缺血性中风急性期大小动脉病变的证候研究
摘要
背景
脑血管疾病是神经系统的常见病和多发病,死亡率约占所有疾病的10%,是目前人类疾病三大死亡原因之一,且50%-70%的存活者遗留瘫痪、失语等严重残疾。由于其具有“发病率高”、“死亡率高”、“致残率高”、“复发率高”的特点,给社会和家庭带来沉重负担,也成为近年来临床研究的热点。依据病理性质,脑血管病大致分为出血性卒中(hemorrhagic stroke)和缺血性卒中(ischemic stroke),前者主要包括脑出血和蛛网膜下腔出血,后者总称为“脑梗死”(cerebral infarction, CI),包括脑血栓形成、腔隙性梗死和脑栓塞等,约占全部脑卒中的70%,中风急性期是中风病治疗的关键时期,认识和把握此阶段的病因病机对本病的治疗具有极为重要的意义
从现代医学研究,缺血性卒中大、小动脉病变患者群,具有不同的病因、发病机制、神经病理学改变、神经影像学改变、临床表现及预后。现代医学对缺血性卒中的分类研究越来越深入。目前国际上对缺血性脑卒中采用的最主要的分类方法,仍然是解剖学和病因学,TOAST分型是国际上常用的分型方法。
既往研究的热点集中于病情比较重的脑大动脉病变,而脑小血管病情较轻、临床症状隐匿,对其关注不足。随着科学的发展,发现脑小血管发病率高,病程呈阶梯样或逐步进展,持续数年后出现神经功能缺损,常导致假性球麻痹和皮层下痴呆。在2008年的国际卒中会议和欧洲卒中会议上都提出了“小血管病引起大问题”
本研究以大小动脉病变为分类标准,进行缺血性中风急性期证候分类及相关西医指标与大小动脉病变的相关性分析、缺血性中风急性期大小动脉病变的中医证候演变规律研究、缺血性中风大小动脉病变与中风病预后之间的关系研究。
研究目的
1.比较缺血性中风急性期大小动脉病变之间的证候、相关西医指标差异
2.寻找缺血性中风急性期大小动脉病变的中医证候演变规律
3.探索缺血性中风大小动脉病变与中风病预后之间的关系
研究方法
以发病7天以内的缺血性中风急性期患者为研究对象,对缺血性脑血管病采用《各类脑血管病诊断要点》为标准,中风病采用《中风病诊断与疗效评定标准》,证候要素诊断评价采用《中风病辨证诊断标准》,主要采用缺血性脑血管病TOAST分型诊断标准结合影像学依据的方法,将患者分为大动脉病变和小动脉病变组,对证候要素进行6个时点的实时、动态采集,时点设计为分别为发病后1、2、3、7、14、28天,以期通过对各时点证候量表评分的动态分析,探讨其演变规律。对患者进行NIHSS,改良Rankin评分、ADL三个量表信息的动态采集,探讨缺血性中风大小动脉病变与预后之间的关系。在北京中医药大学东方医院神经内科和东直门医院神经内科收集病例,共收集病例207例,其中男性129例,女性78例。年龄最小39岁,最大85岁,平均年龄66.63±11.21岁。大血管病变87例,小血管病变120例。
使用Access2003数据库软件建立数据库,双人双录入数据。应用SPSS17.0软件对数据进行分析。
结果
1.缺血性中风急性期证候分类及相关西医指标与大小动脉病变的相关性研究结果
(1)通过大小动脉病变两组患者人群一般信息的比较,两种病变人群在性别、年龄、身高、体重、民族、婚况等几个方面无显著性差异
(2)在既往病史方面,两组人群在冠心病、房颤和其他心脏病史几个方面差异显著。在大动脉病变中,具有此三类病史的患者较多。在并发症方面,出现心律失常的患者虽然只有4个,但全部属于大动脉病变,差异具有显著意义。
(3)在理化检查方面,两组患者在淋巴细胞百分比、HDL、LDL三个方面差异显著,其中大动脉病变患者三个指标水平都较低。
两组人群在颈部血管彩超结果各血管数据方面未见显著性差异。
TCD相关数据显示,大血管病变患者中,血管高流速的比例较高,差异具有显著意义
(4)在神经科量表方面,大动脉病变患者在NIHSS评分、改良Rankin评分,差异具有显著意义
(5)通过对中医证候量表证候判断的组间比较,阴虚阳亢证组间显示出显著差异,此证候在小血管病变中所占比例较高。
通过对中医证候量表单条目评分和总分的比较,只有痰证量表当中的痰一个条目评分在组间显示出显著差异(P=0.034),此条目在大血管病变中评分较高。
(6)与大小动脉病变相关的西医指标采用Logistic回归分析,结果模型当中保留了冠心病史、其它心脏病史、LDL、TCD血管高流速与大小血管病变相关,具有显著意义。
与大小动脉病变相关的中医指标包括中医阴虚阳亢证、痰评分值两项。采用Logistic回归,两者为相互独立因素,其中痰评分值升高支持大动脉病变诊断,阴虚阳亢证判断支持小动脉病变诊断。
2.缺血性中风急性期大小动脉病变的中医证候演变规律
(1)风证证候评分曲线两组表现出不同的特征。大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第3天。每个时点各自进行T检验组间比较,均无显著性差异。采用重复方差分析,包括各时点数据在内的组间差异不显著P=0.295。
各时点风证在研究人群中出现频率的动态趋势和风证评分显示类似的表现。大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第3天。每个时点各自进行间比较,均无显著性差异。
(2)火热证证候评分曲线大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷。但大动脉病变曲线峰值出现在第3天,小动脉出现在第7天。每个时点各自进行T检验组间比较,第2、3、28天有显著性差异。
采用重复方差分析,包括各时点数据在内的组间差异有统计学意义,P=0.025。
各时点火证在研究人群中出现频率的动态趋势与证候评分类似,大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。每个时点各自进行组间比较,第3天有显著性差异。
