目的 监测VCI患者的睡眠质量和睡眠结构,探讨其与认知功能的相关性.方法 收集2019年1月-2020年1月北京市朝阳区双桥医院神经内科门收治的81例患者作为VCI组.收集同时期相同年龄范围的32例体检健康志愿者作为对照组.全部研究对象进行认知功能测试,并进行事件相关电位(ERP)检查.同时进行精神状况量表测试.比较两组的认知功能相关指标[MoCA评分、MMSE评分、ERP(P300)波幅和潜伏期、起立-行走计时测试时间]、睡眠质量(PSQI评分、SRSS评分)、睡眠进程、睡眠结构和REM期参数(多导睡眠图,Polysomnography,PSG).结果 ①认知功能测试结果:VCI组的MoCA评分、MMSE评分较对照组均降低,P300潜伏期较对照组延长,P300波幅较对照组降低,TUGT用时较对照组延长(P<0.05).②睡眠状况测试结果:VCI组和对照组的匹兹堡睡眠质量指数量表(PSQI)总分差异有统计学意义(P<0.05).VCI组和对照组的睡眠状况自评量表(SRSS)评分差异有统计学意义(P<0.05);据多导睡眠图,VCI组较对照组睡眠潜伏期(SL)、觉醒次数(AT)、觉醒时间(ATA)、第1期睡眠比例(S1％)、第2期睡眠比例(S2％)、觉睡比(A/TSA)均增加,而睡眠总时间(TST)、第3期睡眠比例+第4期睡眠比例(S3％+S4％)、快速动眼期(REM)时间及比例、睡眠效率(SE)、睡眠维持率(SMT)均缩短(P<0.05).③VCI组和对照组的睡眠分期分析结果:VCI组、对照组患者在第1期睡眠比例(S1％)、第2期睡眠比例(S2％)、第3期睡眠比例+第4期睡眠比例(S3％+S4％)、快速动眼期比例(REM％)差异有统计学意义(P<0.05).④相关性分析结果:P300与MoCA直线相关系数r1为-0.637(P<0.05),TUGT与MoCA直线相关系数r2为-0.732(P<0.05),PSQI与MoCA直线相关系数r3为-0.801(P<0.05),表明P300、TUGT及PSQI与MoCA间有相关性,呈负向变化趋势.PSG与MoCA直线相关系数r4为0.661(P<0.05),表明PSG与MoCA间有相关性,呈正向变化趋势.结论 VCI患者认知功能下降.VCI患者存在睡眠连续性差、睡眠质量低的情况.PSQI评分与VCI患者认知水平的相关性最大,TUGT用时次之,PSG监测指标(SE)再次之,P300潜伏期与其相关性相对最小.多导睡眠图改变可作为VCI早期诊断的辅助指标.

重症肌无力( MG)是累及神经肌肉接头突触后膜的乙酰胆碱受体的获得性自身免疫疾病,其临床特征表现为局部或全身特定骨骼肌的病态易疲劳和波动性肌肉无力[1].Guil-lain-Barré综合征( GBS)是免疫介导的脱髓鞘性多发性周围神经病.部分MG患者可合并其他自身免疫性疾病,如甲状腺功能亢进、桥本氏甲状腺炎、系统性红斑狼疮等.但MG合并GBS罕见,目前报道年发病率约为二十亿分之一,现报道我科收治的1例如下.

常染色体显性遗传性脑动脉病伴皮质下梗死和白质脑病(CADASIL)是19p13的Notch3基因突变导致的常染色体显性遗传性脑动脉病,确诊是需在小动脉平滑肌细胞表面发现嗜锇性颗粒状致密沉积物( GOM )或者Notch3 基因检查发现突变.患者多在中年起病,以偏头痛、反复发作的缺血性卒中为特点,晚期出现进行性皮质下痴呆.头颅MRI主要表现为皮质下和中央灰质的多发腔隙性梗死以及脑室周围白质的高信号,其中外囊和颞极高信号对 CADASIL 具有很高的诊断价值[1-2].现对1例以硬膜下出血为首发症状的CADASIL患者的临床资料、影像特点和基因检测分析报道如下.

