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joi130108早期强化降压对急性缺血性脑卒中预后无益

Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients With Acute Ischemic Stroke The CATIS Randomized Clinical Trial

Jiang He,MD,PhD;Yonghong Zhang,MD,PhD;Tan Xu,MD,PhD;Qi Zhao,MD,PhD;Dali Wang,MD;Chung-Shiuan Chen,MS;Weijun Tong,MD;Changjie Liu,MD;Tian Xu,MD;Zhong Ju,MD;Yanbo Peng,MD;Hao Peng,MD;Qunwei Li,MD;Deqin Geng,MD;Jintao Zhang,MD;Dong Li,MD;Fengshan Zhang,MD;Libing Guo,MD;Yingxian Sun,MD;Xuemei Wang,MD;Yong Cui,MD;Yongqiu Li,MD ;Dihui Ma,MD;Guang Yang,MD;Yanjun Gao,MD;Xiaodong Yuan,MD;Lydia A.Bazzano,MD,PhD;Jing Chen,MD,MS;for the CATIS Investigators

Supplemental content at https://www.wendangku.net/doc/2213925548.html,

Author Affiliations:Author

affiliations are listed at the end of this article.

Group Information:The China Antihypertensive Trial in Acute

Ischemic Stroke (CATIS)Investigators are listed at the end of this article.Corresponding Authors:Jiang He,MD,PhD,Department of

Epidemiology,Tulane University School of Public Health and Tropical Medicine,1440Canal St,Ste 2000,New Orleans,LA 70112(jhe@tulane .edu).Yonghong Zhang,MD,PhD,Department of Epidemiology,School of Public Health,Medical College of Soochow University,199Renai Rd,Suzhou 215123,China (yhzhang @https://www.wendangku.net/doc/2213925548.html,).

Research

Original Investigation

S troke is the second leading cause of death and the leading cause of serious,long-term disability

worldwide.1Clinical trials have documented that lowering blood pressure reduces the risk of stroke in hypertensive2,3and normotensive patients with a history of stroke or transient ischemic attack.4-6Although the benefit of lowering blood pressure for primary and secondary pre-vention of stroke has been established,the effect of imme-diate antihypertensive treatment in patients with acute ischemic stroke and elevated blood pressure is uncertain.7,8 Elevated blood pressure is common during acute ischemic stroke.In the US National Hospital Ambulatory Medical Care Survey,76.5%of patients with acute ischemic stroke had systolic blood pressures of140mm Hg or greater on arrival at the emergency department.9Observational stud-ies have reported that a decrease in blood pressure within the first48hours after symptom onset was associated with poorer,better,or no difference in adverse clinical outcomes among patients with acute ischemic stroke.10-12There are no published clinical trials with sufficient statistical power to address the question of whether lowering blood pressure reduces adverse clinical outcomes among patients with acute ischemic stroke.

The China Antihypertensive Trial in Acute Ischemic Stroke(CATIS)was a multicenter randomized controlled trial designed to test whether moderate lowering of blood pressure within the first48hours after the onset of an acute ischemic stroke would reduce death and major disability at 14days or hospital discharge.In addition,we also evaluated the effects of antihypertensive treatment during the acute phase of ischemic stroke on3-month mortality,major dis-ability,and vascular events,as assessed at a posttreatment follow-up visit.

Methods

Trial Design and Participants

CATIS was a multicenter,single-blind,blinded end-points ran-domized clinical trial conducted in26hospitals across China. Details of the trial design and methods are summarized in the eMethods in Supplement.In brief,we recruited4071patients 22years or older who had ischemic stroke,confirmed by com-puted tomography or magnetic resonance imaging of the brain within48hours of symptom onset and who had an elevated systolic blood pressure between140mm Hg and less than220 mm Hg.Individuals with a systolic blood pressure of220mm Hg or greater or diastolic blood pressure of120mm Hg or greater were excluded because current clinical guidelines recom-mend antihypertensive treatment in such patients.7,13In ad-dition,patients with severe heart failure,acute myocardial in-farction or unstable angina,atrial fibrillation,aortic dissection, cerebrovascular stenosis,or resistant hypertension,and those in a deep coma,were excluded.Patients treated with intrave-nous thrombolytic therapy(ie,intravenous recombinant tis-sue plasminogen activator[rtPA])at baseline were excluded because of different requirements for blood pressure reduction.7

This study was approved by the institutional review boards at Tulane University in the United States and Soochow Uni-versity in China,as well as ethical committees at the26par-ticipating hospitals.Written consent was obtained from all study participants or their immediate family members.

Intervention

CATIS was designed to evaluate whether an antihyperten-sive treatment intervention aimed at lowering systolic blood pressure by10%to25%within the first24hours after ran-domization,achieving a systolic blood pressure less than 140mm Hg and diastolic blood pressure less than90mm Hg within7days,and maintaining this level of blood pressure control during the remainder of a patient’s hospitalization would reduce adverse clinical outcomes compared with a control group not receiving antihypertensive treatment. Randomization was conducted centrally and was stratified by participating hospitals and use of antihypertensive medi-cations.The randomization schedules were generated using SAS PROC PLAN in SAS and concealed until an eligible par-ticipant was ready for enrollment.After the study partici-pants had been randomly assigned to the antihypertensive treatment or control group,all home antihypertensive medications were discontinued.

Our trial was designed to test a blood pressure reduction strategy rather than the efficacy of specific antihypertensive drugs.As such,several antihypertensive agents,including intravenous angiotensin-converting enzyme inhibitors (enalapril,first-line),calcium channel blockers(second-line),and diuretics(third-line),could be used individually or in combination in the intervention group to achieve the targeted blood pressure reduction according to a prespeci-fied treatment algorithm(eFigure1in Supplement).Patients in the control group discontinued home antihypertensive medications.After their hospital discharge,patients in both groups were prescribed antihypertensive medications according to clinical guidelines.7,13Although treating study physicians and nurses were not blinded to group assign-ment,trial participants as well as the investigators and research staff who collected study outcome data were masked to treatment allocation.

Measurements

Demographic characteristics and medical history were col-lected at the time of enrollment.Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS;scores range from0to42,with higher scores indi-cating a more severe neurologic deficit)by trained neurolo-gists at baseline,14days or hospital discharge,and at a 3-month posttreatment follow-up visit.14Computed tomog-raphy or magnetic resonance imaging of the brain was per-formed according to standard techniques to confirm the diagnosis of ischemic stroke in all trial participants.Three blood pressure measurements were obtained at baseline by trained nurses according to a common protocol adapted from procedures recommended by the American Heart Association.15Blood pressure was measured with the par-ticipant in a supine position using a standard mercury

Research Original Investigation Antihypertensive Therapy and Acute Ischemic Stroke

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sphygmomanometer and1of4cuff sizes(pediatric,regular adult,large adult,or thigh)based on participant arm cir-cumference.After randomization,3blood pressure mea-surements were obtained every2hours for the first24 hours,every4hours during the second and third days,and 3times a day thereafter until hospital discharge or death.

Outcome Assessment

The primary outcome was a combination of death within14 days after randomization and major disability at14days or at hospital discharge if earlier than14days.The secondary outcome was a combination of all-cause mortality and major disability at the3-month posttreatment follow-up. Major disability was defined as a score of3to5on the modi-fied Rankin Scale at14days and3months after randomiza-tion.Scores on the modified Rankin Scale range from0to6, with a score of0indicating no symptoms;a score of5indi-cating severe disability(ie,bedridden,incontinent,or requiring constant nursing care and attention);and a score of6indicating death.16Since development of the initial CATIS protocol,ordinal analysis of the modified Rankin Scale scores is now recommended for acute stroke trials.17 Therefore,in the final statistical analysis plan,which was developed prior to initiation of data analysis,we included an ordered7-level categorical score of the modified Rankin Scale as a secondary outcome for neurologic functional sta-tus.Other secondary outcomes included vascular disease events(eg,vascular deaths,nonfatal stroke,nonfatal myo-cardial infarction,hospitalized and treated angina,hospital-ized and treated congestive heart failure,and hospitalized and treated peripheral arterial disease),recurrent fatal and nonfatal stroke,and all-cause mortality assessed at the 3-month posttreatment follow-up visit.