(3)痰证证候评分曲线大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第3天。每个时点各自进行T检验组间比较,第2、3、7、14、28天均有显著性差异
采用重复方差分析,包括各时点数据在内的组间差异有统计学意义,P=0.0001。
痰证证候比率曲线趋势与评分曲线类似,先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。第3至7天的曲线较为平缓。每个时点各自进行组间比较,第2、3、7、14、28天均有显著性差异。
(4)血瘀证证候评分曲线大动脉曲线先上升,后下降,大动脉峰值出现在第2天,小动脉峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。每个时点各自进行T检验组间比较,第2、3、28天均有显著性差异。采用重复方差分析,包括各时点数据在内的组间差异有统计学意义,P=0.010
血瘀证证候比率曲线趋势均为先上升,后下降,峰值出现在第3天。小动脉曲线未见波谷现象。每个时点各自进行组间比较,第14天有显著性差异。
(5)气虚证证候评分曲线也为一先上升,后下降的曲线。大动脉曲线峰值出现在第3天,小动脉为第7天。每个时点各自进行T检验组间比较,第3、28天均有显著性差异。
采用重复方差分析,包括各时点数据在内的组间差异无统计学意义,P=0.084。
气虚证证候比率曲线趋势与评分曲线类似,先上升,后下降,大动脉曲线峰值出现在第3天,小动脉为第7天。每个时点各自进行组间比较,第28天有显著性差异。
(6)阴虚阳亢证证候评分曲线两组表现出不同的特征。大动脉曲线先上升,后下降,峰值出现在第14天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。每个时点各自进行T检验组间比较,各时点均无显著性差异。
采用重复方差分析,包括各时点数据在内的组间差异无统计学意义,P=0.451。
证候比率曲线趋势与评分曲线表现出类似特征。大动脉曲线先上升,后下降,峰值出现在第14天；小动脉曲线表现出先下降,再上升,第3天有一谷值,峰值为第7天。每个时点各自进行组间比较,第1天有显著性差异。
3.探索缺血性中风大小动脉病变与中风病预后之间的关系
(1)通过各个时点的大小动脉病变组间的非参数检验分析,各个时点之间两组NIHSS均有显著差异,其中大动脉病变组NIHSS在各个时点均较高。NIHSS得分曲线表现出和证候曲线类似的规律,小动脉曲线在第二天有一波谷波峰在3-7天之间。
(2)经非参数检验分析,大小动脉病变与发病后28天改良Rankin评分显著差异。
(3)经非参数检验,大小动脉病变与发病后28天ADL得分无显著差异结论
1.中风病患者卒中发病后,在西医角度,冠心病史、其它心脏病史、LDLTCD血管高流速为与大小血管病变相关的独立因素。从中医角度,中医阴虚阳亢证、痰评分值为与大小血管病变相关的独立因素。
2.中风病各证候要素信息病后1、2、3、7、14、28天六个时点的动态演变显示出一定的规律性,初步总结如下：同一证候要素的评分和发生率时点变化曲线基本显示出类似的趋势；基于大小动脉病变的不同,大动脉病变患者火热证、痰证、血瘀证三证均表现出较高的评分和较高的发生率；基于大小动脉病变的不同,证候评分和发生率动态演变趋势有所不同。
3.中风病发病后NIHSS量表得分的动态演变显示出与证候得分类似的规律性,大动脉病变的曲线多为发病后先上升,后下降的曲线；而小动脉病变曲线表现为先下降后上升,再下降的曲线,在第二天多会出现一个波谷,曲线波峰多在3天-7天之间。
4.大动脉病变较小动脉病变组预后差。
Background
Cerebrovascular disease is a common and frequently occuring illness in nervous system with the mortality of 10% of all the disease,being one of three important causes of death, additionally,50%-70% survivors retain severe disability, such as paralysis and alalia ect.lt becomes the focuse hot spot on clinical study due to the characteristics of "high morbidity", "high mortality", "high disabilities", "high relapsement rate" and the unsustainable burden for the society and families. Cerebrovascular disease can be mainly devided into hemorrhagic stroke and ischemic stroke, and the former one includes the cerebral haemorrhage and subarachnoid hemorrhage, while the latter is called cerebral infarction (CI) including cerebral thrombosis, lacunar infarct and cerebral embolism and so on with about 70% of all the stroke. Acute phase is a critical period of stroke treatment, thus, it is significant to understand and master the stage of pathogeny and pathogenesis on the treatment of this disease.
