Objective To analyze the risk factors of early neurological deterioration(END)after minimally invasive surgery of patients with supratentorial hypertensive intracerebral hemorrhage(ICH). Methods This study was a retrospective case study.Supratentorial hypertensive ICH patients who had undergone minimally invasive surgery in the Emergency Neurology Department,Beijing Tiantan Hospital,Capital Medical University from October 2018 to December 2022 were continuously included.Patients'demographic characteristics and clinical information,as well as imaging information like hematoma volume,location,and peri-hematoma perfusion,were recorded.The evaluation criteria of END was that the NIHSS score increased by≥4 points or the GCS score decreased by≥2 points within 24 hours after surgery.The variables with statistically significant differences selected by univariate analysis were incorporated into the binary logistic regression model(regression method)to analyze the independent risk factors affecting the END of patients.At the same time,the ROC curve of independent risk factors was plotted and the AUC was calculated.De Long test was used to compare the prediction ability of different independent risk factors. Results A total of 157 patients were enrolled,with an average age of(57.1±13.1)years.END occurred in 20 patients(12.7%).Multivariate logistic regression analysis showed that preoperative hematoma volume(OR1.024,95%CI1.001-1.047,P=0.043)and postoperative hematoma expansion(OR41.605,95%CI7.405-233.765,P＜0.001)and preoperative hypoperfusion volume(OR1.011,95%CI1.002-1.020,P=0.012)could independently predict the occurrence of END.The AUC,sensitivity,and specificity of ROC for preoperative hypoperfusion volume were 0.921,0.824,and 0.891.The cut-off value was 119.0 mL.De Long test indicated that the prediction efficacy of preoperative hypoperfusion volume was better than that of preoperative hematoma volume and postoperative hematoma expansion(P<0.05). Conclusions Preoperative hypoperfusion volume was independently correlated with END of patients after minimally invasive surgery in supratentorial hypertensive intracerebral hemorrhage.The greater the hypoperfusion volume,the higher the risk of END.

目的 探讨总胆固醇负荷(TC负荷)与新发外周动脉疾病(peripheral artery disease,PAD)的关系.方法 在开滦队列研究的子队列即无症状性多血管异常社区研究中,2006-2012年每2年对参与者进行随访,每次随访时进行TC测定,TC负荷定义为测量值和临界值之差的加权和.在第3次和第4次随访时完成踝臂指数(ankle-brachial index,ABI)测量,单侧或双侧下肢ABI＜0.90认为存在PAD.根据TC负荷四分位数将参与者分为4组,并通过logistic回归评估TC负荷与PAD之间的关系.结果 本研究共纳入2939例参与者,其中159例(5.4％)合并新发PAD.在单因素分析中,与最低四分位数(Q1)组相比,TC负荷升高与新发PAD无相关(OR1.109,95％CI0.961～1.280,P=0.157),且校正混杂因素后TC负荷与新发PAD仍无相关(OR1.062,95％CI0.916～1.232,P=0.346).在4组参与者中,第2四分位数(Q2)组的参与者新发PAD的发生率最低,与Q2组相比,Q1组及最高四分位数(Q4)组整体参与者新发PAD风险升高(剔除年龄≥65岁的参与者后Q4组差异无统计学意义),而与第3四分位数(Q3)组参与者的差异不具有统计学意义.结论 TC负荷与新发PAD不存在显著的线性相关性,但长期TC水平过高或过低可能会增加新发PAD风险.

目的 评估不同非高密度脂蛋白胆固醇(non-high-density lipoprotein cholesterol,non-HDL-C)水平与周围动脉疾病(peripheral artery disease,PAD)的关系.方法 本研究纳入2010年6月-2011年6月年龄≥40岁、既往无心脑血管病史的社区人群,收集人口学信息、血管相关危险因素、生化相关检查等资料.PAD定义为踝臂指数<0.9;non-HDL-C水平分为:正常<4.1?mmol/L,边缘升高4.1～4.9?mmol/L,升高≥4.9?mmol/L;采用单因素和多因素logistic回归分析non-HDL-C水平与PAD的相关性.结果 共纳入5132例受试者,平均年龄55.13±11.80岁,男性3214例(60.07％),平均non-HDL-C水平为3.42±1.00?mmol/L,其中PAD患病率为3.39％(174/5132).PAD受试者non-HDL-C水平高于无PAD受试者,但差异无统计学意义(3.51±1.03?mmol/L?vs?3.42±1.00?mmol/L,P>0.05).进一步多因素分析结果显示,边缘升高(OR?1.23,95％CI?0.78～1.93,P>0.05)和升高non-HDL-C水平(OR?1.24,95％CI 0.60～2.55,P>0.05)与PAD患病风险无关.结论 本研究中未发现non-HDL-C与PAD的相关性.