Participants were followed up in person at month3by trained neurologists and research nurses unaware of treat-ment assignment.Data on medical history,deaths,vascular events,blood pressure,NIHSS score,and modified Rankin Scale score were obtained.Death certificates were obtained for de-ceased participants,and hospital data were abstracted for all vascular events.A trial-wide outcomes assessment commit-tee,blinded to treatment assignment,reviewed and adjudi-cated vascular events based on criteria established in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial).18

Statistical Analysis

We estimated that with a sample of4000participants,the study would have90%statistical power to detect an abso-lute risk reduction of5%(or a relative risk reduction of14%) in the primary outcome at a significance level of.05for a 2-sided test.19The expected event rate for the primary out-come in the control group was estimated to be35%based on our pilot data,which are more conservative than those reported from previous studies.20We further assumed that 8%of participants would be nonadherent or would be lost to follow-up.

Data were analyzed according to participants’random-ized treatment assignments,regardless of their subsequent medication status(intention-to-treat).The proportions of participants with the primary and secondary outcomes at14 days or discharge and at3-month posttreatment follow-up were compared between the antihypertensive treatment and control groups using aχ2test at a2-sidedαlevel of5%, without correction for multiple comparisons.Logistic regression analysis was used to estimate unadjusted odds ratios(ORs)and95%CIs associated with antihypertensive treatment compared with no antihypertensive treatment.In a sensitivity analysis,ORs were adjusted for baseline age, sex,systolic blood pressure,NIHSS score,time from stroke onset to randomization,and history of antihypertensive medication use.Multiple imputation for missing data in the multivariable analyses was conducted using the Markov chain Monte Carlo method.In addition,the median and interquartile range of modified Rankin Scale scores were calculated,and the difference was compared using the Wil-coxon rank-sum test.21Ordinal logistic regression was used to estimate the effect of blood pressure reduction on the full range of the modified Rankin scale.22

We assessed the heterogeneity of the treatment effect on the primary outcome in prespecified subgroups by age, sex,systolic blood pressure at baseline,NIHSS score at base-line,time from onset of stroke to randomization,history of hypertension,history of antihypertensive treatment,and subtypes of ischemic stroke by adding an interaction term in unadjusted logistic regression models.A data and safety monitoring board met at least annually to review the accu-mulating data for safety and to monitor the trial for either superiority or inferiority of blood pressure reduction on the clinical outcomes.Data analyses were performed using SAS version9.4(SAS Institute Inc)and Stata version12 (StataCorp).

Results

Study Participants

From August2009to May2013,we screened22230consecu-tive patients with acute ischemic stroke,and4071who were eligible and willing to participate were enrolled in CATIS (Figure1).

Of the4071participants,2038were randomly assigned to receive antihypertensive treatment and2033were assigned to control.The mean age was62.0years;64.0%of participants were men,49.1%were taking antihypertensive medication at admission,and77.9%had strokes of thrombotic subtype.Base-line characteristics were balanced between the2groups (Table1).

Blood Pressure Reduction

The mean systolic and diastolic blood pressure levels dif-fered significantly between the2comparison groups from4 hours to14days after randomization(Figure2,Table2). Within24hours,the mean systolic blood pressure was reduced by21.8mm Hg(12.7%)in the treatment group and 12.7mm Hg(7.2%)in the control group(difference,?9.1mm Hg[95%CI,?10.2to?8.1];P<.001).At day7,the mean sys-

Antihypertensive Therapy and Acute Ischemic Stroke Original Investigation Research

tolic blood pressure was137.3mm Hg in the treatment group (with65.7%achieving the target systolic blood pressure of <140mm Hg)compared with146.5mm Hg in the control group(with32.2%having a systolic blood pressure<140mm Hg).At day14,the mean systolic blood pressure was135.2 mm Hg in the treatment group(with72.0%achieving the target systolic blood pressure of<140mm Hg)compared with143.7mm Hg in the control group(with39.5%having a systolic blood pressure<140mm Hg).The mean differences in systolic pressures between the2comparison groups were ?9.3mm Hg(95%CI,?10.1to?8.4;P<.001)at day7after randomization and?8.6mm Hg(95%CI,?9.7to?7.4; P<.001)at day14.

Other Treatments for Ischemic Stroke

Other treatments for ischemic stroke were prescribed by the study participants’physicians as part of their routine care ac-cording to Chinese stroke clinical guidelines and were bal-anced between the2groups(eTable1in Supplement).Pa-tients in the control group discontinued home antihypertensive medications.For example,33.4%of patients in the treatment group received heparin or low-molecular-weight heparin,com-pared with34.1%in the control group(P=.63).In addition,83.9%and12.2%of patients in the treatment group received aspirin and clopidogrel,compared with82.2%and12.9%in the control group(P=.15and.52).Furthermore,2.6%of patients in the treatment group received intravenous fibrinolysis,com-pared with2.3%in the control group(P=.55).Last,2.3%of pa-tients in the control group did not discontinue their home an-tihypertensive medications.

Clinical Outcomes at14Days or Hospital Discharge

At14days or hospital discharge,683of the trial participants (33.6%)in the antihypertensive treatment group,compared with681(33.6%)in the control group,had experienced death or a major disability(OR with antihypertensive treatment,1.00 [95%CI,0.88to1.14];P=.98).The median score from the modified Rankin Scale was not significantly different be-tween the2groups,and the odds of a higher modified Rankin Scale score were not associated with antihypertensive treat-ment(Table2).

Clinical Outcomes at the3-Month Posttreatment

Follow-up Visit

At the3-month visit,84.5%of the participants in the antihy-pertensive treatment group and75.4%in the control group re-ported the use of antihypertensive medications(P<.001)

Figure1.Study Flow

a Individuals with severe heart failure(New York Heart Association class III and IV),myocardial infarction,unstable angina,atrial fibrillation,aortic dissection, cerebrovascular stenosis,or in a deep coma.

b Eligible at screening visit but transferred to another hospital before randomization.

Abbreviations:IQR,interquartile range;NIHSS,National Institutes of Health Stroke Scale.

a Calculated as weight in kilograms divided by height in meters squared.

b Scores range from0(normal neurologi

c status)to42(coma with quadriplegia).

c Twelve patients with both thrombotic an

d embolic,93with thrombotic and lacunar,6with embolic and lacunar,and1with all3subtypes.

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(Table3).Blood pressure was significantly lower in the anti-hypertensive treatment group than in the control group (P<.001).Among participants in the antihypertensive treat-ment group,500(25.2%)died or had a major disability,com-pared with502(25.3%)in the control group(OR with antihy-pertensive treatment,0.99[95%CI,0.86to1.15];P=.93).The median modified Rankin Scale score,death rate,and vascu-lar disease events were similar between the2comparison groups,whereas recurrent stroke was slightly and nonsignifi-cantly reduced in the antihypertensive treatment group(OR, 0.65[95%CI,0.40to1.04];P=.07).

Subgroup Analysis

At14days or hospital discharge,the effects of antihyperten-sive treatment on the primary outcome were consistent across all prespecified subgroups(Figure3).At the3-month posttreatment follow-up visit,ORs for the primary outcome were not significantly different across the prespecified sub-groups,except for time from stroke onset to treatment (Figure4).Among patients who received antihypertensive treatment24hours or more after stroke onset,blood pres-sure lowering was associated with a significant reduction in the primary outcome(OR,0.73[95%CI,0.55to0.97]; P=.03).