From the modern medical research, ischemic stroke large and small artery disease patient groups with different etiology, pathogenesis, neuropathology changes, changes in neural imaging, and clinical outcome. Modern medicine's classification of ischemic stroke deeper. Current international use of ischemic stroke the most important classification is still the anatomy and etiology, TOAST classification is commonly used international classification method. Hot previous research focused on comparative weight of brain artery disease lesions, and cerebral small vessel disease less severe, clinical symptoms hidden, its lack of concern. With the development of science, found a high incidence of cerebral small vessels, a ladder-like or progressive course of disease progress for several years after neurological deficit, often leading to pseudobulbar palsy and subcortical dementia. In 2008, the International Stroke Conference and the European Stroke Conference, both made "small vascular disease is the cause of the problem."
This paper devides intio three parts to study as follows:the classification of syndrome in the ischemic apoplexy at acute stage and the correlation analysis of the Western medicine indicators and the related analysis on the large and small cerebral artery disease, an the study on the development rules in the traditional Chinese medicine of ischemic apoplexy at acute stage as well as the relationship between the ischemic large and small artery pathology and stroke prognosis.
Study Aim
1.The related anaylisis on the acute period of ischemic stroke syndromes meridian card and the size of the correlation in arterial lesions
2.Find the evolution rule of traditional Chinese medicine in artery disease on Acute stage in ischemic apoplexy
3.Explore the relationship between the arterial ischemic stroke lesions and the prognosis for stroke patients
Research methods
Studied the paitents of acute stage in ischemic apoplexy within 7 days and adopted the《Diagnosis main points of all kinds of cerebrovascular disease》on the ischemic cerebrovascular disease, the diagnosis and evaluation of syndrome factor are adopted《the syndrome differentiation and diagnosis criteria of stroke》, mainly using the standard of diagnose and dividing type of ischemic cerebrovascular disease TOAST combined with imageology. The patients are divided into large cerebral artery disease group and arteriolopathy to do the collection on thesyndrome factors in 6-hour real time and dynamic state, therefore, we find that the pointoftime design is respectively 1day,2 days,3 days,7 days,14 days and 28 days after morbidity to discuss the development rule through the syndrome scale scores at each time and the dynamic analysis of syndrome.Additinally, the acquisition of dynamic state of NIHSS,improvement score and ADL rating scale are for the patients to discuss the relationship between the patholog of ischemic large and small artery and prognosis.We collect 207 cases in neurology of Dongfang Hospital in Beijing University of Chinese Medicine and of Dongzhimen Hospital with 129 of masculinity and 78 of feminality.The youngest age is 39 and the oldest is 85 and the avearge age is 66.63±11.21 with 87 Macroangiopathy and 120 Small vessel lesions.
Using the Access2003 database to establish a database,two people log data in the applicatins of SPSS 17.0 software to anyalyze the data.
Result
1. The related study result for the classification of acute ischemic stroke and the related Western syndromes indexs and size of artery disease
(1) Compared with the general information among the two groups of the artery disease patients, we can find that there are not any significant differences among the sex, age, height, weight, ethnicity, marital status and other aspects between them.
(2) As for the past medical history,there are significantly differences on the coronary heart disease, atrial fibrillation, and other aspects in the two groups.There are more patients with the following diseases in the main artery lesion.
(3) As for the physical and chemical inspection, it is significantly different to the lymphocyte percentage, HDL, LDL in the two groups in that the levels of the patietns with large artery lesion are lower in the three indicators.
There is no significant difference in the neck vascular ultrasound data results of the blood vessel.
TCD data shows that the difference is significant on the proportion of vessel is higher with high velocity in the patients with large vessel disease
(4)There is a significance on the difference in the NIHSS score and modified Rankin score for the patients with large artery lesions in the neurological scale.
(5) Compared with groups in the syndrome judgement of the IBS QOL questionnaire in TCM syndrome,the Asthenic yin and predominant yang group show the significant differences, and this syndrome is in a high proportion of small vessel disease.
Compared with the groups of the syndrome scale of the traditional Chinese medicine, we can find that the the groups of yin deficiency and yang upward syndrome shows the significant differences, and this syndrome of small vessel disease is in a high proportion.
(6) Adopted with the logistic regression analysis related to the arterial lesions of the Western targets, it is of significances to the model of the results retains the previous atrial fibrillation history, other history of heart disease, LDL TCD high velocity and the size associated with vessel vascular lesions. The Chinese medicine index associated with the size of arterial lesions include the yin deficiency and yang upward syndrome and sputum score value.Using logistic regression,they are the mutual independence factors in that the increase on the sputum rating value supports the diagnosis of artery disease, and the yin deficiency and yang upward syndrome supports the small artery lesions.
2. The TCM syndrome development rule of the large and small cerebral artery disease in the acute ischemic stroke lesion
(1) The wind syndrome score curves show the different characteristics. Firstly, the artery curve rose,and then it declined,and the peak value was on the third day;firstly the small artery curve decreased and then went up, then went down, it has a wave trough, and the peak was the third day. The repeated variance analysis is used including the nonsignificant difference between groups P=0.295 in the time point data.
