阿尔茨海默病患者精神行为异常与脑白质损害的相关性

目的 探讨阿尔茨海默病(Alzheimer's disease,AD)患者精神行为异常与脑白质损害的相关性.方法 纳入60例60岁以上的AD患者(AD组)和40例年龄、性别相匹配的认知功能正常的老年人(对照组),盲法分析其CT资料,双侧额区、顶枕区、颞区和幕下共8个区域白质损害的总和作为白质损害的总分,并检测CT显示的脑血管病变.AD组分别进行神经精神科问卷评分(Neuropsychiatric Inventory,NPI).结果 AD组脑白质损害总分、左额区、右额区、左顶枕区、右顶枕区白质损害和脑血管病变分别为1.450±2.310、0.340±0.340、0.310±0.560、0.240±0.360、0.140±0.230和0.120±0.330,而对照组分别为9.640±1.566、1.720±0.248、1.680±0.312、1.550±0.244、0.140±0.230和2.230±0.378,两组有显著差异(P分别为0.000、0.001、0.001、0.012、0.006和0.002).Spearman相关分析表明,NPI与白质损害总评分、左额区、右额区、左顶枕区和右顶枕区白质损害评分相关,rs(P)分别为0.487(0.016)、0.490(0.014)、0.502(0.014)、0.507(0.012)和0.521(0.014),而与脑血管病变无关(rs=0.132,P=0.590).结论 脑白质损害和脑血管病变对AD的发病及病情发展至关莺要,脑白质损害与AD患者的精神行为异常密切相关.     

脑小血管病严重程度与头晕症状关系的临床研究

目的研究老年人群脑小血管病严重程度与头晕症状的相互关系。方法依照年龄相关的白质改变(ARWMC)量表,选取2017年1月~2017年9月于陆军总医院神经内科就诊的老年脑白质病变患者120例,通过病史采集、神经科查体、头颅核磁共振检查和前庭功能检查,分为头晕组和非头晕组。统计头晕患者比例,分析各组患者脑小血管病严重程度构成比,脑小血管病严重程度与头晕症状的相关性,分析各脑区损害与头晕分类关系。结果两组患者在年龄、性别、受教育程度方面无显著差异。头晕占44.17%,各类型头晕的发生率依次为眩晕(33.33%),头昏(28.33%),失平衡患者(20.83%)。各组患者脑白质损害严重程度构成比存在显著性差异,脑小血管病严重程度与头晕症状的发生存在相关性。各类型头晕所累及的损害部位不同,眩晕者多见于额叶,头昏者见于顶-枕叶,失平衡者多见于幕下区、额叶部位。结论老年人群头晕症状与脑小血管病损害关系密切,各种类型头晕在脑小血管病患者,尤其是重度脑白质损害患者中常见。     

老年高血压患者脑白质病变在磁共振序列中的半定量评估

目的前瞻性分析老年高血压患者脑白质病变(WML)的MRI特征。方法选择2017年4～12月在本院就诊的老年患者80例,依据2017高血压临床诊断指南,将患者分为血压正常组20例和高血压组60例,高血压组又分为血压升高组20例、高血压1级组20例、高血压2级组20例。患者均行头颅T_1WI、T_2WI、液体衰减反转恢复(FLAIR)序列检查,应用Scheltens视觉评定量表评定患者脑室旁白质评分(0～6分)、深部脑白质评分(0～24分)、基底节白质区评分(0～30分)和幕下白质区评分(0～24分)等,并进行前瞻性分析。结果 4组脑室旁白质枕角评分、深部脑白质额叶、顶叶、枕叶和颞叶评分比较,差异均有统计学意义(P<0.05,P<0.01),4组脑室旁白质额角和侧脑室旁评分、基底节白质区和幕下白质区各处评分比较,差异均无统计学意义(P>0.05)。4组脑室旁白质、基底节白质区和幕下白质区评分WML百分率比较,差异无统计学意义(P>0.05),血压正常组、血压升高组、高血压1级组和高血压2级组深部脑白质评分WML百分率比较,差异有统计学意义(16.0%vs 24.6%vs 42.9%vs 49.4%,P=0.001);且血压升高组较血压正常组明显升高;高血压1级组和高血压2级组较血压升高组均明显升高(P=0.01,P=0.03,P=0.02)。高血压2级组较血压正常组脑室旁白质评分WML百分率明显升高(35.0%vs 56.7%,P=0.03)。血压正常组与高血压组脑室旁白质中的枕角评分和深部脑白质评分WML百分率比较,差异有统计学意义(12.5%vs 17.8%,P=0.016;16.0%vs 39.0%,P=0.001)。结论 3.0T MRI FLAIR序列可以半定量评估高血压患者WML进展程度,可为临床提供更有针对性地干预及治疗方案。     