Sensitivity Analysis

After adjustment for baseline age,sex,systolic blood pres-sure,NIHSS score,time from stroke onset to randomization, and history of antihypertensive medication use,the OR with antihypertensive treatment was1.09(95%CI,0.92to 1.28;P=.33)for death or major disability at14days or hos-pital discharge and1.05(95%CI,0.89to1.25;P=.55)for

Figure2.Mean Systolic and Diastolic Blood Pressure Since Randomization,by Treatment Group

Three blood pressure measurements

were obtained every2hours for the

first24hours,every4hours during

the second and third days,and3

times a day afterward until discharge

or death.Error bars indicate95%

confidence intervals.Tinted regions

indicate range from0days(0hours)

to3days(72hours).

Antihypertensive Therapy and Acute Ischemic Stroke Original Investigation Research

death or major disability at the3-month posttreatment follow-up visit.

Discussion

In this randomized clinical trial,mean systolic blood pres-sure was reduced by12.7%within the first24hours after randomization and was less than140mm Hg by day5and afterward in patients with acute ischemic stroke who received antihypertensive treatment within48hours of symptom onset.In addition,blood pressure remained sig-nificantly lower at3months’follow-up in the antihyperten-sive treatment group compared with the control group. However,the primary outcome of death or major disability was not different at14days or hospital discharge and at 3-month posttreatment follow-up after randomization between the antihypertensive treatment group and the con-trol group,in whom antihypertensive medications had been discontinued during their hospitalization.Median modified Rankin Scale scores were not significantly different between the2comparison groups at14days or discharge and at 3-month posttreatment follow-up.Furthermore,rates of vascular events,recurrent stroke,and all-cause mortality were not significantly different between the2comparison groups at the3-month posttreatment follow-up visit.These findings suggest that unless a patient’s systolic blood pres-sure is220mm Hg or more or diastolic pressure is120mm Hg or more,the decision to lower blood pressure with anti-hypertensive treatment in patients with acute ischemic

Abbreviations:IQR,interquartile range;OR,odds ratio.

a Modified Rankin Scale score of3or greater.

b Scores on the modified Rankin Scale,for which a score of0indicates no

symptoms,a score of5indicates severe disability,and a score of6indicates death.

c Odds of a1-unit higher modifie

d Rankin score.

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stroke does not improve or worsen outcome and therefore should be based on individual clinical judgment.

There are limited data from clinical trials on the effect of antihypertensive treatment in patients with acute ischemic stroke.A meta-analysis of clinical trials assessing the cal-cium channel blocker nimodipine showed no neuroprotec-tive effect in patients with acute ischemic stroke.23Two of these trials reported that nimodipine therapy within48 hours of stroke onset was associated with worse clinical outcomes in patients with acute ischemic stroke.24,25 Recently,a few preliminary randomized trials of blood pres-sure reduction in acute ischemic stroke have been published.26-29A phase2pilot trial of therapy with the angiotensin receptor blocker candesartan cilexetil was stopped early because of significantly lower mortality and fewer vascular events at12months in the treatment group, although blood pressure was similar between the2study groups.26However,a larger phase3trial(SCAST[Scandina-vian Candesartan Acute Stroke Trial])of candesartan therapy enrolling2029patients with acute stroke(ischemic or hemorrhagic)showed that the composite vascular end point did not differ between the treatment groups at6 months,despite a significant difference in blood pressure.29 Furthermore,poorer functional outcomes were reported in the candesartan group.Two other preliminary trials enroll-ing patients with acute ischemic or hemorrhagic stroke also indicated that antihypertensive treatment failed to reduce adverse clinical events.27,28

Several aspects of our study are novel.This is,to our knowledge,the first randomized trial with sufficient statis-tical power to test the effect of immediate blood pressure reduction on adverse clinical outcomes in patients with acute ischemic stroke.Previous large trials have been con-ducted in patients with acute intracerebral hemorrhage30or in patients with either acute ischemic or hemorrhagic stroke.29In addition,this trial compares active antihyper-tensive treatment with the temporary discontinuation of antihypertensive medications in control participants during hospitalization.Furthermore,this study tests an antihyper-tensive treatment strategy using a single drug or a combina-tion of multiple drug classes to achieve target blood pres-sure levels during hospitalization.On the other hand, SCAST was designed to examine the effect of the angioten-sin receptor blocker candesartan compared with placebo on clinical outcomes in patients with acute stroke.29The differ-ence in systolic blood pressure between candesartan and placebo was0.4mm Hg within24hours and4.9mm Hg by day7.29The current trial achieved significantly greater blood pressure reduction between the treatment and con-trol groups.However,the findings from this trial indicate that antihypertensive treatment did not reduce or increase death or major disability in patients with acute ischemic stroke.

The effects of antihypertensive treatment on the com-posite outcome of death and major disability at14days or discharge and at3-month posttreatment follow-up were consistent across subgroups defined by age,sex,systolic blood pressure at admission,NIHSS score,time from onset of stroke to randomization,history of hypertension,current use of antihypertensive medications,and subtypes of ische-mic stroke.The time from stroke onset to antihypertensive treatment was15hours on average,with a wide range.The study findings should be applicable to various subgroups of patients with acute ischemic stroke.

Abbreviations:IQR,interquartile

range;OR,odds ratio.

a Modified Rankin score of3or

greater.

b Includes vascular deaths,nonfatal

stroke,nonfatal myocardial

infarction,hospitalized and treated

angina,hospitalized and treated

congestive heart failure,and

hospitalized and treated peripheral

arterial disease.

c Odds of a1-unit higher modified

Rankin score.

Antihypertensive Therapy and Acute Ischemic Stroke Original Investigation Research

Our study had more than 90%statistical power to detect a 5%absolute risk reduction (or 14%relative risk reduction)in the composite outcome of death and major disability,which was recommended as a clinically meaning-ful risk reduction in acute stroke trials.19In addition,mean systolic blood pressure was reduced by 12.7%within the first 24hours and systolic pressure less than 140mm Hg was achieved by day 5in the antihypertensive treatment group.Sufficient statistical power and well-separated blood pressure levels during the trial minimize the probability of false-negative findings in our study.

Our study must be interpreted in light of several limita-tions.The trial excluded patients with acute ischemic stroke and blood pressure of 220/120mm Hg or greater,so the study findings cannot be applied to such patients.However,less than 0.1%of patients with acute stroke in US emergency departments 9and less than 0.5%of the 22230patients

assessed for eligibility in our study had an admission blood pressure of 220/120mm Hg or greater.In addition,patients treated with intravenous thrombolytic therapy (ie,intrave-nous rtPA)at baseline were excluded from this trial.Although intravenous rtPA is the standard treatment for acute ischemic stroke,the proportion of patients who received the therapy is low.31-33For example,of 1154247patients with acute ischemic stroke in a US national registry,only 66692(5.8%)were treated with intravenous rtPA.33Only 2.4%of patients with acute ischemic stroke were treated with intravenous thrombolytic therapy (1.6%with intravenous rtPA)in the China National Stroke Registry.34Therefore,our findings most likely are applicable for the majority of patients,who currently do not receive intrave-nous thrombolytic therapy.Patients included in this trial had a lower median NIHSS score of 4(interquartile range,2-8),compared with 7(interquartile range,2-10)in Chinese

Figure 3.Effect of Antihypertensive Treatment on Death or Major Disability at 14Days or Hospital Discharge

P Value for Homogeneity

Odds Ratio (95% CI)

Subgroup Age, y Odds Ratio (95% CI).05

.61

.59

.97

.36

.66

.95

.06

Antihypertensive Treatment

Total, No.Events,No. (%)Control

Total, No.Events,No. (%)<65 1.12 (0.94-1.34)1198352 (29.4)1203325 (27.0)833331 (39.7)824356 (43.2)≥650.87 (0.71-1.05)Sex

Women

1.05 (0.85-1.30)715267 (37.3)743269 (36.2)1316416 (31.6)1284412 (3

2.1)Men 0.98 (0.83-1.15)History of hypertension No 1.00 (0.75-1.32)428150 (35.0)430151 (35.1)1603533 (3