The wind frequency at each time point shows a similar performance in the study population trends of dynamic score and wind dynamic score.Firstly the Artery curverose, then it declined,and the peak value was in the third day;firstly the small artery curve declined, and then it decreased, it had a wave trough through in the second day and the peak value was the third day.Compared with each time point, there was no significant difference.
(2) Firstly, the hot syndrome score curve artery curve increased,then it decreased,and the peak value was in the third day; and the small artery curve first decreased and then showed up, and a wave trough was in the second day with the peak value on the third day;however, the peak curve value was in the third day and the small artery was in the 7th day.Compared with the T test for each time point, the 2th,3rd and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.295 in the time point data, which is significant on statistics.
The dynamic trend is similar to the syndrome score of the appeared frequency in the study people at each time ignition proof.The artery curve firstly increased, then it decreased in the third day;small artery curves firstly decreased and then increased,and further it decreased with a wave trough of the third day.Compared with the groups for each time point, the 2th,3rd days have the significant differences.
(3) Firstly,the large artery carve of the Phlegm syndrome score increased,then it decreased,and the peak value was in the third day; and the small artery curve first decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the third day; Compared with the T test for each time point,the 2th,3rd,7th,14th and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.0001 in the time point data, which is significant on statistics.
The ratio of the trend curve in the Phlegm syndrome is similar to the score carve,firstly it increased,then it decreased,and the peak value was in the third day; small artery curve first decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the third day; and it was mild in the the 3rd and the 7th. Compared with each time point, the 2th,3rd,7th,14th and the 28th days have the significant differences.
(4) Firstly, the large artery carve of the score carve in the blood stasis syndrome syndrome it increased,then it decreased,and the peak value was in the third day; small artery curve first decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the third day; Compared with the T test for each time point, the 2th,3rd, and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.0001 in the time point data, which is significant on statistics.
The blood stasis syndrome syndrome firstly increased,then it decreased,and the peak value was in the third day; small artery curve has no wave trough Compared with each time point, the 14th day has the significant differences.
(5) The score carve of qi-deficiency syndrome syndrome firstly increased,then it decreased,and the peak value of large artery carve was in the 3rd day while the small artery carve was in the 7rd day. Compared with the T test for each time point, the,3rd, and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.084 in the time point data, which is not significant on statistics.
The trend curve of deficiency of vital energy syndrome ratio is similar to the score carve, firstly it increased,then it decreased,and the peak value of large artery carve was in the 3rd day while the small artery carve was in the 7rd day. Compared with each time point, the 14th day has the significant differences.
(6) The two groups of the yin deficiency and yang excess syndrome showed different characteristics. Firstly it increased,then it decreased,and the peak value of large artery carve was in the 14th day while the small artery carve firstly decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the 7th day; Compared with the T test for each time point, they haveno significant differences.
The repeated variance analysis is used including the difference between groups P=0.451 in the time point data, which isn't significant on statistics.
The trend curve of syndrome rate is similar to the score carve. The large artery carve firstly increased, then it decreased with a peak value on the 14th day;small artery curves firstly decreased and then increased,and it had a valley value of the third day and the peak value of the 7th day. Compared with each time point, the 1st day has the significant differences.
3.Discussion on the relationship between the ischemic strokel large and small artery pathology and stroke prognosis.
(1) Analyzed on the non-parametric tests of the large and small artery pathology at each time point, there is significantly difference between the two groups of NIHSS in that the NIHSS of large artery pathology was so high at each time point.
NIHSS score curve and the syndrome showed a similar rule curve, the small artery curve has a trough in the next day with the peak between 3-7 days.
(2) It is significant to the large and small artery pathology and the improvement Rankin score after the invasion with 28 days of improvement on the non-parametric tests and analysis.
(3) There is no significant difference on the large and small artery pathology and the 28 days of improvement after the invasion on the non-parametric tests and analysis.
Conclusion
1. The apoplexy invasion of the stroke patients attacked on the first day, and the past history of atrial fibrillation, history of other heart disease, LDL, TCD high flow vascular lesions associated with the independent factors of the size of the vessel, and the LDL level is negatively correlated with macrovascular disease,while the other factors are positive correlation. From the perspective of Chinese medicine, Chinese medicine yin deficiency and yang excess, sputum score value and the size of the independent factors related to vascular disease, in that the increased score value ofsputum supports the diagnosis of large artery disease, yin deficiency and yang excess supports the diagnosis of small artery
2.There is certain regularity of the dynamic progression on the essential factors after the 1st,2nd,3rd,7th,14th and 28th, we can conclude as follows:The same score of syndrome factor and the variation curve of the occurrence rate time point change showed the similar trend; Based on the size of arterial lesions in the different arterial lesions,the patients'FHP, phlegm, blood stasis three certificates have shown a higher rate and incidence; syndrome score and incidence of dynamic evolution trend are different artery disease based on the size of the artery pathology.
3.The trend development of the NIHSS scale score showed the similar regulation of the syndrome score. Firstly the large artery pathology increased,then it decreased, while the small artery carve firstly decreased and then showed up,and further it decreased again,and a wave trough appeared after the second day with the peak value between the 3th and 7th days.
4.The large artery pathology is worser than the prognosis of small artery.