血管性痴呆的扩散张量成像研究

目的应用扩散张量成像(DTI)技术,探讨皮质下缺血性血管性痴呆(SIVD)患者脑白质变化的特点及不同脑区DTI参数改变与认知的关系。方法对34例SIVD患者(SIVD组)及26例健康老年人(对照组)行DTI扫描,测量双侧前额叶、额叶深部、眶额内侧、下额叶、颞叶、顶叶、枕叶白质及T_2WI高信号区、T_2WI高信号周围正常白质区的分量各向异性(FA)、主各向异性(PA)及表观弥散系数(ADC)值。结果对照组左侧前额叶白质PA值大于右侧,ADC值小于右侧。SIVD组双侧前额叶、双侧额叶深部、下额叶、眶额内侧的FA值及PA值明显下降,平均ADC值升高;双侧顶叶的FA值下降,平均ADC值升高;双侧颞叶、枕叶平均ADC值升高;左侧下额叶、眶额内侧白质的FA与PA值较右侧小;左侧下额叶ADC值较右侧大。病变区及病变周围区的FA和PA值小于正常区,ADC值大于正常区。前额叶FA与简易智能状态检查表评分呈正相关。结论 SIVD患者脑白质FA、PA和ADC改变具有区域选择性,前部及左侧脑区损伤明显,后部及右侧相对保留白质的完整性。DTI是研究SIVD脑白质损伤的一种理想的方法。     

轻度认知障碍患者多模态磁共振特征

目的 探讨轻度认知损害者(MCI)和阿尔茨海默病(AD)患者多模态磁共振成像特征与认知功能的关系.方法 共纳入9例遗忘型MCI,15例轻度AD及11例正常对照,以简明精神状况检查(MMSE)和认知功能筛查测验(CASI)评估总体认知功能,对高分辨率结构像进行基于体素形态学分析(VBM),测量扩散张量成像(DTI)图像、各脑区白质各向异性比值(FA)和平均表观弥散系数(ADC),分析脑结构萎缩及白质DTI指标与认知评分的相关性.结果 MMSE和CASI评分与颞、额、顶、扣带回、海马旁回等结构灰质体积改变呈正相关(P<0.001),MMSE和CASI总分与颞、顶叶以及海马旁回的FA值呈正相关,与ADC值呈负相关(P<0.05).结论 MCI和AD患者认知功能与颞、顶、海马旁回等脑区萎缩及白质微观结构损伤密切相关,多模态影像技术可作为认知损害脑机制研究的重要技术手段.     

脑白质疏松认知功能障碍的影像学研究进展

脑白质改变（WMC）及脑白质损害（WML）在老年人中十分常见.脑白质疏松症（LA）的概念于1987年正式提出.其本意为脑白质的缺血性表现,用来与Binswanger病这一特殊病理过程进行鉴别.1项囊括近10年来脑白质改变临床证据的荟萃研究显示,WMC的出现预示着卒中、痴呆及早逝的风险增加.WMC的临床表现包括认知功能障碍、智力下降、运动迟缓、假性延髓麻痹、步态异常等.以下从WMC的影像学分级及针对不同人群的WMC与认知功能下降的临床研究两方面进行论述,并对目前该领域尚待解决的问题进行讨论.     