3.3)1597530 (33.2)Yes 1.00 (0.87-1.16)Baseline Rankin score

1.01 (0.66-1.53)91447 (5.1)90046 (5.1)1117636 (56.9)1125635 (56.4)≥3 1.02 (0.86-1.21)Use of antihypertension medications No 0.95 (0.79-1.13)1022354 (33.8)1045366 (35.0)1009338 (33.5)982315 (3

2.1)Yes 1.07 (0.88-1.29)Time to randomization, h <120.96 (0.80-1.14)1015376 (37.0)1082412 (38.1)401132 (32.9)33199 (29.9)12-23 1.15 (0.84-1.57)609172 (28.2)609167 (27.4)≥24 1.04 (0.81-1.34)Baseline SBP, mm Hg

<160

1.08 (0.87-1.35)715225 (31.5)765228 (29.8)838288 (34.4)851297 (34.9)160-1790.98 (0.80-1.19)478170 (35.6)411156 (38.0)≥1800.90 (0.69-1.19)Baseline NIHSS score

0-4

1.14 (0.87-1.49)1065134 (1

2.6)1009113 (11.2)871460 (52.8)923479 (51.9)5-15 1.04 (0.86-1.25)9589 (9

3.7)9389 (95.7)≥160.67 (0.18-2.44)Stroke subtype Thrombolic 1.01 (0.87-1.18)1513539 (35.6)1540544 (35.3)9360 (6

4.5)9248 (52.2)Embolic 1.67 (0.92-3.01)36666 (18.0)33878 (23.1)Lacunar 0.73 (0.51-1.06)2031

683 (33.6)

2027

681 (33.6)

Overall

1.00 (0.88-1.14)

Major disability was defined as a score of 3to 6on the modified Rankin Scale (score of 0indicates no symptoms,score of 5indicates severe disability,and score of 6indicates death).Each percentage is based on the number of

participants in that subgroup.Data markers indicate point estimates (with the

area of the square proportional to the number of events);error bars indicate 95%CIs.Scores on the National Institutes of Health Stroke Scale (NIHSS)range from 0(normal neurologic status)to 42(coma with quadriplegia).

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JAMA Published online November 17,2013

https://www.wendangku.net/doc/2213925548.html,

national registry data.35We did not detect a significant interaction between NIHSS score and blood pressure reduc-tion in this trial.Another limitation of this trial is the lack of repeated neurologic function tests and brain imaging stud-ies within the first 24hours of blood pressure lowering.These measures might provide early indicators to identify patient subgroups that might be more benefited or harmed by blood pressure reduction.30In addition,this trial was conducted exclusively in Chinese patients.The manage-ment of acute stroke may not be representative of Western populations;eg,there was a high use of heparin among the study patients.However,previous studies have demon-

strated that the association between blood pressure and stroke is consistent between Chinese and Western populations.4,30

Conclusions

Among patients with acute ischemic stroke,blood pressure re-duction with antihypertensive medications,compared with the absence of hypertensive medication,did not reduce the like-lihood of death and major disability at 14days or hospital discharge.

ARTICLE INFORMATION

Author Contributions:Drs He and Y.Zhang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.Drs He and Y.Zhang contributed equally to this work.Published Online:November 17,2013.doi:10.1001/jama.2013.282543.

Author Affiliations:Department of Epidemiology,School of Public Health,Medical College of

Soochow University,Suzhou,China (He,Y.Zhang,T.Xu,Tong,T.Xu,H.Peng);Department of

Figure 4.Effect of Antihypertensive Treatment on Death or Major Disability at 3Months

P Value for Homogeneity

Odds Ratio (95% CI)

Subgroup Age, y Odds Ratio (95% CI).72

.43

.03

.24

.67

.53

.08

.18

.08

Antihypertensive Treatment

Total, No.Events,No. (%)Control

Total, No.Events,No. (%)<65 1.02 (0.83-1.25)1172224 (19.1)1182223 (18.9)816276 (33.8)805279 (34.7)≥650.96 (0.78-1.18)Sex

Women

1.07 (0.85-1.35)701196 (28.0)726193 (26.6)1287304 (23.6)1261309 (24.5)Men 0.95 (0.79-1.14)History of hypertension No 1.06 (0.77-1.44)420107 (25.5)425104 (24.5)1568393 (25.1)1562398 (25.5)Yes 0.98 (0.83-1.15)Baseline Rankin score

0.79 (0.54-1.17)90050 (5.6)88361 (6.9)1088450 (41.4)1103441 (40.0)≥3 1.06 (0.89-1.26)Use of antihypertension medications No 0.95 (0.78-1.16)1004256 (25.5)1033273 (26.4)984244 (24.8)954229 (24.0)Yes 1.04 (0.85-1.28)Time to randomization, h <12 1.10 (0.91-1.34)993298 (30.0)1054295 (28.0)39292 (23.5)32866 (20.1)12-23 1.22 (0.85-1.74)597108 (18.1)600139 (23.2)≥240.73 (0.55-0.97)Baseline SBP, mm Hg

<160

1.04 (0.81-1.33)702155 (2

2.1)754162 (21.5)820223 (27.2)830215 (25.9)160-179 1.07 (0.86-1.33)466122 (26.2)403125 (31.0)≥1800.79 (0.59-1.06)Baseline NIHSS score

0-4

0.83 (0.61-1.12)105089 (8.5)993100 (10.1)848335 (39.5)901320 (35.5)5-15 1.19 (0.98-1.44)9076 (84.4)9282 (89.1)≥160.66 (0.28-1.58)Stroke subtype Thrombolic 0.97 (0.83-1.15)1482392 (26.5)1513408 (27.0)8947 (52.8)8834 (38.6)Embolic 1.78 (0.98-3.23)36248 (13.3)32954 (16.4)Lacunar 0.78 (0.51-1.19)1988

500 (25.2)

1987

502 (25.3)

Total

0.99 (0.86-1.15)

participants in that subgroup.Data markers indicate point estimates (with the

Antihypertensive Therapy and Acute Ischemic Stroke Original Investigation Research

https://www.wendangku.net/doc/2213925548.html,

JAMA Published online November 17,2013E9

Epidemiology,Tulane University School of Public Health and Tropical Medicine,New Orleans, Louisiana(He,Y.Zhang,Zhao,C.-S.Chen,Bazzano, J.Chen);Department of Medicine,Tulane University School of Medicine,New Orleans, Louisiana(He,Bazzano,J.Chen);Tulane Hypertension and Renal Center of Excellence,New Orleans,Louisiana(He,Bazzano,J.Chen); Department of Neurology,Affiliated Hospital of Hebei United University,Hebei,China(D.Wang,Y. Peng);Department of Neurology,Yutian County Hospital,Hebei,China(Liu);Department of Neurology,Kerqin District First People’s Hospital of Tongliao City,Inner Mongolia,China(Ju); Department of Epidemiology,School of Public Health,Taishan Medical College,Shandong,China (Q.Li);Department of Neurology,Affiliated Hospital of Xuzhou Medical College,Jiangsu,China (Geng);Department of Neurology,the88th Hospital of PLA,Shandong,China(J.Zhang); Department of Internal Medicine,Feicheng City People’s Hospital,Shandong,China(D.Li); Department of Neurology,Tongliao Municipal Hospital,Inner Mongolia,China(F.Zhang); Department of Neurology,Siping Central Hospital, Jilin,China(Guo);Department of Cardiology,the First Affiliated Hospital of China Medical University, Liaoning,China(Sun);Department of Neurology, Jilin Central Hospital,Jilin,China(X.Wang); Department of Neurology,General Hospital of First Automobile Works,Jilin,China(Cui);Department of Neurology,Tangshan Worker’s Hospital,Hebei, China(Y.Li);Department of Neurology,the First Affiliated Hospital of Jilin University,Jilin,China (Ma);Department of Neurology,the Second People’s Hospital of Huaian City,Jiangsu,China (Yang);Department of Neurology,Affiliated Hospital of Chengde Medical College,Hebei,China (Gao);Department of Neurology,Kailuan General Hospital,Hebei,China(Yuan).