目的 分析急性缺血性卒中患者(acute ischemic stroke,AIS)住院期间消化道出血(gastrointestinal bleeding,GIB)的发生率、发生时间及危险因素.方法 本研究纳入首都医科大学附属北京天坛医院急性卒中院内并发症队列(inhospital medical complication after acute stroke,iMCAS)研究中AIS患者.收集患者临床信息,根据住院期间是否发生GIB分为GIB组和无GIB组,采用多因素Logistic回归模型,分析AIS患者发生GIB相关危险因素.结果 共纳入1129例AIS患者,平均年龄58.7±12.5岁,女性230例(20.4％).47例住院期间发生GIB,发生率为4.2％,卒中发作至GIB确诊时间为5(3～13)d.合并肝硬化(OR?10.06,95％CI?2.44～41.38)、高入院NIHSS评分(OR?1.13,95％CI?1.08～1.19)、高白细胞计数(OR?1.25,95％CI?1.13～1.38)、住院时间长(OR?1.05,95％CI?1.01～1.10)是AIS患者发生消化道出血的独立危险因素.结论 本单中心研究数据提示合并肝硬化、高入院NIHSS评分、高白细胞计数、住院时间长是AIS患者住院期间发生GIB的独立危险因素.

1 病例介绍 患者女性,56岁,主因"头痛伴间断性抽搐6?d"以症状性癫痫于2016年8月26日收入血管神经病学病区.患者于6?d前无明显诱因出现头痛、视物模糊,继而出现意识丧失、四肢抽搐、双眼上翻、口角向右歪斜,持续5?min后症状缓解,予镇静对症治疗,期间抽搐发作6次.后患者无抽搐发作,但头痛持续不缓解,遂收入院治疗.

目的 探讨标准化病人在神经科住院医师规范化培训中人文素养教学和考核中的应用效果.方法 对首都医科大学附属北京天坛医院首批公开招募的标准化病人10名,开展脑血管病常见病例情景中针对神经科医师人文素养的教学和考核用途的培训,调查神经科医师经过培训的标准化病人在神经科住院医师规范化培训人文素养教学和考核中的评价情况.结果 对标准化病人开展有针对性的神经科人文素养教学和考核前培训,有助于提升神经科住院医师规范化培训人文素养教学质量和考核效果.结论 对标准化病人开展神经科人文素养教学和考核前培训,对提升神经科医师人文素养教学质量有重要意义,值得推广.

Objective To investigate whether the predictive reliability of an increase in the mean blood flow velocity ratio of the ipsilateral to contralateral middle cerebral arteries (I/C mBFV) ≥120 cm/s is higher than that of the conventional absolute flow velocity (mBFV) for delayed cerebral ischemia (DCI) in higher modified Fisher grade. Methods Patients admitted into NICU of Beijing Tiantan Hospital, Capital Medical University from November 2011 to November 2013 who underwent transcranial Doppler sonography (TCD) and diagnosed with subarachnoid hemorrhage (SAH) ≥3 by modified Fisher grade were consecutively enrolled into study retrospectively. The mBFV value in bilateral middle cerebral arteries and I/C mBFV were recorded. The end point was delayed cerebral ischemia (DCI). The I/C mBFV and middle cerebral artery mBFV ≥120 cm/s were calculated for predicting the sensitivity, specificity, positive predictive value and negative predictive value of DCI. Results A total of 44 patients were included in the study, among which, 18 patients developed DCI, with incidence rate of 41％. For middle cerebral artery mBFV ≥120 cm/s, the sensitivity, specificity, positive predictive value and negative predictive value of TCD in predicting DCI were 77.8％, 50％,53.8％, 75％, respectly. For I/C mBFV ≥1.5, the sensitivity, specificity, positive predictive value and negative predictive value of TCD in predicting DCI were 71.8％, 41.7％, 50％, 71.4％, respectively. Conclusion For SAH patients with higher modified Fisher grade, TCD was still an important tool for predicting DCI. The predictive value of mBFV ≥120 cm/s was higher than that of I/C mBFV≥1.5.

Objective To further verify the correlation between intracranial pressure (ICP) and blood flow parameters of transcranial Doppler ultrasound (TCD) in patients with cerebral hemorrhage. The optimal mathematical models of intracranial pressure were established, which were predicted quantitatively by blood lfow parameters of TCD, and then evaluated the accuracy. <br> Methods According to the inclusion and exclusion criteria, demographic data, major neurological function scores and characteristics of lesions of 22 patients with cerebral hemorrhage were registered. The intracranial pressure monitor was used to monitor the intraparenchymal pressure continuously at the bedside. TCD detection was reviewed daily. The blood lfow parameters of MCA and ICA, the instant ICP values, temperature, blood pressure, heart rate, and oxygen saturation were recorded. The analyses of multiple linear regression were completed to establish the optimal mathematical model of ICP evaluated by TCD parameters, and then evaluate the accuracy for the diagnosis of intracranial hypertension (ICP>15 mmHg). <br> Results The correlation analysis of PI and ICP showed positive correlation, and the correlation coefficient wasr=0.66 (P<0.01). The mathematical model was ICPe=-16.8+26.8×PI+0.12×Vm, adjusted R2=0.46; When ICP>15 mmHg, the area under curve of ICPe was 0.93, and 95% conifdence interval was 0.88-0.97. <br> Conclusion PI is positively correlated with ICP, and is the most important predictive indicator of the ICP evaluation. ICPe=-16.8+26.8×PI+0.12×Vm (adjusted R2=0.46) could predict the ICP to diagnose the intracranial hypertension (ICP>15 mmHg) with high accuracy.

