方法:應(yīng)用SPSS17.0軟件包進(jìn)行統(tǒng)計(jì)分析。計(jì)數(shù)資料以百分率表示,采用χ2檢驗(yàn);多因素分析采用Logistic回歸分析。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

2.1 CCA-IMT與顱內(nèi)動(dòng)脈粥樣硬化的關(guān)系:與CCA-IMT≤1.10mm組比較,CCA-IMT>1.10mm組顱內(nèi)動(dòng)脈粥樣硬化(輕度硬化+單支狹窄+多支狹窄)比率高[86.9%(205/236)∶65.9%(91/138),χ2=7.297,P<0.05]。同樣與CCA-IMT≤1.13mm組比較,CCA-IMT>1.13mm組顱內(nèi)動(dòng)脈粥樣硬化比率高[90.2%(111/123)∶73.7%(185/251),χ2= 4.726,P<0.05];CCA-IMT>1.13mm組顱內(nèi)動(dòng)脈狹窄(單支狹窄+多支狹窄)比率87.0%(107/123),高于對(duì)照組的50.6%(127/251)(χ2=5.782,P<0.05);CCA-IMT>1.13mm組顱內(nèi)動(dòng)脈多支狹窄比率更高為58.5%(72/123),而CCA-IMT≤1.13mm組顱內(nèi)動(dòng)脈多支狹窄比率僅為32.7%(82/251),2組差異有統(tǒng)計(jì)學(xué)意義(χ2=35.784,P<0.05)。

2.2 CCA-IMT與顱內(nèi)單一動(dòng)脈狹窄的關(guān)系:CCAIMT>1.10mm組分別合并大腦前動(dòng)脈、大腦中動(dòng)脈、大腦后動(dòng)脈、頸內(nèi)動(dòng)脈顱內(nèi)段、椎動(dòng)脈、基底動(dòng)脈上述單一動(dòng)脈狹窄的比率與CCA-IMT≤1.10mm組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。

2.3 CCA-IMT的危險(xiǎn)因素:年齡與CCA-IMT關(guān)系密切,年齡越大,CCA-IMT值越高(χ2=7.903,P<0.05)。另外,高血壓、高脂血癥既是腦卒中的危險(xiǎn)因素又是CCA-IMT增厚的危險(xiǎn)因素(= 10.800,=6.121,P<0.05)。性別、糖尿病、

冠心病、吸煙與CCA-IMT增厚無(wú)關(guān)。Logistic多因素分析顯示,高血壓?。∣R高血壓=4.062,P= 0.001)、高脂血癥(OR高脂血癥=3.433,P=0.015)與CCA-IMT增厚有關(guān)。

3 討 論

顱內(nèi)大動(dòng)脈和顱外頸動(dòng)脈狹窄是ICVD的常見原因,本研究發(fā)現(xiàn)ICVD患者顱內(nèi)動(dòng)脈狹窄(79.1%)和頸動(dòng)脈粥樣硬化(72.4%)的比率均較高。中國(guó)患者以顱內(nèi)動(dòng)脈狹窄為主[5],顱內(nèi)動(dòng)脈狹窄的進(jìn)展與同側(cè)缺血性事件的發(fā)生獨(dú)立相關(guān)[6],因其對(duì)患者生命構(gòu)成威脅大且預(yù)后多不良,因此早期發(fā)現(xiàn)、預(yù)防及控制顱內(nèi)動(dòng)脈狹窄的發(fā)生發(fā)展有重要的意義。

