急性脑梗死患者伴吞咽障碍的临床特征及发生卒中相关性肺炎的影响因素分析

摘要 目的：分析急性脑梗死患者伴吞咽障碍的临床特征及发生卒中相关性肺炎（SAP）的影响因素。方法：选取 2019年 10月~2021年 10月本院收治的 190例急性脑梗死患者为调查研究对象,根据患者的洼田饮水试验评分分为吞咽良好组（98例）和吞咽障碍组（92例）,对比两组患者的临床资料,探讨急性脑梗死患者伴吞咽障碍的临床特征。并对 92例吞咽障碍组患者发病期间SAP发生率进行统计,并将患者分为 SAP组和非 SAP组,对两组患者的基础资料、临床资料等进行组间对比分析,并采用单因素分析和多因素 Logistic回归分析探讨影响急性脑梗死吞咽障碍患者发生 SAP的危险因素。结果：吞咽障碍组与吞咽良好组患者的性别、体质指数（BMI）、吸烟史、饮酒史、基础疾病史等比较无统计学差异（P>0.05）,而吞咽障碍组患者的年龄、美国国立卫生院神经功能缺损评分（NIHSS）、梗死面积、梗死部位脑干比例均高于吞咽功能良好组（P<0.05）。92例急性脑梗死伴吞咽障碍患者中有 34例患者发生 SAP,发生率为 36.96%。经单因素分析显示,SAP组与非 SAP组患者的性别、BMI、饮酒史、高血压病史、高脂血病史比较无统计学差异（P>0.05）,而 SAP组患者的年龄、NIHSS评分、吸烟史患者比例、糖尿病史患者比例均高于非 SAP组（P<0.05）。经 Logistic多因素回归分析显示,高龄、高 NIHSS评分、吸烟史、糖尿病史是急性脑梗死伴吞咽障碍并发 SAP发生的独立危险因素（P<0.05,OR＞1）。结论：急性脑梗死患者中高龄、神经功能缺损严重、梗死面积大以及脑干部位梗死患者易出现吞咽功能障碍,且有部分患者会出现 SAP,而高龄、高 NIHSS评分、吸烟史、糖尿病史是诱发 SAP发生的影响因素,值得临床关注。     

Strokes among black people in Harare,Zimbabwe: results of computed tomography and associated risk factors.

Computed tomography was performed and risk factors evaluated in 100 consecutive adult patients presenting to the two teaching hospitals in Harare with a clinical diagnosis of stroke. The mean age of the patients was 52; only 28 were 65 or older. Non-stroke lesions were found in seven patients and were predicted by a recent history of convulsions (p less than 0.0001). Five lesions (four subdural haematomas and one cerebral cysticercosis) were remediable. Hypertension was present in 27 (93%) of the 29 patients with cerebral haemorrhage and in 49 (53%) of the 93 patients with stroke lesions. In 22 (45%) of these patients the hypertension had not been diagnosed, and another 22 had defaulted from treatment. All 13 patients who died before computed tomography had hypertension, and over half showed evidence of haemorrhagic stroke. There was a cardiac source for all 12 cases of cerebral embolism. In eight of the 100 patients cerebral infarction was attributed to neurosyphilis. None of the patients had clinical evidence of atherosclerosis. Smoking and oral contraceptives did not seem important risk factors for stroke. Detection and control of hypertension remain the most important measures needed to reduce the incidence of and mortality from stroke in Zimbabwe.     