Study concept and design:He,Y.Zhang,Bazzano,J. Chen.

Acquisition of data:He,Y.Zhang,Tan Xu,D.Wang, C.-S.Chen,Tong,Liu,Tian Xu,Ju,Y.Peng,H.Peng, Q.Li,Geng,J.Zhang,D.Li,F.Zhang,L.Guo,Sun,X. Wang,Cui,Y.Li,Ma,Yang,Y.Gao,X.Yuan,J.Chen. Analysis and interpretation of data:He,Y.Zhang, Zhao,C.-S.Chen,J.Chen.

Drafting of the manuscript:He,Y.Zhang.

Critical revision of the manuscript for important intellectual content:He,Y.Zhang,Tan Xu,Zhao,D. Wang,C.-S.Chen,Tong,Liu,Tian Xu,Ju,Y.Peng,H. Peng,Q.Li,Geng,J.Zhang,D.Li,F.Zhang,L.Guo, Sun,X.Wang,Cui,Y.Li,Ma,Yang,Y.Gao,X.Yuan, Bazzano,J.Chen.

Statistical analysis:He,Zhao,C.-S.Chen. Obtained funding:He,Y.Zhang. Administrative,technical,or material support:He,Y. Zhang,Bazzano.

Study supervision:He,Y.Zhang,J.Chen.

Conflict of Interest Disclosures:All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support:This study was supported by Tulane University and Collins C.Diboll Private Foundation,both in New Orleans,Louisiana; Soochow University,a Project of the Priority Academic Program Development of Jiangsu Higher Education Institutions,China,and the National Natural Science Foundation of China(grant 81320108026).The Changzhou Pharmaceutical

Factory provided the study drug(enalapril)for this

trial.

Role of the Sponsor:The funding agencies had no

role in the design and conduct of the study;the

collection,management,analysis,and

interpretation of the data;the preparation,review,

or approval of the manuscript;or the decision to

submit the manuscript for publication.

Group Information:The China Antihypertensive

Trial in Acute Ischemic Stroke(CATIS)

Investigators:Study steering committee:Jiang

He(chair),Jing Chen,Weijun Tong,Yonghong

Zhang,Tan Xu;Data and safety monitoring board:

Paul K.Whelton(chair),Jose Biller,C.Lillian Yau,

Zhenxin Zhang,Xingquan Zhao.Study and data

coordinating center:Tulane University School of

Public Health and Tropical Medicine and School of

Medicine,New Orleans,Louisiana:Lydia A.Bazzano,

Chung-Shiuan Chen,Jing Chen,L.Lee Hamm,Jiang

He,Tanika N.Kelly,Shengxu Li,Sheryl

Martin-Schild,Katherine https://www.wendangku.net/doc/2213925548.html,ls,Qi Zhao;School of

Public Health,Medical College of Soochow

University,Suzhou,China:Xiaoqing Bu,Fanlong

Kong,Hongmei Li,Hao Peng,Lingyan Tang,Weijun

Tong,Aili Wang,Ke Wang,Jiahui Wu,Juan Xu,Tan

Xu,Tian Xu,Mingzhi Zhang,Shaoyan Zhang,

Yonghong Zhang.Participating hospitals:

Department of Neurology,Affiliated Hospital of

Hebei United University,Hebei,China(Dali Wang,

Yanbo Peng,Li Zhang,Xiaojing Zhao,Suling Gao,

Jiang Zhang);Department of Neurology,Yutian

County Hospital,Hebei,China(Changjie Liu,

Jinchao Wang,Lingjun Kong,Yanhong Wu,Yanan

Cao,Baoli Liu);Department of Neurology,Kerqin

District First People’s Hospital of Tongliao City,

Inner Mongolia,China(Zhong Ju,Bing Zhao,

Haiying Liu,Maoli Bu,Yongjiang Li);School of

Public Health,Taishan Medical College,Shandong,

China(Qunwei Li);Department of Neurology,

Affiliated Hospital of Xuzhou Medical College,

Jiangsu,China(Deqin Geng,Fangfang Zhu,Junjun

Shan,Chao Ren,Yanbo Cheng);Department of

Neurology,the88th Hospital of PLA,Shandong,

China(Jintao Zhang,Cuiling Zhou,Yulan Zhao,Yujie

Bi,Na Zhong);Department of Internal Medicine,

Feicheng City People’s Hospital,Shandong,China

(Dong Li,Cuilan Liang,Shanliang Qiao,Guansheng

Zhang,Wei Wang);Department of Neurology,

Tongliao Municipal Hospital,Inner Mongolia,China

(Fengshan Zhang,Yanqiu Du,Jianhui Zhang,

Shuhua He);Department of Neurology,Siping

Central Hospital,Jilin,China(Libing Guo,Qingjuan

Du,Chunying Zhang,Wenhui Ma);Department of

Cardiology,the First Affiliated Hospital of China

Medical University,Liaoning,China(Yingxian Sun);

Department of Neurology,Jilin Central Hospital,

Jilin,China(Xuemei Wang,Jiale Liu,Yongshun

Wang,Dawei Yin);Department of Neurology,

General Hospital of First Automobile Works,Jilin,

China(Yong Cui,Jing Tian,Hong Chang,Yonghong

Gao);Department of Neurology,Tangshan Worker’s

Hospital,Hebei,China(Yongqiu Li,Haifeng Gao,

Dongsen Zhang);Department of Neurology,the

First Affiliated Hospital of Jilin University,Jilin,

China(Dihui Ma);Department of Neurology,

Dongping County People’s Hospital,Shandong,

China(Dongsheng Zhang,Jianjun Cui);Department

of Neurology,the Second People’s Hospital of

Huaian City,Jiangsu,China(Guang Yang,Liandong

Zhao,Jinlong Zheng);Department of Neurology,

Affiliated Hospital of Chengde Medical College,

Hebei,China(Yanjun Gao,Liang Zhao);Department

of Neurology,Kailuan General Hospital,Hebei,

China(Xiaodong Yuan,Shujuan Wang);Department

of Neurology,Anshan Changda Hospital,Liaoning,

China(Xiujie Han,Dan Zhou,Yulin Song);

Department of Neurology,Wenshang County

Chinese Traditional Medicine Hospital,Shandong,

China(Mingyu Zhang);Department of Neurology,

the First Affiliated Hospital of Harbin Medical

University,Heilongjiang,China(Shurong Duan);

Department of Neurology,First People’s Hospital of

Kezuohouqi,Inner Mongolia,China(Tao Feng);

Department of Neurology,Suzhou Kowloon

Hospital of Shanghai Jiaotong University School of

Medicine,Jiangsu,China(Jizhen Li);Department of

Neurology,Anshan Hospital of the First Affiliated

Hospital,China Medical University,Liaoning,China

(Suzhen Liu,Likui Hu);Department of Neurology,

Anshan Central Hospital,Liaoning,China(Wei Hu);

Department of Neurology,Anshan Shuangshan

Hospital,Liaoning,China(Chun Nie);Department

of Neurology,Affiliated Hospital of Inner Mongolia

National University,Inner Mongolia,China

(Nuenjiya Zhao).

Additional Contributions:We thank the study

participants and their relatives and the clinical staff

at all participating hospitals for their support and

contribution to this project.