國(guó)外研究[7-8]發(fā)現(xiàn),CCA-IMT增厚與顱內(nèi)動(dòng)脈狹窄密切相關(guān)。研究[9]表明,CCA-IMT增厚和頸動(dòng)脈班塊是ICVD的獨(dú)立預(yù)測(cè)因子。提示CCA-IMT增厚和頸動(dòng)脈斑塊與ICVD、顱內(nèi)動(dòng)脈狹窄有關(guān)。本研究結(jié)果顯示,CCA-IMT>1.10mm和CCA-IMT>1.13mm均與顱內(nèi)動(dòng)脈粥樣硬化關(guān)系密切,且CCAIMT>1.13mm還與顱內(nèi)動(dòng)脈狹窄、多支動(dòng)脈狹窄密切相關(guān),CCA-IMT數(shù)值越高,顱內(nèi)動(dòng)脈病變?cè)街?。說明動(dòng)脈粥樣硬化是全身性的血管疾病,頸動(dòng)脈和顱內(nèi)動(dòng)脈粥樣硬化有相同的發(fā)病機(jī)制、相似的危險(xiǎn)因素、共同的病理生理學(xué)基礎(chǔ)。

年齡是CCA-IMT值增高的一個(gè)危險(xiǎn)因素。本研究發(fā)現(xiàn)隨著年齡增高,CCA-IMT的數(shù)值逐漸增加(P<0.05)。日本有研究發(fā)現(xiàn)隨著年齡增長(zhǎng),每年CCA-IMT大約增加0.009mm[10]。但年齡與CCAIMT之間的關(guān)系還需更長(zhǎng)時(shí)間的隨訪觀察來(lái)證實(shí)。

本研究還發(fā)現(xiàn)高血壓病、高脂血癥與CCA-IMT值增高密切相關(guān)。與Khan等[11]研究一致。血脂尤其是低密度脂蛋白膽固醇升高可以損傷血管內(nèi)皮,形成粥樣斑塊,促進(jìn)血小板凝集形成血栓。血清總膽固醇升高反映了低密度脂蛋白膽固醇顆粒的增加,而低密度脂蛋白膽固醇是血漿脂蛋白最主要的致動(dòng)脈粥樣硬化性脂蛋白,可將血中總膽固醇攜帶到外周組織,載脂蛋白E是低密度脂蛋白膽固醇受體的專一配體,在低密度脂蛋白膽固醇的清除中起關(guān)鍵作用。這些血脂成分的變化必然影響動(dòng)脈粥樣硬化斑塊的形成。因此,積極控制高血壓病、高脂血癥,對(duì)預(yù)防大動(dòng)脈粥樣硬化性腦卒中有積極意義。

[1]LENG XY,CHEN XY,CHOOK P,et al.Correlation of large artery intracranial occlusive disease with carotid intima-media thickness and presence of carotid plaque[J].Stroke,2013,44(1):68-72.

[2]邸衛(wèi)英,高瑞麗,高陽(yáng),等.缺血性腦卒中患者頸動(dòng)脈超聲檢測(cè)的臨床意義[J].河北醫(yī)科大學(xué)學(xué)報(bào),2006,27(5):385-388.

[3]SZABóKJ,ADáNY R,BALLA J,et al.Advances in the prevention diagnosis and therapy of vascular diseases[J].Orv Hetil,2012,153(13):483-498.

[4]NENEZI?D,TANASKOVI?S,GAJIN P,et al.Diagnostic dilemmas of multislice CT angiography in the evaluation of the degree of common carotid artery stenosis[J].Srp Arh Celok Lek,2010,138(7/8):494-497.

[5]鄧曉,石勝良,程道賓,等.缺血性卒中患者顱內(nèi)動(dòng)脈狹窄的相關(guān)危險(xiǎn)因素分析[J].中華神經(jīng)醫(yī)學(xué)雜志,2010,9(7):666-669.

[6]李瑤宣,李呂力,鐘維章,等.頸動(dòng)脈內(nèi)-中膜厚度和斑塊對(duì)顱內(nèi)動(dòng)脈狹窄嚴(yán)重程度的預(yù)測(cè)價(jià)值[J].中國(guó)神經(jīng)精神疾病雜志,2010,36(4):201-204.

