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Lancet Neurol:孤立性脑干症状预测后循环卒中

2012-12-18 我要评论0

       最近,发表于《柳叶刀神经病学》的一项前瞻性研究发现,在椎基底动脉系统的脑卒中的患者中,卒中发生前常有孤立性短暂性脑干症状,但是大多数症状不符合TIA的传统定义。孤立性短暂性脑干症状的预后还有待更多研究来证实

       短暂性孤立性脑干症状(例如孤立性眩晕、构音障碍、复视)一直未被分类为短暂性缺血发作(TIA),并且预后数据有限。如果这些短暂性神经性发作(TNA)是由椎基底动脉缺血缺血导致,则在出现后循环卒中之前数天及数周期间它们应有共同表现。因此研究者想评估椎基底动脉缺血性卒中前的TNA发生频率。

       研究者通过在英国牛津郡进行的一项前瞻性、基于人群的发病率研究(牛津血管研究,2002~2010年)对确诊患者发生缺血性卒中前90天期间的所有潜在缺血事件进行了研究,并比较了椎基底动脉卒中与颈动脉卒中之前的TNA发生率。

       研究将脑干症状性孤立性眩晕、有非局灶性症状的眩晕、孤立性复视、短暂性全身无力以及双眼视力障碍分类为椎基底动脉区域的TNA,将不典型一过性黑蒙和肢体抖动分类为颈动脉区域的TNA,将孤立性发音含糊、变异型偏头痛、短暂性意识错乱和半身感觉针刺症状分类为未确定区域的TNA。

       结果发现,在1141例缺血性卒中患者中,1034例(91%)患者的血管区域可被归类:椎基底动脉卒中275例,颈动脉卒中759例。椎基底动脉卒中(45/275)前的孤立性脑干TNA比颈动脉卒中前的孤立性脑干TNA(10/759,OR为14.7,95%CI 7.3~29.5,P<0.0001)更频繁,在卒中前2天尤为明显(椎基底动脉卒中前22/252,vs.颈动脉卒中前2/751,OR为35.8,95%CI 8.4~153.5,P<0.0001)。

       在椎基底动脉卒中前(平均时间为4天,IQR为1~30)的全部59例TNA中,只有5例(8%)达到国立神经系统病症和卒中研究所(NINDS)的TIA标准,其他54例为孤立性眩晕(n=23),非NINDS双眼视力障碍(n=9),有其他非局灶性症状的眩晕(n=10),孤立性发音含糊、半身感觉针刺症状或复视(n=8),以及非局灶性事件(n=4)。45例孤立性脑干TNA患者中只有10例(22%)在卒中之前就医,其中只有1例被他们的医师怀疑为血管原因。

       因此,通过该研究,作者认为在明确的椎基底动脉卒中患者中,卒中之前有短暂性孤立性脑干症状是常见的,并且大多数症状未符合TIA的传统定义。短暂性孤立性脑干症状的发生后需警惕椎基底动脉卒中。




Background
Transient isolated brainstem symptoms (eg, isolated vertigo, dysarthria, diplopia) are not consistently classified as transient ischaemic attacks (TIAs) and data for prognosis are limited. If some of these transient neurological attacks (TNAs) are due to vertebrobasilar ischaemia, then they should be common during the days and weeks preceding posterior circulation strokes. We aimed to assess the frequency of TNAs before vertebrobasilar ischaemic stroke.
Methods
We studied all potential ischaemic events during the 90 days preceding an ischaemic stroke in patients ascertained within a prospective, population-based incidence study in Oxfordshire, UK (Oxford Vascular Study; 2002—2010) and compared rates of TNA preceding vertebrobasilar stroke versus carotid stroke. We classified the brainstem symptoms isolated vertigo, vertigo with non-focal symptoms, isolated double vision, transient generalised weakness, and binocular visual disturbance as TNAs in the vertebrobasilar territory; atypical amaurosis fugax and limb-shaking as TNAs in the carotid territory; and isolated slurred speech, migraine variants, transient confusion, and hemisensory tingling symptoms as TNAs in uncertain territory.
Findings
Of the 1141 patients with ischaemic stroke, vascular territory was categorisable in 1034 (91%) cases, with 275 vertebrobasilar strokes and 759 carotid strokes. Isolated brainstem TNAs were more frequent before a vertebrobasilar stroke (45 of 275 events) than before a carotid stroke (10 of 759; OR 14·7, 95% CI 7·3—29·5, p<0·0001), particularly during the preceding 2 days (22 of 252 before a vertebrobasilar stroke vs two of 751 before a carotid stroke, OR 35·8, 8·4—153·5, p<0·0001). Of all 59 TNAs preceding (median 4 days, IQR 1—30) vertebrobasilar stroke, only five (8%) fulfilled the National Institute of Neurological Disorders and Stroke (NINDS) criteria for TIA. The other 54 cases were isolated vertigo (n=23), non-NINDS binocular visual disturbance (n=9), vertigo with other non-focal symptoms (n=10), isolated slurred speech, hemisensory tingling, or diplopia (n=8), and non-focal events (n=4). Only 10 (22%) of the 45 patients with isolated brainstem TNAs sought medical attention before the stroke and a vascular cause was suspected by their physician in only one of these cases.
Interpretation
In patients with definite vertebrobasilar stroke, preceding transient isolated brainstem symptoms are common, but most symptoms do not satisfy traditional definitions of TIA. More studies of the prognosis of transient isolated brainstem symptoms are required.
Funding
Wellcome Trust, UK Medical Research Council, Dunhill Medical Trust, Stroke Association, National Institute for Health Research (NIHR), Thames Valley Primary Care Research Partnership, and the NIHR Biomedical Research Centre, Oxford.
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