低频脉冲电疗联合针灸对脑卒中后吞咽障碍患者吞咽功能、脑血流以及血浆一氧化氮、超氧化物歧化酶的影响

目的:探讨低频脉冲电疗联合针灸对脑卒中后吞咽障碍患者吞咽功能、脑血流以及血浆一氧化氮、超氧化物歧化酶的影响。方法:选取2013年3月~2019年12月期间我院收治的脑卒中后吞咽障碍患者80例,按照随机数字表法分为对照组(n=40)和研究组(n=40),对照组患者予以低频脉冲电疗,研究组在对照组基础上联合针灸治疗,比较两组患者的疗效、吞咽功能、脑血流、血浆一氧化氮、超氧化物歧化酶水平以及不良反应发生情况。结果:研究组治疗1个月后的临床总有效率为92.50%(37/40),高于对照组的72.50%(29/40)(P<0.05)。两组治疗1个月后右侧椎动脉、基底动脉、左侧椎动脉的平均血流速度均升高,且研究组高于对照组(P<0.05)。两组患者治疗1个月后一氧化氮下降,且研究组低于对照组(P<0.05);超氧化物歧化酶升高,且研究组高于对照组(P<0.05)。两组患者治疗1个月后洼田饮水试验等级均降低,且研究组低于对照组(P<0.05)。两组不良反应发生率对比差异无统计学意义(P>0.05)。结论:低频脉冲电疗联合针灸治疗脑卒中后吞咽障碍患者,可有效促进脑循环,改善患者吞咽功能,减轻机体氧化应激,疗效显著。     

Cortical processing of swallowing in ALS patients with progressive dysphagia--a magnetoencephalographic study

Amyotrophic lateral sclerosis (ALS) is a rare disease causing degeneration of the upper and lower motor neuron. Involvement of the bulbar motor neurons often results in fast progressive dysphagia. While cortical compensation of dysphagia has been previously shown in stroke patients, this topic has not been addressed in patients suffering from ALS. In the present study, we investigated cortical activation during deglutition in two groups of ALS patients with either moderate or severe dysphagia. Whole-head MEG was employed on fourteen patients with sporadic ALS using a self-paced swallowing paradigm. Data were analyzed by means of time-frequency analysis and synthetic aperture magnetometry (SAM). Group analysis of individual SAM data was performed using a permutation test. We found a reduction of cortical swallowing related activation in ALS patients compared to healthy controls. Additionally a disease-related shift of hemispheric lateralization was observed. While healthy subjects showed bilateral cortical activation, the right sensorimotor cortex was predominantly involved in ALS patients. Both effects were even stronger in the group of patients with severe dysphagia. Our results suggest that bilateral degeneration of the upper motor neuron in the primary motor areas also impairs further adjusted motor areas, which leads to a strong reduction of 'swallowing related' cortical activation. While both hemispheres are affected by the degeneration a relatively stronger activation is seen in the right hemisphere. This right hemispheric lateralization of volitional swallowing observed in this study may be the only sign of cortical plasticity in dysphagic ALS patients. It may demonstrate compensational mechanisms in the right hemisphere which is known to predominantly coordinate the pharyngeal phase of deglutition. These results add new aspects to our understanding of the pathophysiology of dysphagia in ALS patients and beyond. The compensational mechanisms observed could be relevant for future research in swallowing therapies.     

Long term prognosis after occlusion of middle cerebral artery.

Seventy patients who had developed occlusion of the middle cerebral artery confirmed by angiography between 1970 and 1980 were followed up after an average of six years. Fourteen patients had died in the acute stage of the initial stroke. In the remaining 56 patients actuarial analysis showed that the observed incidence of survival for five years was 81.8% compared with an incidence of 94.1% in a matched normal population. Six patients sustained new strokes, four of which were ipsilateral to the middle cerebral artery occlusion. The observed cumulative incidence of subsequent strokes was 2% a year for the first five years of follow up. Twelve patients developed epileptic seizures.     

Predicting the outcome of stroke: acute stage after cerebral infarction.

On admission to hospital during the acute phase of a stroke presumed due to ischaemic infarction in one cerebral hemisphere 93 patients were examined to determine the factors associated with a poor prognosis for immediate survival. The patients particularly at risk were those who were overtly unconscious and those with any combination of impaired consciousness, dense hemiplegia, and failure of conjugate ocular gaze towards the side of the limb weakness. Necropsy evidence suggested that these signs usually indicate infarction of the whole of one middle cerebral artery territory which is often secondary to internal carotid artery occlusion and commonly produces fatal cerebral oedema.     