脑血管疾病是神经系统的常见病和多发病,死亡率约占所有疾病的10%,是目前人类疾病三大死亡原因之一,且50%-70%的存活者遗留瘫痪、失语等严重残疾。由于其具有“发病率高”、“死亡率高”、“致残率高”、“复发率高”的特点,给社会和家庭带来沉重负担,也成为近年来临床研究的热点。依据病理性质,脑血管病大致分为出血性卒中(hemorrhagic stroke)和缺血性卒中(ischemic stroke),前者主要包括脑出血和蛛网膜下腔出血,后者总称为“脑梗死”(cerebral infarction, CI),包括脑血栓形成、腔隙性梗死和脑栓塞等,约占全部脑卒中的70%,中风急性期是中风病治疗的关键时期,认识和把握此阶段的病因病机对本病的治疗具有极为重要的意义
从现代医学研究,缺血性卒中大、小动脉病变患者群,具有不同的病因、发病机制、神经病理学改变、神经影像学改变、临床表现及预后。现代医学对缺血性卒中的分类研究越来越深入。目前国际上对缺血性脑卒中采用的最主要的分类方法,仍然是解剖学和病因学,TOAST分型是国际上常用的分型方法。
既往研究的热点集中于病情比较重的脑大动脉病变,而脑小血管病情较轻、临床症状隐匿,对其关注不足。随着科学的发展,发现脑小血管发病率高,病程呈阶梯样或逐步进展,持续数年后出现神经功能缺损,常导致假性球麻痹和皮层下痴呆。在2008年的国际卒中会议和欧洲卒中会议上都提出了“小血管病引起大问题”
本研究以大小动脉病变为分类标准,进行缺血性中风急性期证候分类及相关西医指标与大小动脉病变的相关性分析、缺血性中风急性期大小动脉病变的中医证候演变规律研究、缺血性中风大小动脉病变与中风病预后之间的关系研究。
研究目的
1.比较缺血性中风急性期大小动脉病变之间的证候、相关西医指标差异
2.寻找缺血性中风急性期大小动脉病变的中医证候演变规律
3.探索缺血性中风大小动脉病变与中风病预后之间的关系
研究方法
以发病7天以内的缺血性中风急性期患者为研究对象,对缺血性脑血管病采用《各类脑血管病诊断要点》为标准,中风病采用《中风病诊断与疗效评定标准》,证候要素诊断评价采用《中风病辨证诊断标准》,主要采用缺血性脑血管病TOAST分型诊断标准结合影像学依据的方法,将患者分为大动脉病变和小动脉病变组,对证候要素进行6个时点的实时、动态采集,时点设计为分别为发病后1、2、3、7、14、28天,以期通过对各时点证候量表评分的动态分析,探讨其演变规律。对患者进行NIHSS,改良Rankin评分、ADL三个量表信息的动态采集,探讨缺血性中风大小动脉病变与预后之间的关系。在北京中医药大学东方医院神经内科和东直门医院神经内科收集病例,共收集病例207例,其中男性129例,女性78例。年龄最小39岁,最大85岁,平均年龄66.63±11.21岁。大血管病变87例,小血管病变120例。
使用Access2003数据库软件建立数据库,双人双录入数据。应用SPSS17.0软件对数据进行分析。
结果
1.缺血性中风急性期证候分类及相关西医指标与大小动脉病变的相关性研究结果
(1)通过大小动脉病变两组患者人群一般信息的比较,两种病变人群在性别、年龄、身高、体重、民族、婚况等几个方面无显著性差异
(2)在既往病史方面,两组人群在冠心病、房颤和其他心脏病史几个方面差异显著。在大动脉病变中,具有此三类病史的患者较多。在并发症方面,出现心律失常的患者虽然只有4个,但全部属于大动脉病变,差异具有显著意义。
(3)在理化检查方面,两组患者在淋巴细胞百分比、HDL、LDL三个方面差异显著,其中大动脉病变患者三个指标水平都较低。
两组人群在颈部血管彩超结果各血管数据方面未见显著性差异。
TCD相关数据显示,大血管病变患者中,血管高流速的比例较高,差异具有显著意义
(4)在神经科量表方面,大动脉病变患者在NIHSS评分、改良Rankin评分,差异具有显著意义
(5)通过对中医证候量表证候判断的组间比较,阴虚阳亢证组间显示出显著差异,此证候在小血管病变中所占比例较高。
通过对中医证候量表单条目评分和总分的比较,只有痰证量表当中的痰一个条目评分在组间显示出显著差异(P=0.034),此条目在大血管病变中评分较高。
(6)与大小动脉病变相关的西医指标采用Logistic回归分析,结果模型当中保留了冠心病史、其它心脏病史、LDL、TCD血管高流速与大小血管病变相关,具有显著意义。
与大小动脉病变相关的中医指标包括中医阴虚阳亢证、痰评分值两项。采用Logistic回归,两者为相互独立因素,其中痰评分值升高支持大动脉病变诊断,阴虚阳亢证判断支持小动脉病变诊断。
2.缺血性中风急性期大小动脉病变的中医证候演变规律
(1)风证证候评分曲线两组表现出不同的特征。大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第3天。每个时点各自进行T检验组间比较,均无显著性差异。采用重复方差分析,包括各时点数据在内的组间差异不显著P=0.295。
各时点风证在研究人群中出现频率的动态趋势和风证评分显示类似的表现。大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第3天。每个时点各自进行间比较,均无显著性差异。
(2)火热证证候评分曲线大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷。但大动脉病变曲线峰值出现在第3天,小动脉出现在第7天。每个时点各自进行T检验组间比较,第2、3、28天有显著性差异。
采用重复方差分析,包括各时点数据在内的组间差异有统计学意义,P=0.025。
各时点火证在研究人群中出现频率的动态趋势与证候评分类似,大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。每个时点各自进行组间比较,第3天有显著性差异。