年龄相关性脑白质改变:影像学、危险因素和临床意义

年龄相关性脑白质改变(age-related white matter changes,ARWMC)被认为是小动脉硬化性小血管病的表现,与高龄和血管危险因素有关.脑白质改变(white matter changes,WMC)已被公认为脑小血管病的表现之一,是老年人认知损害和功能丧失的病理学基础.研究表明,但WMC发展到一定程度时,会出现许多临床症状,包括认知损害、痴呆、抑郁、步态障碍、尿失禁,并与卒中和死亡风险增高相关.     

Broca区的脑半球偏侧化静息态功能连接研究

目的探讨布罗卡区(Broca’s area)与其他功能脑区的连接。方法研究192名正常人静息态下的功能磁共振数据,通过左右Broca与全脑体素的相关分析,研究Broca的功能连接,并通过统计分析比较左右Broca功能连接的差异。结果与Broca连接呈正相关的脑区有额中回、额下回,颞中回和缘上回;呈负相关的脑区有颞极颞中回,中央后回,顶叶,额内侧回,枕叶,且在同侧半球连接中,左侧Broca与额下回、Wernicke区连接强度大于右侧Broca与额下回、Wernicke右侧对应区连接,左侧Broca与背外侧前额叶皮层、前扣带回皮层和颞顶联合区等注意认知区及梭状回和舌回等视觉野部分区域连接小于右侧Broca连接。结论本研究发现Broca多功能相关及Broca与其他脑区功能连接的偏侧化存在的多样性,这将为大脑功能网络偏侧化研究奠定基础。     

婴幼儿外伤性硬膜下积液21例诊治体会

1.临床资料:本组男17例,女4例;年龄4个月～2岁;病程2天～6个月。均有头部外伤史,其小以坠床和从自行车上摔下占多数。21例均行头颅CT扫描,示硬膜下积液发生在大脑半球凸面。双侧积液16例,其中位于双侧额颞顶区8例,双侧额颞区3例,双侧额顶区2例,双额区3例。单侧积液5例,其中单侧额颞顶区3例;单侧额颞区和单侧额区各1例。     

Binswanger病与Alzheimer病脑电地形图对比研究

本文对照观察了Ｂｉｎｓｗａｎｇｅｒ病（ＢＤ）和Ａｌｚｈｅｉｍｅｒ病（ＡＤ）各３０例患者脑电地形图的变化。结果发现，ＢＤ患者局灶性和阵发性脑电改变的阳性率明显高于ＡＤ患者，并且双侧脑电功率谱不对称，以额、中央、枕区θ波多见，而ＡＤ患者双侧功率谙基本对称，以额、颞、顶区δ波多见。ＢＤ患者智能障碍程度与脑电异常改变有显著相关性，提示脑电地形图检查对ＢＤ和ＡＤ的鉴别诊断有参考价值。     

Location of white matter changes and response to donepezil in patients with Alzheimer's disease: A retrospective and observational study

Aim

The response to donepezil in patients with Alzheimer's disease varies, and it is important to identify the potential responder before therapy. Cerebral white matter changes (WMC) are frequently observed in older patients, and the effect of WMC on therapeutic response remains controversial. The present study aimed to investigate the relationships between the location of WMC, severe WMC and the response to donepezil.

Methods

Among 418 patients with Alzheimer's disease receiving donepezil, 196 patients were eligible for analysis. Five brain areas on each side were analyzed using computed tomography scans and the Age‐Related White Matter Changes Rating Scale before therapy. The Cognitive Abilities Screening Instrument was used annually. Patients were defined as responders if their baseline Cognitive Abilities Screening Instrument score minus their follow‐up Cognitive Abilities Screening Instrument score was ≤0.