The proteome of human brain microdialysate

BACKGROUND: Cerebral microdialysis has been established as a monitoring tool in neurocritically ill patients suffering from severe stroke. The technique allows to sample small molecules in the brain tissue for subsequent biochemical analysis. In this study, we investigated the proteomic profile of human cerebral microdialysate and if the identified proteins might be useful predictors for disease characteristics in stroke for tissue at risk in the contralateral hemisphere. We analysed cerebral protein expression in microdialysate from three stroke patients sampled from the hemisphere contralateral to the lesion. Using a proteomic approach based on two-dimensional gel electrophoresis and subsequent mass spectrometry, we created a protein map for the global protein expression pattern of human microdialyste. RESULTS: We found an average of 158 +/- 24 (N = 18) protein spots in the human cerebral microdialysate and could identify 95 spots, representing 27 individual proteins. Most of these have been detected in human cerebrospinal fluid before, but 10 additional proteins mainly of cerebral intracellular origin were identified exclusively in the microdialysate. CONCLUSIONS: The 10 proteins found exclusively in human cerebral microdialysate, but not in cerebrospinal fluid, indicate the possibility to monitor the progression of the disease towards deterioration. The correlation of protein composition in the human cerebral microdialysate with the patients' clinical condition and results of cerebral imaging may be a useful approach to future applications for neurological stroke diagnosis, prognosis, and treatment.     

Lower cranial nerve motor function in unilateral vascular lesions of the cerebral hemisphere.

Motor function subserved by cranial nerves V, VII, X, XI, and XII was assessed in 100 patients with hemiparesis due to a unilateral vascular lesion of the cerebral hemisphere. Several of the findings were not described clearly in many of the standard textbooks of neurology. Weakness of sternomastoid when present was always contralateral to the hemiparesis. This emphasises the principle that the cerebral hemisphere controls movement of the body parts in or towards the contralateral half of the body rather than simply the contralateral muscle groups. An apparent exception to this was seen, however, in the small group of patients who had unilateral weakness of the tongue. In those patients deviation of the tongue was towards the hemiparetic side--that is, the cerebral hemisphere controlled the contralateral half of the tongue and hence protrusion towards the ipsilateral side. Mild dysarthria was common with both right and left sided hemiparesis.     

Auditory and cognitive deficits associated with acquired amusia after stroke: a magnetoencephalography and neuropsychological follow-up study

Acquired amusia is a common disorder after damage to the middle cerebral artery (MCA) territory. However, its neurocognitive mechanisms, especially the relative contribution of perceptual and cognitive factors, are still unclear. We studied cognitive and auditory processing in the amusic brain by performing neuropsychological testing as well as magnetoencephalography (MEG) measurements of frequency and duration discrimination using magnetic mismatch negativity (MMNm) recordings. Fifty-three patients with a left (n = 24) or right (n = 29) hemisphere MCA stroke (MRI verified) were investigated 1 week, 3 months, and 6 months after the stroke. Amusia was evaluated using the Montreal Battery of Evaluation of Amusia (MBEA). We found that amusia caused by right hemisphere damage (RHD), especially to temporal and frontal areas, was more severe than amusia caused by left hemisphere damage (LHD). Furthermore, the severity of amusia was found to correlate with weaker frequency MMNm responses only in amusic RHD patients. Additionally, within the RHD subgroup, the amusic patients who had damage to the auditory cortex (AC) showed worse recovery on the MBEA as well as weaker MMNm responses throughout the 6-month follow-up than the non-amusic patients or the amusic patients without AC damage. Furthermore, the amusic patients both with and without AC damage performed worse than the non-amusic patients on tests of working memory, attention, and cognitive flexibility. These findings suggest domain-general cognitive deficits to be the primary mechanism underlying amusia without AC damage whereas amusia with AC damage is associated with both auditory and cognitive deficits.     

Some epidemiologic and clinical problems in ischemic cerebral stroke

The study involved 739 patients with the ischemic cerebral stroke into two groups: with reversible and irreversible ischemic cerebral stroke. General characteristics of patients (incidence, sex, age etc.) was similar to the characteristics of patients from other centres. Morbidity rate for ischemic cerebral strokes was 93.9, including reversible stroke 21.3 and other 72.6; mortality factor 47.2, and mortality rate 29.6%. An increase in morbidity for irreversible stroke in women over 80 years of age is striking. The authors suggest that the classification of cerebral strokes should include reversible strokes whereas progressive stroke should not be considered distinguished entity.     