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Antihypertensive Therapy and Acute Ischemic Stroke Original Investigation Research

脑卒中危险因素及预后措施的探讨

脑卒中危险因素及预后措施的探讨发表时间：2012-04-13T11:44:30.450Z 来源：《中外健康文摘》2012年第6期供稿作者：王亚春[导读] 无论低危、中危、还是高危患者都应立即采取非药物治疗措施。王亚春（内蒙古包头医学院第一附属医院神经内科 014010）【中图分类号】R743.3【文献标识码】A【文章编号】1672-5085（2012）6-0275-01 【摘要】目的探讨脑卒中危险因素及预后。高血压是脑卒中的主要基础病因，严重危及中老年人的健康。脑卒中的致残率和死亡率较高。因此，提高对高血压的认识针对病因进行早期预防、及时治疗，具有极其重要意义。方法收集我院2008－2009年82例脑卒中患者的临床特点，危险因素及预后措施。结果 82例患者，男性48人、女性34人，心房纤颤16例，平均年龄38－81岁。其中患高血压56例、病灶局限在前后循环者12例、病灶局限在后循环者5例、病灶累及前循环双侧24例、病灶在前后循环均累及21例。结论高血压、脑动脉粥样硬化、糖尿病、心脏病、TAI、肥胖、血脂、血小板聚集性增高、遗传、及酒精中毒、吸烟等在脑卒中起着重要作用。【关键词】脑卒危险因素预防措施 1 资料与方法 1.1 一般资料我院收治82例患者有中，男性48例、女性34例，平均年龄在38－81岁之间。所有患者均符合以下条件：①起病急，有脑实质损害的症状和体征。②头颅CT或MRI确诊为脑卒中，符合全国脑神经科学会义制定的脑血管疾病的诊断标准[2]。 1.2 入院82例患者中，有意识障碍者26例、56例有高血压病史、35例患有脑动脉粥样硬化、高21例心脏病、糖尿病7例。既往脑梗死病例8例、短暂性脑出血发病史5例。所有患者均有不同程度的神经系统症状和体征。偏瘫者57例，偏身感觉障碍者2例、头晕34例、探讨22例，语言障碍者26例、共济失调3例、吞咽困难7例。 1.3 辅助检查：所有患者经头颅CT扫描检查52例，经头颅MRI检查确诊，基底节区脑梗死33例，额、颞、枕叶脑梗死13例，脑干及小脑梗死7例，属腔隙性脑梗死19例，其它检查有异常者如：心电图、血糖、纤维蛋白原、血脂异常、血沉增快等。 2 讨论脑卒中是导致中老年人死亡和致残的重要疾病，近年来脑卒中的发病率、死亡率均有明显提高。而高血压是全球最常见的心血管疾病。在我国心脑血管疾病中发生最高，其次是脑动脉硬化、高脂血症、冠心病、糖尿病、血流变学异常、肥胖、大量饮酒、吸烟等。不良情绪、环境因素是应激诱发脑卒中的重要危险因素。高血压是遗传因素与环境因素长期相互作用的结果，而影响高血压发病的危险因素可分为不可改变的危险因素和可改变的危险因素，而不可改变的因素：①年龄和性别：高血压患病率随年龄增长而增高，年龄每增加10岁，患病率增高10%，且男性高于女性，35岁以后女性高血压患病率及升高幅度可超过男性。②遗传因素：高血压患者多有遗传史。可改变的因素：体重和肥胖是高血压的危险因素，同时也是冠心病和脑卒中发病的独立危险因素。而膳食高盐、低钾、低钙、长期过量饮酒、缺乏体力劳动、精神紧张等不良心理也可引起高血压。而脂代谢异常可导致早发性动脉粥样硬化，大脑中小动脉纤维蛋白性坏死、玻璃样变性及内膜增生易产生脑卒中，而糖尿病是以高血糖为主要症状，在长期血糖刺激下神经系统受到损伤。③心脏病：是40岁以下脑卒中的主要原因，多发生在大动脉、中动脉分部区。多见于：⑴冠心病、心肌梗塞。⑵心功能不全或严重心率失常，导致血流紊乱，动脉灌注压下降，脑灌注不足。⑶心脏病手术时发生的脑梗死。⑷治疗心血管药物导致的脑血流下降、血管畸形、动脉炎、血液病及血液成分异常，易于梗塞微循环发生梗死。⑸嗜烟酒及酒精中毒是中青年的直接危险因素。⑹其他因素：如偏头痛、高钠、高胆固醇饮食、不良生活习惯等导致高血压、动脉粥样硬化而引起脑卒中。 3 预防后措施 3.1 高血压病是脑血管和心血管病的共同首要危险因素，脑卒中的发生、发展与血压增高关系极为密切。通过积极控制血压，可以减少脑卒中的发病率和死亡率。高血压又是一种常见的慢性病，健康文明的生活方式对于预防高血压有至关重要的作用。我们把健康文明的生活方式归纳以下几个方面：①合理膳食、低盐、多吃蔬菜水果。②戒烟戒酒或适量饮酒。③控制体重。④开展有规律的体育锻炼。⑤减少精神压力，保持平衡心态。 3.2 无论低危、中危、还是高危患者都应立即采取非药物治疗措施。非药物治疗适合于各型高血压患者，是危险因素综合控制的步骤之一，非药物治疗可以提高疗效，减少药物用量，从而降低药物的副作用，减少治疗费用。参考文献 [1] 第二届全国少数民族地区神经内科学术研讨会.2003. 10.广西?桂林. [2] 临床医学新进展?内蒙古自治区继续医学教育委员会. 2009、2010.

影响脑卒中患者预后的相关因素分析_王冠洲

DOI ：10．13429/j．cnki．cjcr．2014．06．014 作者单位：463138河南省驻马店市遂平县嵖岈山镇中心卫生院影响脑卒中患者预后的相关因素分析王冠洲，刘静贤，熊建中，魏彦兵【摘要】目的探讨脑卒中患者生存情况及影响预后的相关因素。方法选择2012年1月至12月收治的脑卒中患者198例为研究对象，观察患者年龄、入院时神经系统功能评分（NIHSS ）等指标，随访发病后12个月内生存结局，应用Cox 比例风险回归进行影响生存因素的分析。结果（1）患者发病14d 及1、6、 12个月累计生存率分别是79．8%、77．3%、74．2%和70．9%（Kaplan-Meier 法）。（2）单因素Cox 比例风险回归分析：年龄、入院时眼球运动障碍、失语、尿失禁、格拉斯哥昏迷评分（GCS ）、NIHSS 和脑中线结构偏移与脑卒中12个月生存预后相关（P ＜0．01）。（3）多因素Cox 比例风险回归显示：入院时GCS （ＲＲ=0．727）、NIH-SS （ＲＲ=1．137）和年龄（ＲＲ=1．078）是影响预后的独立因素。结论年龄、入院时神经系统功能缺损严重和昏迷程度是脑卒中患者预后（死亡）的独立影响因素。【关键词】脑卒中；预后；随访；生存分析中图分类号：Ｒ743．3 文献标识码：B 文章编号：1674－8182（2014）06－0674－03 脑卒中已经成为威胁人类生命健康的重大疾病之一，严重影响着患者的生活质量，给家庭和社会带来沉重的经济负担。探讨脑卒中预后的相关影响因素，并采取针对性的干预措施，可以有效地改善脑卒中患者的预后，降低病死率。本研究对198例老年脑卒中患者出院后12个月的随防资料进行分析，旨在寻找影响脑卒中患者预后的相关因素，并为临床决策提供科学依据。1 资料与方法 1．1病例选择我院2012年1月至12月收治198例脑卒中患者，其中男130例（65．66%），女68例（34．34%）；年龄34 91（60．19?11.03）岁；缺血性脑卒中132例，出血性脑卒中66例。入选标准：（1）符合1996年全国第四届脑血管病学术会议通过的诊断标准［1］，并经头部CT 或MＲI 影像诊断证实为出血性脑卒中或缺血性脑卒中；（2）首次脑卒中；（3）发病到就诊时间未超过48h 。排除标准：（1）短暂性脑缺血发作；（2）无症状性脑梗死；（3）颅内肿瘤或蛛网膜下腔出血；（4）既往有帕金森病、老年性痴呆等；（5）合并有心、肺、肝、肾等脏器严重病变者。1．2治疗方法缺血性脑卒中患者给予溶栓、改善循环、抗血小板聚集治疗，出血性脑卒中患者给予脱水降颅压或手术治疗，并纠正酸中毒、补液、抗感染等对症治疗，康复期行功能锻炼。 1．3观察指标（1）一般情况：性别、年龄、入院时体温（T ）、血压（BP ）；（2）既往史：高血压病史、心脏病史、糖尿病史；（3）卒中类型：出血性脑卒中、缺血性脑卒中；（4）入院时病情严重程度：格拉斯哥昏迷评分（GCS ），是否眼球运动障碍、失语、尿失禁等；（5）采用美国国立卫生研究院卒中量表（National In-stitute of Health Stroke Scale ，NIHSS ）评价入院时的神经系统功能缺损情况；（6）影像学指标：脑中线结构是否偏移；（7）实验室指标：白细胞（WBC ）、血小板（PLT ）、血糖（PG ）、血红蛋白（Hb ）、血清白蛋白（ALB ）等。 1．4随访以患者发病为始点，至患者死亡、失访或最后一次随访时间为终点，最长随访时间12个月。随访由经过培训的专业人员进行，方式采取信访、电话询问、社区回访和门诊复诊等形式。 1．5统计学分析采用SPSS 16．0统计软件，Kap-lan-Meier 法计算生存率，单因素和多因素Cox 比例风险回归筛选影响预后的相关因素，置信区间为95%，检验水平α=0．05。2 结果 2．1生存状况描述截至随访终止，失访10例，死亡60例，其中因脑卒中死亡57例。14d 及1、 6、12个月累计生存率分别是79．8%、77．3%、74．2%、70.9%，平均生存272．353d （95%CI ：251．127 293.579），未获得中位生存时间。见图1 。图1 198例脑卒中患者生存曲线（Kaplan- Meier 法）2．2 脑卒中预后的单因素Cox 比例风险回归变量赋值数量化，性别为女=0，男=1；高血压病史、心脏 476中国临床研究2014年6月第27卷第6期Chinese Journal of Clinical Ｒesearch ，June 2014，Vol.27，No.6