(3)痰证证候评分曲线大动脉曲线先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第3天。每个时点各自进行T检验组间比较,第2、3、7、14、28天均有显著性差异
采用重复方差分析,包括各时点数据在内的组间差异有统计学意义,P=0.0001。
痰证证候比率曲线趋势与评分曲线类似,先上升,后下降,峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。第3至7天的曲线较为平缓。每个时点各自进行组间比较,第2、3、7、14、28天均有显著性差异。
(4)血瘀证证候评分曲线大动脉曲线先上升,后下降,大动脉峰值出现在第2天,小动脉峰值出现在第3天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。每个时点各自进行T检验组间比较,第2、3、28天均有显著性差异。采用重复方差分析,包括各时点数据在内的组间差异有统计学意义,P=0.010
血瘀证证候比率曲线趋势均为先上升,后下降,峰值出现在第3天。小动脉曲线未见波谷现象。每个时点各自进行组间比较,第14天有显著性差异。
(5)气虚证证候评分曲线也为一先上升,后下降的曲线。大动脉曲线峰值出现在第3天,小动脉为第7天。每个时点各自进行T检验组间比较,第3、28天均有显著性差异。
采用重复方差分析,包括各时点数据在内的组间差异无统计学意义,P=0.084。
气虚证证候比率曲线趋势与评分曲线类似,先上升,后下降,大动脉曲线峰值出现在第3天,小动脉为第7天。每个时点各自进行组间比较,第28天有显著性差异。
(6)阴虚阳亢证证候评分曲线两组表现出不同的特征。大动脉曲线先上升,后下降,峰值出现在第14天；小动脉曲线表现出先下降后上升,再下降,第2天有一波谷,峰值为第7天。每个时点各自进行T检验组间比较,各时点均无显著性差异。
采用重复方差分析,包括各时点数据在内的组间差异无统计学意义,P=0.451。
证候比率曲线趋势与评分曲线表现出类似特征。大动脉曲线先上升,后下降,峰值出现在第14天；小动脉曲线表现出先下降,再上升,第3天有一谷值,峰值为第7天。每个时点各自进行组间比较,第1天有显著性差异。
3.探索缺血性中风大小动脉病变与中风病预后之间的关系
(1)通过各个时点的大小动脉病变组间的非参数检验分析,各个时点之间两组NIHSS均有显著差异,其中大动脉病变组NIHSS在各个时点均较高。NIHSS得分曲线表现出和证候曲线类似的规律,小动脉曲线在第二天有一波谷波峰在3-7天之间。
(2)经非参数检验分析,大小动脉病变与发病后28天改良Rankin评分显著差异。
(3)经非参数检验,大小动脉病变与发病后28天ADL得分无显著差异结论
1.中风病患者卒中发病后,在西医角度,冠心病史、其它心脏病史、LDLTCD血管高流速为与大小血管病变相关的独立因素。从中医角度,中医阴虚阳亢证、痰评分值为与大小血管病变相关的独立因素。
2.中风病各证候要素信息病后1、2、3、7、14、28天六个时点的动态演变显示出一定的规律性,初步总结如下：同一证候要素的评分和发生率时点变化曲线基本显示出类似的趋势；基于大小动脉病变的不同,大动脉病变患者火热证、痰证、血瘀证三证均表现出较高的评分和较高的发生率；基于大小动脉病变的不同,证候评分和发生率动态演变趋势有所不同。
3.中风病发病后NIHSS量表得分的动态演变显示出与证候得分类似的规律性,大动脉病变的曲线多为发病后先上升,后下降的曲线；而小动脉病变曲线表现为先下降后上升,再下降的曲线,在第二天多会出现一个波谷,曲线波峰多在3天-7天之间。
4.大动脉病变较小动脉病变组预后差。
Background
Cerebrovascular disease is a common and frequently occuring illness in nervous system with the mortality of 10% of all the disease,being one of three important causes of death, additionally,50%-70% survivors retain severe disability, such as paralysis and alalia ect.lt becomes the focuse hot spot on clinical study due to the characteristics of "high morbidity", "high mortality", "high disabilities", "high relapsement rate" and the unsustainable burden for the society and families. Cerebrovascular disease can be mainly devided into hemorrhagic stroke and ischemic stroke, and the former one includes the cerebral haemorrhage and subarachnoid hemorrhage, while the latter is called cerebral infarction (CI) including cerebral thrombosis, lacunar infarct and cerebral embolism and so on with about 70% of all the stroke. Acute phase is a critical period of stroke treatment, thus, it is significant to understand and master the stage of pathogeny and pathogenesis on the treatment of this disease.