Results

There was no significant difference in demographic data between responder and non‐responder groups. Patients in the responder group had significantly less involvement of WMC in the frontal area (P = 0.0213) and nearly a trend for less involvement of WMC in the basal ganglia (P = 0.1103). After adjustment for age, sex, education, polymorphism of apolipoprotein E, hypertension and diabetes, WMC in the frontal area (OR 0.446, P = 0.0139) and basal ganglia (OR 0.243, P = 0.0380) were significantly associated with a reduced therapeutic response.

Conclusions

Patients with WMC in the frontal area and basal ganglia had significant decreases in their therapeutic response to donepezil. The location of WMC, independent of their severity, might be associated with the therapeutic response in patient with Alzheimer's disease. Geriatr Gerontol Int 2018; 18: 123–129 .     

老年性脑微出血的磁共振成像研究

目的探讨老年性脑微出血(CMB)的检出率及分布特征。方法回顾性分析2012年1月²013年12月行头颅磁共振检查的老年受试者638例,按年龄分为602013年12月行头颅磁共振检查的老年受试者638例,按年龄分为60⁶9岁357例,7069岁357例,70⁷9岁244例和≥80岁37例。采用常规MRI扫描和磁敏感加权成像序列,分别记录皮质及皮质下区、基底节、丘脑、小脑、脑干CMB的个数并进行分级。结果 638例中伴有CMB者195例,CMB检出率为30.6%,CMB的检出率随年龄增长而增加(χ2=10.963,P=0.000),CMB分级与年龄呈正相关(r=0.153,P<0.01);与6079岁244例和≥80岁37例。采用常规MRI扫描和磁敏感加权成像序列,分别记录皮质及皮质下区、基底节、丘脑、小脑、脑干CMB的个数并进行分级。结果 638例中伴有CMB者195例,CMB检出率为30.6%,CMB的检出率随年龄增长而增加(χ2=10.963,P=0.000),CMB分级与年龄呈正相关(r=0.153,P<0.01);与60⁶9岁和7069岁和70⁷9岁比较,≥80岁患者脑干CMB发生率明显升高,差异有统计学意义(23.58%vs 15.42%和12.78%,P<0.05)。结论 CMB发生率及分级与年龄呈正相关,磁共振成像对老年人群CMB的检出具有重要的临床意义。     

Urinary complaints in nondisabled elderly people with age-related white matter changes: the Leukoaraiosis And DISability (LADIS) Study

OBJECTIVES: To investigate, in a cohort of nondisabled elderly people, the association between urinary complaints and severity of age‐related white matter changes (ARWMC). DESIGN: Cross‐sectional data analysis from a longitudinal multinational study. SETTING: The Leukoaraiosis And DISability Study, assessing ARWMC as an independent predictor of the transition from functional autonomy to disability in elderly subjects. PARTICIPANTS: Six hundred thirty‐nine subjects (288 men, 351 women, mean age 74.1±5.0) with magnetic resonance imaging (MRI)‐detected ARWMC of different severity. MEASUREMENTS: ARWMC severity was graded on MRI as mild, moderate, and severe (Fazekas scale). MRI assessment also included ARWMC volumetric analysis and the count of infarcts. Urinary complaints (nocturia, urinary frequency, urgency, incontinence) were recorded based on subjects' answers to four questions. RESULTS: In comparing the three ARWMC severity groups, there was a significant difference only in prevalence of urgency, with 16% of subjects in the mild severity group, 17% in the moderate severity group, and 25% in the severe group (P=.03). Adjusting for age, sex, lacunar and nonlacunar infarcts, diabetes mellitus, and use of diuretics, severe ARWMC retained an independent effect in the association with urinary urgency (odds ratio=1.74, 95% confidence interval=1.04–2.90, severe vs mild group). Subjects with urinary urgency also had higher ARWMC volumes (25.2, vs 20.4 mm³ in those without urinary urgency; P<.001). Urgency was confirmed to be associated with the severe degree of ARWMC, irrespective of complaints of memory, gait disturbances, or history of depression. CONCLUSION: In a cohort of nondisabled elderly people, severe ARWMC were associated with urinary urgency, independent of other potential confounders and vascular lesions of the brain.     