肩手综合征是脑卒中后常见的并发症

肩手综合征是脑卒中后常见的并发症常出现患者肩关节及手部肿痛活动受限或伴有皮色改变其早期常表现为患手出现肿胀产生明显的运动受限手指变粗皮纹消失皮肤呈粉红色或紫红色关节活动受限表现为手被动旋后腕背伸受限手指间关节处于伸展位屈曲时受限被动活动时可引起疼痛按照病情演变分为三期： I 期：急性期肩部疼痛活动受限常伴指腕关节的疼痛;手指大多保持轻度屈曲位且屈曲的可动范围受限;手部肿胀皮肤潮红皮肤温度增高等血管运动性改变;腕关节活动尤其是屈曲时疼痛加重;X线片多可见肩手部骨骼局灶性脱钙 II 期：营养障碍期肩手部疼痛肿胀活动受限症状持续或减轻手及上肢皮肤菲薄皮肤温度降低;手部小肌肉明显萎缩手掌筋膜肥厚 III 期：肩手部疼痛减轻或消失手部血管运动性改变消失而肌肉萎缩明显形成挛缩畸形;X线片可见患肢广泛骨质疏松但不典型的形式也可只表现为其中的某一期或受累的肢体远端或近端的某一部分对于本病的治疗有三个环节分别是：控制病程进展积极进行功能锻炼避免和减小畸形发生对本病的患者应给抗炎药物如保太松衍生物(phenylburazone derivatives)和颈星状神经节反复封闭手指动力性夹板有助于防止发生畸形和恢复手指手的肌力使用皮质类固醇尤其在疾病早期不仅可减轻疼痛而且可控制病情发展改善疾病预后对情绪不稳精神忧郁的患者要引导身心健康适当用安定(valium)和利眠宁(librium)避免长期使用麻醉剂和镇静剂请精神科医师会诊协助治疗止痛功能锻炼和颈星状神经节封闭(0.5%～1% sylocain)均有助于反射性交感神经营养不良的恢复血管扩张药也可采用本病发病机制尚不明确目前较为公认的机制是脑血管病急性发作影响到运动中枢前方的血管运动中枢血管运动神经麻痹引发患肢的交感神经兴奋性增高及血管痉挛反应末梢血流增加产生局部组织营养障碍从而出现水肿疼痛疼痛刺激又进一步经末梢感觉神经传至脊髓引发脊髓中间神经的异常兴奋性刺激造成血管运动性异常的恶性循环肩-手综合征（shoulder hand syndrome, SHS）是脑卒中偏瘫患者的常见并发症，影响中风患者的上肢康复。本文综述了近年来防治方法及治疗机制等相关方面的研究进展。治疗方法包括健康教育，康复训练（如体位摆放、运动疗法、物理因子疗法、向心性加压缠绕和支具的应用），药物和脊髓刺激疗法对疼痛的处理，交感神经阻滞，针推及中药疗法等多综合应用，并强调了预防的重要性。提出参考与预后相关的临床因素和临床特征，评价各种疗法的作用，进行合理的优化组合，发挥中医药疗法的优势，提高诊疗水平。【关键词】肩-手综合征脑卒中防治进展

脑卒中预后影响因素分析

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缺血性脑卒中诊疗常规

内二科急性缺血性脑卒中诊疗指南急性缺血性脑卒中(脑梗死)是最常见的脑卒中类型，占全部脑卒中的60%-80%。其急性期的时间划分尚不统一，一般指发病后2周内。急性缺血性脑卒中的处理应强调早期诊断、早期治疗、早期康复和早期预防再发。缺血性脑卒中是指由于脑的供血动脉（颈动脉和椎动脉）狭窄或闭塞、脑供血不足导致的脑组织坏死的总称。有四种类型的脑缺血：短暂性脑缺血发作（TIA）；可逆性神经功能障碍（RIND）；进展性卒中（SIE）；完全性卒中（CS）。TIA无脑梗死存在，而RIND、SIE和CS有不同程度的脑梗死存在。急性期诊断与治疗一、评估和诊断脑卒中的评估和诊断包括：病史和体征、影像学检查、实验室检查、疾病诊断和病因分型等。 (一)病史和体征 1.病史采集：询问症状出现的时间最为重要。其他包括神经症状发生及进展特征，心脑血管病危险因素，用药史、药物滥用、偏头痛、痫性发作、感染、创伤及妊娠史等。 2.一般体格检查与神经系统体检：评估气道、呼吸和循环功能后，立即进行一般体格检查和神经系统体检。 (二)脑病变与血管病变检查 1.脑病变检查：(1)平扫CT：急诊平扫CT可准确识别绝大多数颅内出血，并帮助鉴别非血管性病变(如脑肿瘤)，是疑似脑卒中患者首选的影像学检查方法。(2)多模式CT：灌注CT可区别可逆性与不可逆性缺血，因此可识别缺血半暗带。但其在指导急性脑梗死治疗方面的作用尚未肯定。(3)标准MRI：标准MRI(T1加权、T2加权及质子相)在识别急性小梗死灶及后颅窝梗死方面明显优于平扫CT。可识别亚临床梗死灶，无电离辐射，不需碘造影剂。但有费用较高、检查时间

长及患者本身的禁忌证(如有心脏起搏器、金属植入物或幽闭恐怖症)等局限。 2.血管病变检查：颅内、外血管病变检查有助于了解脑卒中的发病机制及病因，指导选择治疗方案。常用检查包括颈动脉双功超声、经颅多普勒(TCD)、磁共振血管成像(MRA)、CT血管成像(CTA)和数字减影血管造影(DSA)等。颈动脉双功超声对发现颅外颈部血管病变，特别是狭窄和斑块很有帮助;TCD可检查颅内血流、微栓子及监测治疗效果，但其受操作技术水平和骨窗影响较大。 (三)实验室及影像检查选择对疑似脑卒中患者应进行常规实验室检查，以便排除类脑卒中或其他病因。所有患者都应做的检查：①平扫脑CT或MRI;②血糖、血脂肝肾功能和电解质;③心电图和心肌缺血标志物;④全血计数，包括血小板计数;⑤凝血酶原时间(PT)、国际标准化比率(INR)和活化部分凝血活酶时间(APTT);⑥氧饱和度;⑦胸部X线检查。部分患者必要时可选择的检查：①毒理学筛查;②血液酒精水平;③妊娠试验;④动脉血气分析(若怀疑缺氧);⑤腰穿(怀疑蛛网膜下腔出血而CT未显示或怀疑脑卒中继发于感染性疾病); (四)诊断急性缺血性脑卒中的诊断可根据：(1)急性起病;(2)局灶性神经功能缺损，少数为全面神经功能缺损;(3)症状和体征持续数小时以上(溶栓可参照适应证选择患者);(4)脑CT或MRI排除脑出血和其他病变;(5)脑CT或MRI有责任梗死病灶。 (五)病因分型对急性缺血性脑卒中患者进行病因分型有助于判断预后、指导治疗和选择二级预防措施。当前国际广泛使用TOAST病因分型，将缺血