Cerebrovascular Diseases in West Central India

Cerebral angiographic findings in ischaemic stroke are described and discussed in detail. Though the Indian patients studied had altogether different social customs, living standards, and dietary habits from Western people, the relative incidence of various cerebral vascular lesions did not differ significantly. Irrespective of the poor nutritional status of the patients, thrombosis associated with atherosclerosis was chiefly responsible for a non-embolic cerebral infarction. Atherothrombosis in the young normotensive persons not showing any evidence of arteritis, diabetes mellitus, or hypercholesterolaemia was also identified.The grave risks involved in cerebral angiography in cases of acute stroke are re-emphasized.As to prognosis, the nutritional status, the type and territory of an ictal lesion, and the blood levels of sugar and cholesterol had no significant influence on the immediate survival-after a non-embolic cerebral infarction. However, a significantly greater number of deaths were encountered in the hypertensive patients. Female patients and patients with a large cerebral infarction had a poor prognosis.     

Striatal Infarction Elicits Secondary Extrafocal MRI Changes in Ipsilateral Substantia Nigra

Focal ischemia may induce pathological alterations in brain areas distant from the primary lesion. In animal models, exofocal neuron death in the ipsilateral midbrain has been described after occlusion of the middle cerebral artery (MCA). Using sequential magnetic resonance imaging (T2- and diffusion-weighted) at 3 Tesla, we investigated acute ischemic stroke patients on days 1, 2, 6, 8, and 10 after stroke onset. Sixteen consecutive patients who had suffered a stroke involving the caudate nucleus and/or putamen of either hemisphere were recruited into the study. Four additional patients with strokes sparing the caudate nucleus and putamen but encompassing at least one-third of the MCA territory served as controls. Ischemic lesions involving striatal structures resulted in hyperintense lesions in ipsilateral midbrain that emerged between days 6 and 10 after stroke and were not present on the initial scans. In contrast, none of the control stroke patients developed secondary midbrain lesions. Hyperintense lesions in the pyramidal tract or the brain stem caused by degeneration of the corticospinal tract could be clearly distinguished from these secondary midbrain gray matter lesions and were detectable from day 2 after ischemia. Co-registration of high-resolution images with a digitized anatomic atlas revealed localization of secondary lesions primarily in the substantia nigra pars compacta. Apparent diffusion coefficient (ADC) values in the secondary lesions showed a delayed sharp decline through day 10. Normalization of ADC values was observed at late measurements. Taken together, our study demonstrates that striatal infarction elicits delayed degenerative changes in ipsilateral substantia nigra pars compacta.     

Incidence of stroke in Oxfordshire: first year's experience of a community stroke register.

The Oxfordshire Community Stroke Project is a prospective study of all new cases of stroke and transient ischaemic attack in a defined population of about 103 000 patients registered with 49 general practitioners; every case is assessed by a neurologist and most patients undergo a CT scan or are examined post mortem, or both, to ensure accurate diagnosis. Out of 404 cases registered in the first year, 168 patients had suffered a first stroke, 52 a recurrent stroke, and 41 a transient ischaemic attack; 143 were excluded. Of the 168 patients with their first stroke, 153 (91%) were seen by a neurologist and 149 (89%) had a CT scan or came to necropsy. The pathological diagnosis was cerebral infarction in 127 cases (76%), intracranial haemorrhage in 22 (13%), and unknown in 19 (11%). The estimated yearly incidence of first stroke was 1.95/1000 population (age adjusted to 1981 population of England and Wales).     