320排CT脑灌注参数与非体外循环下冠状动脉旁路移植术后缺血缺氧性脑病相关性研究

目的:探讨非体外循环下冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCABG)后患者缺血缺氧性脑病(hypoxic-ischemic encephalopathy,HIE)与320排动态容积CT脑灌注参数的相关性。方法:选取择期行OPCABG手术的患者,其中女性50例,男性225例,年龄36~79岁,平均年龄(62.68±7.83)岁。剔除其他神经系统合并症患者,其中HIE患者37例,未出现神经系统并发症患者217例。收集患者影像学、神经系统查体信息,录入数据库进行分析。结果:①本研究术后发生HIE发生率4.36%。②HIE两组间各种灌注参数变化率结果显示:颞叶rCBV、颞叶rCBF、枕叶rMTT、基底节rMTT、额叶Delay及基底节Delay变化率差异有统计学意义。③枕叶rMTT变化率最为敏感;以枕叶rMTT变化率ROC曲线结果显示:枕叶rMTT变化率10.13%为ROC的移动诊断界点。结论:脑灌注参数与术后发生HIE关系密切,本研究中枕叶rMTT为较敏感指标。     

额部入路锥颅血肿穿刺抽吸引流术治疗自发性基底核出血

目的探讨经额部入路锥颅血肿抽吸引流术治疗自发性基底核出血的临床疗效。方法选择自发性基底核出血患者154例,出血量均为50-80ml。按入院时间顺序,将患者随机分为额部入路组（79例）和颞部入路组（75例）。额部入路组经穿刺靶点定位后,采用经额部入路锥颅置管血肿抽吸引流术。颞部入路组采用传统颞部入路锥颅置管血肿抽吸引流术。比较两组术后7、14、30d的神经功能缺损评分（改良爱丁堡＋斯堪的那维亚评分标准）、残余血肿量以及脑疝、再出血、脑积水的发生率和死亡率。结果①术后7d复查头部CT,示额部入路组残余血肿平均体积明显低于颞部入路组（t=9.17,P〈0.01）;脑疝发生率及死亡率均低于颞部入路组,差异有统计学意义（χ^2=4.04;χ^2=4.53,均P〈0.05）;术后14及30d两组比较,神经功能缺损评分差异有统计学意义（t=9.48;t=16.81,均P〈0.05）;再出血、脑疝、脑积水、死亡率两组比较,差异无统计学意义（P〉0.05）。②术后30d内病例合并统计,额部入路组再出血、脑疝、脑积水发生率及死亡率分别为3.8%（3/79）、6.3%（5/79）、3.8%（3/79）、5.1%（4/79）;颞部入路组分别为16.0%（12/75）、18.7%（14/75）、5.3%（4/75）、21.3%（16/75）,除脑积水发生率差异无统计学意义外,其余差异均有统计学意义（P〈0.05）。结论经额部入路锥颅血肿抽吸引流术疗效及安全性优于传统的颞部入路手术方式。     

Relationship between abnormal vagus nerve tension and basal ganglia cerebral infarction induced paroxysmal atrial fibrillation