脑卒中护理手册

脑卒中护理手册目录 1. 脑卒中的基本概述 2. 脑卒中的常见症状及临床体征的评估 3. 脑血管病的危险因素 4. 脑血管病的辅助检查 5. 缺血性脑血管病的治疗及护理 6. 出血性脑血管病的治疗及护理 7. 脑卒中血管内治疗及护理 8. 脑卒中患者的康复治疗

脑卒中的基本概述脑血管疾病是指各种原因导致的脑血管性疾病的总称。卒中为脑血管疾病的主要临床类型，包括缺血性卒中和出血性卒中，以突然发病，迅速出现局限性或弥散性脑功能缺损为共同临床特征，为一组器质性脑损伤导致的脑血管疾病。脑卒中是危害中老年人身体健康和生命的主要疾病之一，是目前导致人类死亡的第二位原因，它与缺血性心脏病，恶性肿瘤构成多数国家的三大致死疾病。目前我国脑卒中已成为超过恶性肿瘤成为中国第一致死病因，发病率120-180/10万，每年死亡病例大于150万，存活者600-700万，且2/3 存活患者留有不同程度的残疾。本病高发病率，高死亡率和高致残率给社会，家庭带来沉重的负担和痛苦。脑卒中常见症状及临床体征的评估一.头痛：通常指局限于头颅上半部，包括眉弓，耳轮上缘和枕外隆突连线以上部位的疼痛。评估：1.病史（1）了解头痛的部位，性质和程度：询问是全头痛，局部头痛还是部位转换不定的头痛：是搏动性头痛还是胀痛，钻痛，钝痛，触痛，撕裂痛或紧箍痛，是轻微痛，剧烈痛还是无法忍受的疼痛。（2）头痛的规律：询问头痛发病的急缓，是持续性还是发作性，起始与持续时间，发作频率，激发，加重或缓解的因素。急起的头痛可能提示蛛网膜下腔出血，脑出血。（3）有无先兆及伴发症状：蛛网膜下腔出血导致的头痛，病人可伴有恶心，呕吐等症状。（4）疼痛常用工具：1.数字式疼痛评定法：将一条直线等分为10 段，一端0 代表无痛，另一端10 代表极度疼痛，病人可选择其中一个能代表自己疼痛感受的数字来表示疼痛程度。2.文字描述式，将一直线等分5 段，其中一端表示“没有疼痛” 。另一端表示

脑卒中的症状表现有哪些

脑卒中的症状表现有哪些脑卒中后遗症是指中风患者发病造成神经细胞及组织坏死，经过一段时间的治疗，除神志清醒外，其余症状依然会不同程度地存在，如偏瘫(半身不遂)、半侧肢体障碍、肢体麻木、偏盲、失语等症状! 脑中风给人类健康和生命造成极大威胁，给患者带来极大痛苦，家庭及社会负担沉重。因此，充分认识脑中风的严重性，提高脑中风的治疗与预防水平、降低脑中风的发病率，致残率和死亡率是当务之急。研究发现脑卒中常见预兆依次为： (1)头晕，特别是突然感到眩晕。 (2)肢体麻木，突然感到一侧面部或手脚麻木，有的为舌麻、唇麻。 (3)暂时性吐字不清或讲话不灵。 (4)肢体无力或活动不灵。 (5)与平时不同的头痛。 (6)不明原因突然跌倒或晕倒。 (7)短暂意识丧失或个性和智力的突然变化。 (8)全身明显乏力，肢体软弱无力。 (9)恶心呕吐或血压波动。 (10)整天昏昏欲睡，处于嗜睡状态。 (11)一侧或某一侧肢体不自主地抽动。 (12)双眼突感一时看不清眼前出现的事物。脑卒中四大常见后遗症临床特征： 1、中枢性瘫痪：中枢性瘫痪，又称上运动神经元性瘫痪，或称痉挛性瘫痪、硬瘫。是由于大脑皮层运动区锥体细胞及其发出的神经纤维--锥体束受损而产生。由于上运动神经元受损，失去了对下运动神经元的抑制调控作用，使脊髓的反射功能"释放"，产生随意运动减弱或消失，临床上主要表现为肌张力增高，腱反射亢进，出现病理反射，呈痉挛性瘫痪。

2、麻木：患侧肢体，尤其是肢体的末端、如手指或脚趾、或偏瘫侧的面颊部皮肤有蚁爬感觉，或有针刺感，或表现为刺激反应迟钝。麻木常与天气变化有关，天气急剧转变、潮湿闷热，或下雨前后，天气寒冷等情况下，麻木感觉尤其明显。 3、嘴歪眼斜：一侧眼袋以下的面肌瘫痪。表现为鼻唇沟变浅，口角下垂，露齿。鼓颊和吹哨时，口角歪向健侧，流口水，说话时更为明显。 4、周围性瘫痪：周围性瘫痪，又称下运动神经元性瘫痪，或称弛缓性瘫痪、软瘫。是因脊髓前角细胞及脑干运动神经核，及其发出的神经纤维--脊骸前根、脊神经、颅神经受损害产生的瘫痪。由于下运动神经元受损，使其所支配的肌肉得不到应有的冲动兴奋，临床上表现为肌张力降低，反射减弱或消失，伴肌肉萎缩，但无病理反射。脑卒中注意 1、一旦发生卒中征兆，要迅速恢复冷静，拨打120。牢记“时间就是大脑”，千万不要有“休息一下可能就好了”的想法，后者只会耽误诊治，失去最好的治疗时机。 2、切忌仰卧位，头应偏向一侧，及时清除口腔内异物，如呕吐物、假牙等，保持呼吸道通畅。 3、切忌自行服药，没有确诊前随意用药可能会加重病情。由神经科医生进行评估和治疗，在医生指导下吃药、随访。原文链接：https://www.wendangku.net/doc/2213925548.html,/nzf/2014/0807/190444.html

脑卒中绿色通道定稿版

脑卒中绿色通道精编 W O R D版 IBM system office room 【A0816H-A0912AAAHH-GX8Q8-GNTHHJ8】

联系收住院手术治疗。 4．对确诊或高度疑似缺血性脑梗死的患者，急诊科医师应立即与神经内科会诊医师联系住院治疗，符台溶栓条件的患者，神经内科医师有责任告知患者和家属其治疗方案，以及各种治疗方案的利弊，并立即进行溶栓治疗的准备工作，以免延误治疗时机。 5.神经内科接到急诊科会诊通知后必须在15分钟内派出二线医师到达急诊科。必要时可请科主任参加会诊。三、静脉溶栓治疗； l.由神经内科医师负责与患者或家属解释该治疗的各项相关内容。 2.溶检前在急诊科进行相关的化验、心电图等检查，并做好监护急救药品和抢救器械的准备。 3．溶栓前必须签署溶栓治疗同意书。 4.因静脉溶栓治疗育明要的时效性，应在超早期内执行，可根据患者的具体情况决定是在急诊科或在神经内科进行。 5．静脉溶栓治疗方法参照我国脑血管病防治指南进行。四、专业培训：