Time-dependent contribution of non neuronal cells to BDNF production after ischemic stroke in rats

Although brain-derived neurotrophic factor (BDNF) plays a central role in recovery after cerebral ischemia, little is known about cells involved in BDNF production after stroke. The present study testes the hypothesis that neurons are not the unique source of neosynthesized BDNF after stroke and that non neuronal-BDNF producing cells differ according to the delay after stroke induction. For this purpose, cellular localization of BDNF and BDNF content of each hemisphere were analysed in parallel before and after (4h, 24h and 8d) ischemic stroke in rats. Stroke of different severities was induced by embolization of the brain with variable number of calibrated microspheres allowing us to explore the association between BDNF production and neuronal death severity. The main results are that (a) unilateral stroke increased BDNF production in both hemispheres with a more intense and long-lasting effect in the lesioned hemisphere, (b) BDNF levels either of the lesioned or unlesioned hemispheres were not inversely correlated to neuronal death severity whatever the delay after stroke onset, (c) in the unlesioned hemisphere, stroke resulted in increased BDNF staining in neurons and ependymal cells (at 4h and 24h), (d) in the lesioned hemisphere, beside neurons and ependymal cells, microglial cells (at 24h), endothelial cells of cerebral arterioles (at 4h and 24h) and astrocytes (at 8d) exhibited a robust BDNF staining as well. Taken together, overall data suggest that non neuronal cells are able to produce substantial amount of BDNF after ischemic stroke and that more attention should be given to these cells in the design of strategies aimed at improving stroke recovery through BDNF-related mechanisms.     

Value of computed tomography in patients with stroke: Oxfordshire Community Stroke Project.

The usefulness of computed tomography (CT) was assessed in 325 consecutive patients with a "clinically definite first stroke" from a community stroke register. CT detected five "non-stroke" lesions (two cerebral gliomas, one cerebral metastasis, and two subdural haematomas), a frequency of 1.5%. Five patients were identified with cerebellar haemorrhage, but only one survived long enough to have a CT scan. CT was useful in excluding intracranial haemorrhage as the cause of the stroke in four patients receiving anticoagulants and seven receiving antiplatelet treatment; it showed intracranial haemorrhage in one patient taking aspirin. Forty six patients were in atrial fibrillation at the time of their stroke; four had intracranial haemorrhages and three had haemorrhagic cerebral infarcts. Nineteen patients with presumed ischaemic minor stroke were considered suitable for carotid endarterectomy; CT showed small haemorrhages in two. The CT scan provides very useful information in a minority (up to 28%) of patients with first stroke, who can be selected on quite simple criteria: (a) doubt (usually because of an inadequate history) whether the patient has stroke or a treatable intracranial lesion; (b) the possibility of cerebellar haemorrhage or infarction; (c) the exclusion of intracranial haemorrhage in patients who either are already taking or likely to need antihaemostatic drugs or are being considered for carotid endarterectomy; (d) if the patient deteriorates in a fashion atypical of stroke.     

经颅磁刺激联合高压氧（HBO)治疗脑梗死240 例临床疗效分析

目的:观察经颅磁刺激(transcranial magnetic stimulation,TMS)联合高压氧(hyperbaricoxygen,HBO)治疗脑梗死的临床疗效。方法:采用随机数字表法将240例脑梗死患者分为联合治疗组、HBO组及常规组,每组80例。常规组患者给予常规治疗,HBO组患者在常规干预基础上辅以HBO治疗,联合治疗组患者则在常规干预基础上辅以HBO及TMS联合治疗。上述治疗均以10 d为1个疗程,共治疗2个疗程。于治疗前、治疗2个疗程后比较各组患者神经功能缺损程度,并同时于上述时间点检测各组患者中枢运动传导时间(CMCT)及血清中脑源性神经营养因子(BDNF)、神经生长因子(NGF)表达情况。结果:各组患者分别经2个疗程治疗后,发现联合治疗组NIHSS评分、总有效率均显著优于HBO组及常规组水平(均P0.05);另外联合治疗组血清中BDNF含量与NGF含量均较治疗前明显升高(P0.05),与常规组及HBO组间差异亦具有统计学意义(均P0.05)。结论:TMS联合HBO治疗脑梗死具有协同作用,能进一步改善患者受损神经功能及日常生活质量,其治疗机制可能与增强神经营养因子表达有关。     

Cortical swallowing processing in early subacute stroke

Background  

Dysphagia is a major complication in hemispheric as well as brainstem stroke patients causing aspiration pneumonia and increased mortality. Little is known about the recovery from dysphagia after stroke. The aim of the present study was to determine the different patterns of cortical swallowing processing in patients with hemispheric and brainstem stroke with and without dysphagia in the early subacute phase.     