Objective:To assess the safety and efficacy of Anthocyanins for the treatment of Alzheimer's disease.Methods:From November 2018 to December 2020, a multicenter, double-blind, randomized controlled clinical study was conducted in 6 hospitals.The regular medication for the two groups was memantine, with the addition of a combination preparation containing Anthocyanins for the experimental group and a placebo for the control group.The Mini-Mental State Scale(MMSE), Montreal Cognitive Assessment Scale(MoCA), Alzheimer's Disease Assessment Scale-Cognitive Subscale(ADAS-cog), Activities of Daily Living Scale(ADCS-ADL)and Hamilton Depression Scale(HAMD)were used for assessment at the beginning.After 16 weeks of treatment, MMSE, MoCA, ADCS-ADL, ADAS-cog and the Clinician's Interview-Based Impression of Change Plus Caregiver Input(CIBIC-Plus)Scale were conducted and adverse events were recorded.Results:A total of 66 patients were enrolled, with 33 in the control group and 33 in the experimental group.There were no significant differences in cognitive function scores between the two groups before enrollment.Differences in MMSE scores, MOCA scores and ADAS-cog scores before and after treatment between the control group and the experimental group were 1.9±2.4 vs.3.4±2.0( t=2.62, P=0.011), 1.8±1.9 vs.2.9±1.4( t=2.45, P=0.018)and 3.0±2.3 vs.5.3±4.6( t=2.45, P=0.019), respectively.The differences were statistically significant.Instrumental activities of daily living(IADL)scores before and after treatment in the control group were 21.6±5.7 vs.22.6±6.2( t= 2.09, P= 0.046), and those in the experimental group were 22.7±5.4 vs.23.4±5.4( t= 2.45, P= 0.021). The differences between the two groups before and after treatment were statistically significant. Conclusions:Treatment with Anthocyanins can delay the decline of cognitive function and activities of daily living ability in patients with Alzheimer's disease.Anthocyanins may be a promising therapeutic drug for Alzheimer's disease in the future.

目的 探讨急性单纯胼胝体梗死的临床特点.方法 选择2010年1月-2018年12月本院2694例脑梗死患者中,经MRI确诊的16例急性单纯胼胝体梗死患者(单纯胼胝体梗死组)和同时期42例合并有颅内其他部位梗死的复合胼胝体梗死(复合胼胝体梗死组),比较两组的临床资料,包括一般资料、危险因素、临床症状及体征、影像学表现等,分析单纯胼胝体梗死患者临床特点.结果 ①急性单纯胼胝体梗死占同期脑梗死发生率的0.59％(16/2694),主要危险因素是高血压、糖尿病和高脂血症;病变血管以大脑前动脉最多见;临床以肢体瘫痪、认知障碍和精神行为异常为主要表现;②与复合胼胝体梗死组相比,单纯胼胝体梗死组中既往有脑梗死病史的占比少(31.3％vs 66.7％,P<0.05);从发病到就诊的时间长(68.3±12.7hvs 16.4±10.2h,P<0.05);肢体单瘫更多见(69.2％vs 28.0％,P<0.05),肢体肌力NIHSS评分低(1.6±0.4vs 3.6±0.8,P<0.05);大脑中动脉受累的占比少(62.5％vs 90.5％,P<0.05);预后更好(93.8％vs 61.5％,P<0.05).结论 急性单纯胼胝体梗死发生率低,常伴有多种动脉硬化危险因素,以肢体单瘫、认知障碍和精神行为异常为主要表现,预后较好.

近年来,眩晕疾病的诊疗引起国内外医学界的重视,我国许多医院正在诞生一个新的学科——眩晕医学科(也称眩晕诊疗中心),眩晕医学科的建立提高了眩晕疾病的诊疗水平.为了促进眩晕医学科的建设,学会总结了学科建设中的经验和不足,提出了眩晕医学科建设的临床路径.本文就眩晕门诊、眩晕实验室、眩晕病房、人才队伍建设和诊疗流程等临床路径进行了论述,为眩晕医学科建设提供参考.

F波是评价周围神经病变的功能状态、病变的定位诊断、病变严重程度、确定治疗方案以及评估预后的重要检测方法.针对F波各参数进行分析,总结F波临床应用的新进展,为神经系统疾病的早期诊断、预后评估提供更多的参考和帮助.

Restless legs syndrome (RLS) is a sensory-motility disorder, characterized by an urge to move the legs accompanied by uncomfortable sensations during periods of rest, which improves with movement. RLS typically affects the limbs. Up to now, it has been reported that RLS can affect atypical parts such as the mouth, abdomen, genitals, and bladder, and propose a variant of RLS. In this article, the research progress in variant of RLS is reviewed to improve the clinician′s understanding of the disease, and reduce misdiagnosis and mistreatment.