From the modern medical research, ischemic stroke large and small artery disease patient groups with different etiology, pathogenesis, neuropathology changes, changes in neural imaging, and clinical outcome. Modern medicine's classification of ischemic stroke deeper. Current international use of ischemic stroke the most important classification is still the anatomy and etiology, TOAST classification is commonly used international classification method. Hot previous research focused on comparative weight of brain artery disease lesions, and cerebral small vessel disease less severe, clinical symptoms hidden, its lack of concern. With the development of science, found a high incidence of cerebral small vessels, a ladder-like or progressive course of disease progress for several years after neurological deficit, often leading to pseudobulbar palsy and subcortical dementia. In 2008, the International Stroke Conference and the European Stroke Conference, both made "small vascular disease is the cause of the problem."
This paper devides intio three parts to study as follows:the classification of syndrome in the ischemic apoplexy at acute stage and the correlation analysis of the Western medicine indicators and the related analysis on the large and small cerebral artery disease, an the study on the development rules in the traditional Chinese medicine of ischemic apoplexy at acute stage as well as the relationship between the ischemic large and small artery pathology and stroke prognosis.
Study Aim
1.The related anaylisis on the acute period of ischemic stroke syndromes meridian card and the size of the correlation in arterial lesions
2.Find the evolution rule of traditional Chinese medicine in artery disease on Acute stage in ischemic apoplexy
3.Explore the relationship between the arterial ischemic stroke lesions and the prognosis for stroke patients
Research methods
Studied the paitents of acute stage in ischemic apoplexy within 7 days and adopted the《Diagnosis main points of all kinds of cerebrovascular disease》on the ischemic cerebrovascular disease, the diagnosis and evaluation of syndrome factor are adopted《the syndrome differentiation and diagnosis criteria of stroke》, mainly using the standard of diagnose and dividing type of ischemic cerebrovascular disease TOAST combined with imageology. The patients are divided into large cerebral artery disease group and arteriolopathy to do the collection on thesyndrome factors in 6-hour real time and dynamic state, therefore, we find that the pointoftime design is respectively 1day,2 days,3 days,7 days,14 days and 28 days after morbidity to discuss the development rule through the syndrome scale scores at each time and the dynamic analysis of syndrome.Additinally, the acquisition of dynamic state of NIHSS,improvement score and ADL rating scale are for the patients to discuss the relationship between the patholog of ischemic large and small artery and prognosis.We collect 207 cases in neurology of Dongfang Hospital in Beijing University of Chinese Medicine and of Dongzhimen Hospital with 129 of masculinity and 78 of feminality.The youngest age is 39 and the oldest is 85 and the avearge age is 66.63±11.21 with 87 Macroangiopathy and 120 Small vessel lesions.
Using the Access2003 database to establish a database,two people log data in the applicatins of SPSS 17.0 software to anyalyze the data.
Result
1. The related study result for the classification of acute ischemic stroke and the related Western syndromes indexs and size of artery disease
(1) Compared with the general information among the two groups of the artery disease patients, we can find that there are not any significant differences among the sex, age, height, weight, ethnicity, marital status and other aspects between them.
(2) As for the past medical history,there are significantly differences on the coronary heart disease, atrial fibrillation, and other aspects in the two groups.There are more patients with the following diseases in the main artery lesion.
(3) As for the physical and chemical inspection, it is significantly different to the lymphocyte percentage, HDL, LDL in the two groups in that the levels of the patietns with large artery lesion are lower in the three indicators.
There is no significant difference in the neck vascular ultrasound data results of the blood vessel.
TCD data shows that the difference is significant on the proportion of vessel is higher with high velocity in the patients with large vessel disease
(4)There is a significance on the difference in the NIHSS score and modified Rankin score for the patients with large artery lesions in the neurological scale.
(5) Compared with groups in the syndrome judgement of the IBS QOL questionnaire in TCM syndrome,the Asthenic yin and predominant yang group show the significant differences, and this syndrome is in a high proportion of small vessel disease.
Compared with the groups of the syndrome scale of the traditional Chinese medicine, we can find that the the groups of yin deficiency and yang upward syndrome shows the significant differences, and this syndrome of small vessel disease is in a high proportion.
(6) Adopted with the logistic regression analysis related to the arterial lesions of the Western targets, it is of significances to the model of the results retains the previous atrial fibrillation history, other history of heart disease, LDL TCD high velocity and the size associated with vessel vascular lesions. The Chinese medicine index associated with the size of arterial lesions include the yin deficiency and yang upward syndrome and sputum score value.Using logistic regression,they are the mutual independence factors in that the increase on the sputum rating value supports the diagnosis of artery disease, and the yin deficiency and yang upward syndrome supports the small artery lesions.
2. The TCM syndrome development rule of the large and small cerebral artery disease in the acute ischemic stroke lesion
(1) The wind syndrome score curves show the different characteristics. Firstly, the artery curve rose,and then it declined,and the peak value was on the third day;firstly the small artery curve decreased and then went up, then went down, it has a wave trough, and the peak was the third day. The repeated variance analysis is used including the nonsignificant difference between groups P=0.295 in the time point data.
The wind frequency at each time point shows a similar performance in the study population trends of dynamic score and wind dynamic score.Firstly the Artery curverose, then it declined,and the peak value was in the third day;firstly the small artery curve declined, and then it decreased, it had a wave trough through in the second day and the peak value was the third day.Compared with each time point, there was no significant difference.