目的:探讨Stanford A型主动脉夹层合并意识障碍的治疗及预后.方法:回顾性分析8例Stanford A型主动脉夹层合并意识障碍患者的发病原因及临床表现、治疗及预后.结果:本组Stanford A型主动脉夹层患者意识障碍发病率达34.8％,意识障碍水平重且多伴严重高血压及多器官受损.结论:意识障碍与弓上血管血流动力学改变有关,通过积极的治疗意识障碍水平多能恢复,并为进一步治疗做准备.

Objective Transcranial Doppler(TCD) is recommended to monitor for the development of arterial vasospasm. Our aim is to evaluate the effect of TCD in prediction, ifnding and treating delayed cerebral ischemia(DCI). <br> Methods We analyzed 222 patients(Pts) who had at least 1 transcranial Doppler examination after the admission in neuro-ICU of Tiantan hospital from Oct. 27, 2011 to Oct. 31, 2013. Abnormal MCA mean blood lfow velocity(mBFV) was deifned as>80 cm/s. Arterial vasospasm was deifned as>120cm/s. Patients were divided into 3 groups that were 85 Pts in vasospasm group, 14 Pts in increasing mBFV group and 123 Pts in normal group respectively. <br> Results There were more DCI in the vasospasm group and increasing mBFV group than normal group(68.2%, 35.7%, 3.2%, P<0.1). Intensive treatments were given to them and the higher alleviation rate were found in the above two groups than normal group(P<0.01). But the poor outcomes in 90 days that was deifned as mRS≥4 were more in vasospasm group and increasing mBFV group(30.6%, 21.4%, 15.4%, P=0.031)because of being serious conditions at the baseline. This two groups had less GCS, Hent-HessⅠ~Ⅲ, WFNSⅠ~Ⅲand more Modiifed Fisher GradesⅢ~Ⅳ, Intracranial hematoma than normal group. <br> Conclusion Although given intensive treatments, the Transcranial Doppler vasospasm and increasing mBFV groups had more DCIs and more poor outcomes than normal group. Transcranial Doppler should be use as an essential tool to identify patients at higher risk to develop DCI after subarachnoid hemorrhage.

本指南对预测一个人发生首发卒中的风险的方案进行了评估.首发卒中的危险因素或者危险标识根据是否能被干预分类(不可干预的、可干预的和潜在可干预的),或者根据证据强度分类(证据充分和证据不充分).不可干预的险因素包括年龄,性别、低出生体重、种族和遗传易感性.证据充分并可干预的危险因素包括高血压、暴露于吸烟环境、糖尿病、心房颤动和某些其他心脏疾病、血脂异常,颈动脉狭窄,镰状细胞病、绝经后激素治疗、饮食不当、缺乏运动,肥胖和身体脂肪分布.证据不充分或者潜在可干预的危险因素包括代谢综合征、酗酒、滥用药物、口服避孕药、睡眠呼吸紊乱、偏头痛、高同型半胱氨酸血症,高脂蛋白(a)、高凝状态、炎症和感染.本指南还对使用阿司匹林预防首次卒中的数据进行了回顾,针对各种危险因素,提出了减少卒中风险可采取的策略.本指南综述了各种已经明确和近期明确的危险因素的证据,对2006年的指南进行了完整的修订.新版指南涉及的范围更加广泛.2006年指南着重于缺血性卒中的预防,由于危险因素和预防措施的重叠,本指南新加了出血性卒中的预防,并将重点放在以患者为本的个体化卒中预防.

(上接第8期第670页) 2 证据充分的可干预危险因素 2.1 高血压高血压既是脑梗死的危险因素,也是脑出血(intracerebral hemorrhage, ICH)重要的危险因素.血压和卒中之间存在强烈的、连续的、分级别的、一致的和独立的相关性,而且是有预测意义以及病因学意义的.

1前言1.1推荐级别Ⅰ类:有证据表明和(或)普遍共识表明该措施或治疗有用、有效;Ⅱ类:关于该措施或治疗的有用性/有效性存在着证据冲突和(或)意见分歧;Ⅱa类:证据或意见更倾向于有用的或有效的;Ⅱb类:相对于已证实的证据或意见更倾向于无用的或无效的;Ⅲ类:有证据表明和(或)普遍共识表明该措施或治疗无用/无效,而且某些情况下甚至可能有害.