目的 探讨急性单纯胼胝体梗死的临床特点.方法 连续回顾性分析2010年1月至2018年12月首都医科大学附属复兴医院2694例脑梗死患者中,经MRI确诊的16例急性单纯胼胝体梗死患者临床资料,包括患者性别、年龄、卒中危险因素、影像学特征等,并记录患者胼胝体梗死的部位、胼胝体供血动脉有无狭窄以及颅内外狭窄血管的数量等,评价治疗前与出院时美国国立卫生研究院卒中量表(NIHSS)评分的变化.出院后6个月完成门诊病情评估.16例急性单纯胼胝体梗死患者中,男10例,女6例;年龄46～82岁,平均(69.4±2.3)岁;高血压病14例,2型糖尿病12例,高脂血症11例,冠心病5例(含心房颤动1例),高同型半胱氨酸血症4例,脑梗死6例,脑出血1例;吸烟史8例,饮酒史4例.结果 急性单纯胼胝体梗死占同期脑梗死的发生率为0.6％(16/2694),均伴有多个动脉粥样硬化危险因素,最主要危险因素是高血压病.16例急性单纯胼胝体梗死患者中,病变血管以大脑前动脉狭窄(14例)、大脑中动脉狭窄(10例)和颈内动脉狭窄(8例)多见;病变部位以胼胝体膝部和体部多见(12例),且以单侧受损为主(累及单侧胼胝体15例);临床以肢体瘫痪(13例)、认知障碍(10例)和精神行为异常(8例)为主要表现,偏身感觉异常(2例)、偏盲(1例)及共济失调(3例)较少见;经治疗后多数患者的病情可明显改善.治疗前NIHSS评分为(4.3±1.5)分,出院时NIHSS评分为(2.9±1.2)分,治疗前后的差异有统计学意义(t=3.914,P=0.023).出院6个月门诊随访结果显示,2例基本痊愈,13例显著进步,1例无变化,无死亡患者.结论 急性单纯胼胝体梗死发生率较低,其发病与颅内多支动脉狭窄密切相关,前循环血管可能更易受累.临床症状复杂多样,尤其应关注患者肢体肌力、认知功能及精神行为表现,一般预后良好.

卒中是心脏和大血管手术期间可能发生的最严重的并发症之一,可导致手术预后不良,住院时间延长,甚至致残率和致死率的上升.由于接受心脏和大血管手术的患者本身心血管功能不良,加之围手术期血流动力学的改变,和其他生理和心理等众多危险因素的存在,心脏和大血管手术卒中的发生率和危害程度高于其他类型手术.因此关注心脏和大血管手术卒中的危险因素与预防对于临床十分重要.

Nonbacterial thromboendocarditis (NBTE) is a heterogeneous disease characterized by the formation of valve vegetations. NBTE is associated with malignancy and hypercoagulability caused by various causes, and is one of the causes of cryptogenic stroke. Transesophageal echocardiography and MRI are important examination methods to diagnose NBTE-related stroke. NBTE patients with malignant tumor have a higher risk of stroke than general population, and the recurrence rate of stroke in the short term is high and the prognosis is poor. Therefore, early identification of NBTE-related stroke, timely secondary prevention and treatment are necessary and important. Treatment of NBTE includes tumor therapy and anticoagulation therapy.

IMPORTANCE Genetic variants of ABCB1 may affect intestinal absorption of clopidogrel bisulfate. However, it is unclear whether ABCB1 polymorphisms are associated with clopidogrel efficacy for minor ischemic stroke or transient ischemic attack (TIA). OBJECTIVES To investigate the association between ABCB1 polymorphisms and clopidogrel efficacy for minor stroke or TIA. DESIGN, SETTING, AND PARTICIPANTS In this prespecified secondary analysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) randomized clinical trial, 3010 patients with minor stroke or TIA at 73 sites in China with experience in conducting genetic studies were included from October 1, 2009, to July 30, 2012. The analysis was conducted on March 20, 2018. Four single-nucleotide polymorphisms (ABCB1-154T>C [rs4148727], ABCB13435C>T [rs1045642], CYP2C19*2 [681G>A, rs4244285], and CYP2C19*3 [636G>A, rs4986893]) were genotyped among 2836 patients treated with clopidogrel plus aspirin (n = 1414) or aspirin alone (n = 1422). The association of ABCB1 genetic variants (-154 TC/CC and 3435 CT/TT) with clopidogrel efficacy was evaluated in the context of CYP2C19 status, another gene associated with clopidogrel efficacy. INTERVENTIONS Patients in the CHANCE trial were randomized to treatment with clopidogrel combined with aspirin or to aspirin alone. MAIN OUTCOMES AND MEASURES Primary efficacy outcome was stroke recurrence after 3 months. The safety outcome was any bleeding risk after 3 months. RESULTS Among 2836 patients, the median age was 61.8 years (interquartile range, 54.4-71.1 years) and 1887 patients (66.5%) were male. A total of 2146 (75.7%) patients were carriers of ABCB1-154TC/CC (570 [20.1%]) or 3435 CT/TT (1851 [65.3%]) genotype. Clopidogrel plus aspirin treatment was associated with reduced risk of new stroke in patients with ABCB1-154 TT and 3435 CC genotype (hazard ratio [HR], 0.43; 95% Cl, 0.26-0.71) but not in those with ABCB1 -154 TC/CC or 3435 CT/TT genotype (HR, 0.78; 95% CI, 0.60-1.03) compared with aspirin (P=.04 for interaction). A combined association of ABCB1 and CYP2C19 polymorphisms with new stroke was observed. The risk of bleeding for clopidogrel plus aspirin treatment was not associated with the ABCB1 genotypes (2.3% and 1.3% vs 1.9% and 2.2%; P=.25 for interaction in patients with or without ABCB1-154 TC/CC or 3435 CT/TT genotype) CONCLUSIONS AND RELEVANCE The ABCB1 polymorphism was associated with the reduced efficacy of clopidogrel plus aspirin treatment compared with aspirin among patients with minor ischemic stroke or TIA. Genetic polymorphism of ABCB1 should be considered when prescribing clopidogrel for these patients.