Objective: To investigate the relationship between basal ganglia cerebral infarction and paroxysmal atrial fibrillation(PAF) caused by abnormal vagus nerve tension.Methods: A total of 1 483 cases of elder patients with cerebral infarction who received head CT or MRI examination during the period were enrolled, including 830 male and613 female, with the average age as 78 years. These cases were divided into basal infarction ganglia group(n = 1 045) and non-basal ganglia infarction group(n = 438)according to the anatomic site of cerebral infarction. The differences of the incidence of PAF, left atrial diameter and heart rate variability were compared between the two groups.Results: In basal ganglia infarction group, the incidence rate of PAF was significantly higher than that of non-basal ganglia infarction group(P 0.05). The incidence trend of cerebral infarction in basal ganglia was age-related, in the 79 years basal ganglia cerebral infarction group, the incidence of PAF was significantly higher than that of nonbasal ganglia infarction group(P 0.05). There was no significant difference in the left atrial diameter between the basal ganglia infarction group and non-basal ganglia infarction group. Basal ganglia cerebral infarction patients with high PAF had higher heart rate variability than non-basal ganglia infarction group.Conclusion: Elderly patients with basal ganglia infarction have high incidence of PAF.Sympathetic nerve damage in cerebral basal ganglia, increased vagal tension and cardiac vagal tension are the direct causes of PAF. The results indicates that the increased central vagal nerve tension mediated PAF probably is an indication of supplying sympathetic neurotransmitter or cardiac vagal denervation treatment.     

单光子发射断层扫描在血管性认知功能障碍早期诊断中的价值

目的评价单光子发射断层扫描（SPECY）在血管性认知功能障碍（Vascular cognitive impairment，VCI）早期诊断的价值，探讨局部脑缺血程度与VCI严重程度的相关性。方法对22例血管性轻度认知障碍（VaMCI）病人、24例血管性痴呆（VD）病人和18例对照组病人定量分析脑区局部脑血流（疋BF）。结果VD组与VaMCI组相比，额叶、颞叶、顶叶、基底节疋BF减少（P〈0．05），尤以额叶、颞叶rCBF减低最为显著（P〈0．01），额叶、颞叶rCBF减低与MMSE评分间存在正相关（r=0．98，P〈0．01：r=0．76，P〈0．05），尤以额叶更显著。结论VCI病人存在以额叶为中心的低灌注，且与MMSE评分存在正相关，对VCI的诊断有辅助作用，同时对预测VCI和早治疗有一定作用。     

The relationship between cerebral white matter changes, mental function and blood pressure in normal elderly

The authors examined the relationship between cerebral white matter changes and mental function, blood pressure in 39 neurologically normal aged (21 males, 18 females, mean age 75.0 years) who had no latent lesions on MRI images. The severity of cerebral white matter changes was estimated by T1 value images on MRI and was measured in the bilateral frontal lobe on an axial slice at the level of the basal ganglia and in the bilateral anterior, middle, and posterior portions on axial slices at the level of the body of the lateral ventricle. Mental function was measured by the Hasegawa's dementia rating scale (HDS) and Kohs' block design test (Kohs' test). The severity of cerebral frontal white matter changes increased significantly with age (p less than 0.05). However there was no significant correlation between the severity of cerebral white matter changes and HDS, Kohs' test. The severity of frontal white matter changes correlated with the mean arterial blood pressure (p less than 0.02). These results suggest that the severity of cerebral white matter changes is not related with mental function in the normal elderly, and that the severity of frontal white matter lesions is related with mean arterial blood pressure.     

MR study of the brain stem in elderly subjects]

Findings in patients in whom brain stem lesions were suspected were studied by a high-field-strength (1.5 T) MR imager. MR scans were obtained in 97 patients over a 10-month period. The mean age was 71 years (range, 39-94 years). A high incidence of infarction and lesions showing a high signal on T2-weighted image, but an almost normal signal on the T1-weighted image were observed at the pons in elderly cases. Furthermore, cases in which these two findings were observed, had a high incidence of lesion at other regions than pons. Cases with a past history of hypertension had higher incidence of lesions at the pons than normotensive patients (alpha less than 0.01). These findings suggest that MRI examination in the elderly could detect a high incidence abnormal lesions at the brain stem as well as in basal ganglia.