Effects of treatment for hypertension on cerebral haemorrhage and infarction.

One hundred and sixty nine patients admitted to hospital for stroke over 30 months were examined to see whether treating hypertension had influenced the incidence of cerebral haemorrhage and infarction. Seventy eight (46%) of them had normal blood pressure, 47 (28%) previously diagnosed hypertension for which they were receiving treatment, and 44 (26%) previously undiagnosed and untreated hypertension. Haemorrhagic stroke was commoner among patients with untreated hypertension, whereas infarction was commoner in patients with treated hypertension. Infarction and haemorrhage were equally prevalent in patients with normal blood pressure. Effective treatment in this population seemed to have had a substantially different impact on vascular disease, giving rise to cerebral haemorrhage as opposed to infarction. This is consistent with evidence from other studies that treatment for hypertension has little or no effect on the progression of atheroma.     

老年脑梗死患者急性期全脑血管造影及脑动脉狭窄的危险因素分析

目的:探究老年脑梗死患者急性期全脑血管造影(DSA)及脑动脉狭窄的危险因素。方法:选择2010年1月~2016年9月期间我院收治的562例老年脑卒中患者为研究对象。经DSA造影观察脑血管动脉造影脉狭窄情况,并收集患者一般资料,采用单因素分析及多因素logistics回归分析脑动脉狭窄的危险因素。结果:562例脑卒中患者经DSA检查共发现469例患者出现脑动脉狭窄,中度狭窄301例,血管重度狭窄168例;颅内段发生率显著高于颅外段(P0.05);高龄(OR=1.434,P0.05)、高血压(OR=2.084,P0.05)、糖尿病(OR=2.235,P0.05)及吸烟(OR=2.734,P0.05)是老年脑卒中患者脑血管狭窄的危险因素。结论:DSA显示老年人脑卒中患者多存在脑血管动脉狭窄的发生,年龄、高血压、糖尿病及吸烟是老年脑卒中患者脑血管狭窄的危险因素。     

Dysphagia in Acute Stroke: Incidence,Burden and Impact on Clinical Outcome

Background

Reported frequency of post-stroke dysphagia in the literature is highly variable. In view of progress in stroke management, we aimed to assess the current burden of dysphagia in acute ischemic stroke.

Methods

We studied 570 consecutive patients treated in a tertiary stroke center. Dysphagia was evaluated by using the Gugging Swallowing Screen (GUSS). We investigated the relationship of dysphagia with pneumonia, length of hospital stay and discharge destination and compared rates of favourable clinical outcome and mortality at 3 months between dysphagic patients and those without dysphagia.

Results

Dysphagia was diagnosed in 118 of 570 (20.7%) patients and persisted in 60 (50.9%) at hospital discharge. Thirty-six (30.5%) patients needed nasogastric tube because of severe dysphagia. Stroke severity rather than infarct location was associated with dysphagia. Dysphagic patients suffered more frequently from pneumonia (23.1% vs. 1.1%, p<0.001), stayed longer at monitored stroke unit beds (4.4±2.8 vs. 2.7±2.4 days; p<0.001) and were less often discharged to home (19.5% vs. 63.7%, p = 0.001) as compared to those without dysphagia. At 3 months, dysphagic patients less often had a favourable outcome (35.7% vs. 69.7%; p<0.001), less often lived at home (38.8% vs. 76.5%; p<0.001), and more often had died (13.6% vs. 1.6%; p<0.001). Multivariate analyses identified dysphagia to be an independent predictor of discharge destination and institutionalization at 3 months, while severe dysphagia requiring tube placement was strongly associated with mortality.

Conclusion

Dysphagia still affects a substantial portion of stroke patients and may have a large impact on clinical outcome, mortality and institutionalization.