神经病学是一门专业性很强的实践医学,教学内容涉及多个不同学科,其理论知识抽象难懂、解剖内容枯燥乏味,一直以来都是教学工作的难点.如何在教学中提高学生的积极性和学习能力,是在有限的课堂时间内最大程度地提高教学质量的关键.在当前互联网信息时代的背景下,基于微课的翻转课堂的教学模式有了充分发挥的空间.将"微课"与"翻转课堂"结合起来,运用到神经内科的临床教学中,提出了具体的教学方案,并对教学效果进行了评估、分析和总结.

Common methods for preventing stroke in patients with atrial fibrillation (AF) includes anticoagulant drugs, such as warfarin and new oral anticoagulants (NOAC), and left atrial appendage occlusion (LAAO). In recent years, some studies have shown that LAAO was not inferior to warfarin in the prevention of stroke in AF patients, and even better than warfarin, while randomized comparative studies of LAAO and NOAC are very few. However, the recent study suggested that LAAO increased the long-term AF-related outpatient care visit rate and hospitalization rate in AF patients, and might have an impact on the occurrence and development of AF, which brought some controversy. This suggested us that it is important to identify the indications of LAAO in clinical practice, and the patients suitable for LAAO should be strictly selected according to the comprehensive assessment of long-term benefit and risk.

黄光 异己手综合征( AHS)是患者无法支配患手,或将患侧肢体误认为他人肢体,并可伴有非自愿性肢体活动的一种少见的临床症候群[1-2] .胼胝体由于血供丰富,出现梗死概率小,常单侧受损,且多合并颅内其他部位梗死[3] .单纯双侧胼胝体梗死少见,约为脑梗死发病率的0.12% [4-5] .以AHS为首发症状的单纯双侧胼胝体梗死鲜有报告,现报道我科收治的1例如下.

眩晕/头晕的诊治涉及多个学科,神经科医师不仅要掌握神经科常见的中枢性眩晕/头晕,而且要掌握其他科室疾病导致的眩晕/头晕才能避免误诊、漏诊和误治.然而,目前尚无开展针对神经科医师有关眩晕/头晕进行讲授的专门课程,有必要对眩晕/头晕相关基础知识进行梳理,让神经科年轻医师深刻理解眩晕/头晕的概念、分类及疾病谱,牢记眩晕/头晕相关疾病的诊断标准,熟悉眩晕/头晕的问诊、查体内容和评估前庭功能的方法,建立正确的诊断急诊、门诊和病房眩晕/头晕患者的临床思维,掌握头晕/眩晕的防治措施,不断更新和学习最新国内外有关眩晕/头晕的新理论、新进展、新成果,并运用到临床实践中,对逐渐提高神经科青年医师诊治眩晕/头晕的水平有重要意义.