(2) Firstly, the hot syndrome score curve artery curve increased,then it decreased,and the peak value was in the third day; and the small artery curve first decreased and then showed up, and a wave trough was in the second day with the peak value on the third day;however, the peak curve value was in the third day and the small artery was in the 7th day.Compared with the T test for each time point, the 2th,3rd and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.295 in the time point data, which is significant on statistics.
The dynamic trend is similar to the syndrome score of the appeared frequency in the study people at each time ignition proof.The artery curve firstly increased, then it decreased in the third day;small artery curves firstly decreased and then increased,and further it decreased with a wave trough of the third day.Compared with the groups for each time point, the 2th,3rd days have the significant differences.
(3) Firstly,the large artery carve of the Phlegm syndrome score increased,then it decreased,and the peak value was in the third day; and the small artery curve first decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the third day; Compared with the T test for each time point,the 2th,3rd,7th,14th and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.0001 in the time point data, which is significant on statistics.
The ratio of the trend curve in the Phlegm syndrome is similar to the score carve,firstly it increased,then it decreased,and the peak value was in the third day; small artery curve first decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the third day; and it was mild in the the 3rd and the 7th. Compared with each time point, the 2th,3rd,7th,14th and the 28th days have the significant differences.
(4) Firstly, the large artery carve of the score carve in the blood stasis syndrome syndrome it increased,then it decreased,and the peak value was in the third day; small artery curve first decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the third day; Compared with the T test for each time point, the 2th,3rd, and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.0001 in the time point data, which is significant on statistics.
The blood stasis syndrome syndrome firstly increased,then it decreased,and the peak value was in the third day; small artery curve has no wave trough Compared with each time point, the 14th day has the significant differences.
(5) The score carve of qi-deficiency syndrome syndrome firstly increased,then it decreased,and the peak value of large artery carve was in the 3rd day while the small artery carve was in the 7rd day. Compared with the T test for each time point, the,3rd, and the 28th days have the significant differences.
The repeated variance analysis is used including the difference between groups P=0.084 in the time point data, which is not significant on statistics.
The trend curve of deficiency of vital energy syndrome ratio is similar to the score carve, firstly it increased,then it decreased,and the peak value of large artery carve was in the 3rd day while the small artery carve was in the 7rd day. Compared with each time point, the 14th day has the significant differences.
(6) The two groups of the yin deficiency and yang excess syndrome showed different characteristics. Firstly it increased,then it decreased,and the peak value of large artery carve was in the 14th day while the small artery carve firstly decreased and then showed up,and further it decreased again,and a wave trough was in the second day with the peak value on the 7th day; Compared with the T test for each time point, they haveno significant differences.
The repeated variance analysis is used including the difference between groups P=0.451 in the time point data, which isn't significant on statistics.
The trend curve of syndrome rate is similar to the score carve. The large artery carve firstly increased, then it decreased with a peak value on the 14th day;small artery curves firstly decreased and then increased,and it had a valley value of the third day and the peak value of the 7th day. Compared with each time point, the 1st day has the significant differences.
3.Discussion on the relationship between the ischemic strokel large and small artery pathology and stroke prognosis.
(1) Analyzed on the non-parametric tests of the large and small artery pathology at each time point, there is significantly difference between the two groups of NIHSS in that the NIHSS of large artery pathology was so high at each time point.
NIHSS score curve and the syndrome showed a similar rule curve, the small artery curve has a trough in the next day with the peak between 3-7 days.
(2) It is significant to the large and small artery pathology and the improvement Rankin score after the invasion with 28 days of improvement on the non-parametric tests and analysis.
(3) There is no significant difference on the large and small artery pathology and the 28 days of improvement after the invasion on the non-parametric tests and analysis.
Conclusion
1. The apoplexy invasion of the stroke patients attacked on the first day, and the past history of atrial fibrillation, history of other heart disease, LDL, TCD high flow vascular lesions associated with the independent factors of the size of the vessel, and the LDL level is negatively correlated with macrovascular disease,while the other factors are positive correlation. From the perspective of Chinese medicine, Chinese medicine yin deficiency and yang excess, sputum score value and the size of the independent factors related to vascular disease, in that the increased score value ofsputum supports the diagnosis of large artery disease, yin deficiency and yang excess supports the diagnosis of small artery
2.There is certain regularity of the dynamic progression on the essential factors after the 1st,2nd,3rd,7th,14th and 28th, we can conclude as follows:The same score of syndrome factor and the variation curve of the occurrence rate time point change showed the similar trend; Based on the size of arterial lesions in the different arterial lesions,the patients'FHP, phlegm, blood stasis three certificates have shown a higher rate and incidence; syndrome score and incidence of dynamic evolution trend are different artery disease based on the size of the artery pathology.
3.The trend development of the NIHSS scale score showed the similar regulation of the syndrome score. Firstly the large artery pathology increased,then it decreased, while the small artery carve firstly decreased and then showed up,and further it decreased again,and a wave trough appeared after the second day with the peak value between the 3th and 7th days.
4.The large artery pathology is worser than the prognosis of small artery.
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