[7]MATSUMOTOM,INOUE K,MORIKIA.Associations of brachial ankle pulse wave velocity and carotid atherosclerotic lesions with silent cerebral lesions[J].Hypertens Res,2007,30(9):767-773.

[8]LEE YH,YEH SJ.Correlation of common carotid artery intima media thickness,intracranial arterial stenosis and post-stroke cognitive impairment[J].Acta Neurol Taiwan,2007,16(4):207-213.

[9]PRATIP,TOSETTO A,VANUZZO D,et al.Carotid intimamedia thickness and plaques can predict the occurrence of ischemic cerebrovascular events[J].Stroke,2008,39(9):2470-2476.

[10]HOMMA S,HIROSE N,ISHIDA H,et al.Carotid plaque and intima-media thickness assessed by b-mode ultrasonography in subjects ranging from young adults to centenarians[J].Stroke,2001,32(4):830-835.

[11]KHAN SP,AHMED KZ,YAQUB Z,et al.Carotid intima-media thickness correlation with lipid profile in patients with familial hypercholesterolemia versus controls[J].JColl Physicians Surg Pak,2011,21(1):30-33.

(本文編輯:趙麗潔)

RELATIONSHIP BETWEEN CAROTID INTIMA-MEDIA THICKNESS AND
PLAQUEW ITH INTRACRANIAL ATHEROSCLEROSIS IN PATIENTSW ITH ISCHEM IC STROKE

BAIHongzhong1,ZHANG Xueping2,LIWen3,ZHANG Qing4,CHEN Yanqiang4*
(1.Department of Medical Service,Hebei Chest Hospital,Hebei Province,Shijiazhuang 050041,China;2.Department of Nursing,Hebei Chest Hospital,Hebei Province,Shijiazhuang 050041,China;3.Department of Medicine Imaging,
Hebei Chest Hospital,Hebei Province,Shijiazhuang 050041,China;4.Department of Neurology,Hebei Chest Hospital,Hebei Province,Shijiazhuang 050041,China)

Objective To investigate the correlation between carotid intima-media thickness(CCA-IMT),carotid plaques,and the extent of intracerebral atherosclerosis in patients with ischemic cerebrovascular disease(ICVD).MethodsCarotid vascular ultrasound and intracranial vascular structure check were examined in 374 patients with ICVD.According to the result of carotid vascular ultrasound,all patients were divided into normal carotid artery group,CCA-IMT thickening group and carotid plaque group.According to the structure of intracerebral artery,all the patients were divided into normal intracerebral artery group and atheroscleresis group,and the latter group was subdivided intomild atheroscleresis group,single artery stenosis group and multiple artery stenosis group.Analysis was performed on the relationship between CCA-IMT and intracerebral atherosclerosis.ResultsCompared with normal groups,the rate of intracerebral atherosclerosis in CCA-IMT group was higher.The rates of

cerebrovascular accident;carotid stenosis;atherosclerosis

R743

A

1007-3205(2013)06-0626-03

2013-02-25;

2013-04-26

河北省衛(wèi)生廳重點(diǎn)課題(20120238)

白洪忠(1975-),男,河北滄縣人,河北省胸科醫(yī)院主治醫(yī)師,醫(yī)學(xué)學(xué)士,從事醫(yī)學(xué)影像診斷研究。

*通訊作者。E-mail:chenyanqiang497@126.com

10.3969/j.issn.1007-3205.2013.06.003

intracerebral atherosclerosis and arterial stenosis and multiple intracranial artery stenosis in carotid plaque patientswere higher.Patientswith ICVD disease accompanied by older age,hypertension,hyperlipidemia weremore likely subjected to increased CCA-IMT value.ConclusionThe thickening of CCA-IMT is related with the intracranial atherosclerosis.Carotid atherosclerotic plaque and intracranial artery stenosis are closely related.Hypertension and hyperlipidemia should be effectively controlled to prevent CCA-IMT thickening.

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