约90%的卒中为缺血性卒中,尽管诊断技术在进步,但不明原因的缺血性卒中仍然常见,被称为隐源性卒中.隐源性卒中大多数具有栓塞特征,其栓子可能起源于心脏.心输出血量的15%供应大脑,各种心脏栓子随着血流进入头颈动脉,阻塞脑动脉及其分支,由于脑血流突然中断导致缺血性卒中,该类型卒中大多数起病突然、神经功能受损严重.栓子在最初的血管流动撞击后可以移位或碎裂,其中约五分之一的心源性卒中表现为非突发性.栓塞所致卒中最重要的神经影像学特点是脑皮质和皮质下多部位的梗死,同时可以伴有全身多系统性栓塞.大部分隐源性卒中其栓子很可能来自于心脏,偶尔是来自于静脉系统通过心肺异常通路,比如合并卵圆孔未闭(patent foramen ovale,PFO),进入体循环的矛盾性栓塞(paradoxical embolism,PE).临床上将其称为"原因不明的栓塞性卒中(embolic stroke of undetermined source,ESUS)",占缺血性卒中的20%.诊断ESUS需要排除近段动脉狭窄或心房颤动(atrial fibrillation,AF)等已知心源性疾病[1-2].

Objective To study the clinical characteristics of herpes zoster ophthalmicus with oculomotor nerve palsy, improve awareness of the disease and reduce misdiagnosis and mistreatment. Method We analyzed the diagnosis and treatment of one patient of herpes zoster ophthalmicus with oculomotor nerve palsy, reviewed the literature and summarized the pathogeny,pathogenesis,clinical manifestations,differential diagnosis, treatment and prognosis of herpes zoster ophthalmicus with oculomotor nerve palsy. Results In this case, the rash of the right head and face with headache was a starting manifestation, the rash area was gradually grown clustered blisters. Accompanied by diplopia, the right eyelid was gradually swollen and lifted with weakness. Herpes was seen in the area of the right ophthalmic branch of the trigeminal nerve. The conjunctiva of the right eye was congested. The right oculomotor nerve was not completely paralyzed. After admission, antiviral and hormones were given, supplemented by nutritional nerve, acupuncture and so on, and the symptoms obviously recovered. Conclusion For headache without herpes, we should consider whether there was herpes zoster infection. Herpes zoster ophthalmicus can cause eye infections, accompanied by complete or incomplete oculomotor palsy. It should be differentiated from Tolosa-Hunt syndrome, intracranial aneurysms, diabetes and other diseases. Early treatment should be combined with antiviral, hormone, nutritional nerve, acupuncture and physical therapy. Early diagnosis and early treatment would result in better prognosis and some patients would leave neuralgia.

1 病例资料 患者,男性,90 岁,主因"右侧头面部皮疹伴疼痛 4 天,右眼睑抬举费力 1 天"入院. 2017 年 10 月 2 日,患者劳累后出现右侧额、颞、眼部周围皮肤针刺样疼痛,呈发作性,持续数分钟后缓解,程度轻,未予以重视. 10 月 3 日,患者于相应部位皮肤出现红色皮疹,此后皮疹逐渐增多,并出现水泡,疼痛逐渐加重.10 月 5 日,患者右侧眼睑肿胀,抬举费力,右眼结膜红肿伴不自主流泪,为求进一步诊治收入院. 既往史:有高血压、高脂血症病史,否认糖尿病、甲状腺功能亢进及肿瘤病史. 入院时查体:血压 130 / 80 mmHg,神志清楚,右侧前额、颞部、鼻背侧、眼周皮肤可见成簇样排列、大小不等水泡,未过中线;右眼角膜反射减弱,右侧额面部皮肤针刺觉较左侧过敏;右侧眼睑水肿、下垂,抬举费力,结膜充血,流泪.

INTRODUCTION:Paradoxical embolism (PDE) refers to direct passage of venous thrombi into the arterial circulation through an arteriovenous shunt. It is well-known that the pulmonary thromboembolism (PTE) can cause opening of the foramen ovale leading to paradoxical arterial embolism. Long term follow up of PDE patient over 10 years was not reported in the literature.PATIENT CONCERNS:A 57-year-old woman presented with initial symptoms of numbness/weakness and hypoxemia. Ultrasonography and pulmonary arteriography indicated pulmonary thromboembolism.DIAGNOSIS:Pulmonary embolism and paradoxical multiple arterial embolism or acute PTE concomitant with paradoxical multiple arterial embolism.INTERVENTIONS:Craniectomy and anticoagulation treatment was administered and the patient received low-dose warfarin therapy for 10 years.OUTCOMES:The patient is currently stable with no abnormalities seen in the deep veins of the bilateral lower limbs. The international normalized ratio (INR) was controlled within the range of 1.20 to 1.51. As this is a 10-year follow-up case report, the patient has responded well to the treatment and has been followed-up. The follow-up has been annual and the patient has been stable CONCLUSION:: Low intensity and persistent anticoagulation therapy can inhibit blood thrombophilia and reduce the risk of bleeding. It is noteworthy that such an approach used effectively in this patient. To best our knowledge, it is first report for long term follow up PDE patient successfully over 10 years.