经颅多普勒发泡试验与中青年隐源性脑卒中病因的筛查

目的探讨经颅多普勒发泡试验(cTCD)在筛查隐源性脑卒中(CS)病因中的应用价值。方法分析北京华信医院神经内科47例中青年CS患者的临床特征,进行c TCD、经食管超声心动图(TEE)检查,行反常性栓塞量表(RoPE)评分,评价cTCD与TEE两种检查方法在诊断卵圆孔未闭(PFO)的阳性率及cTCD阳性结果与RoPE评分的相关性。结果 47例患者中,cTCD检出22例PFO阳性患者,TEE检出16例PFO阳性患者,两种方法对PFO检出率高度吻合,且c TCD阳性率高于TEE。cTCD检出PFO阳性患者的梗死病灶多出现于皮质。随着RoPE评分的增加,cTCD阳性率逐渐升高。结论 PFO是CS的常见病因,cTCD可作为中青年CS病因筛查的首选。     

偏头痛患者右向左分流发生率及分 流量的研究——一项基于217例中 国偏头痛患者的研究

【摘要】
背景 近年来,对比增强多普勒超声（contrast-enhanced transcranial Doppler,cTCD）的研究发现,右
向左分流（right-to-left shunt,RLS）可能是偏头痛的危险因素,但是这些数据均来自西方国家,尚无
中国人群的数据可用。
目的 评估中国偏头痛人群中RLS的发生率,并分析RLS分流量与偏头痛的关系。
方法 本研究共纳入217例确诊为偏头痛的患者及100例健康志愿者,均给予cTCD评估RLS发生情况
及分流量大小。
结果 在偏头痛组,RLS发生率为44.2%（96/217）,其中大量分流率为23.5%（51/217）;在健康组,
RLS发生率为28.0%（28/100）,其中5.0%（5/100）为大量分流。在先兆偏头痛组,RLS发生率为66.1%
（39/59）,大量分流占37.3%（22/59）;在无先兆偏头痛组,RLS发生率为36.1%（57/158）,大量分流
率为18.4%（29/158）。偏头痛组RLS阳性率和大量分流率高于健康组（P <0.05）。先兆偏头痛组RLS
阳性率和大量分流率高于无先兆偏头痛组（P <0.05）和健康组（P <0.05）。尽管无先兆偏头痛组与健
康组RLS阳性率相似,但是大量分流率在无先兆偏头痛组高于健康组（P <0.05）。
结论 RLS与偏头痛的发生有密切关系,尤以先兆偏头痛为著。     

肺动静脉瘘所致隐源性卒中病例分析 及初筛方法研究 肺动静脉瘘所致隐源性卒中病例分析及初筛方法研究

目的 分析肺动静脉瘘（pulmonary a rteriovenous f istula，PAVF）致隐源性卒中患者临床表现，比较各
种诊断方法特点，寻找筛查方法。
方法 2例PAVF所致隐源性卒中患者详细临床资料，并行经食管超声（transesophageal echocardiography，
TEE）、经颅多普勒增强试验（contrast transcranial Doppler，cTCD）。
结果 2例患者cTCD结果显示栓子信号具备出现晚、数量多、时间久、持续性（即不受Valsalva动作影
响）的特点。TEE结果显示CDFI未见异常，右心声学造影Valsalva动作（valsalva maneuver，VM）后5个心动
周期左房内肺静脉开口处见大量微泡。
结论 缺血性卒中是PAVF最常见的肺外表现，发生与PAVF与供血动脉直径及数量有关。cTCD敏感易
操作，结合动脉血气分析可用于该病的初筛，而且适于疗效评价及随访。     

RoPE量表结合cTCD对隐源性脑卒中的应用价值

目的 探讨反常性栓塞风险量表(Risk of Paradoxical Embolism, RoPE)结合经颅多谱勒超声发泡试验(contrast-enhanced transcranial Doppler, cTCD)对隐源性脑卒中(Cryptogenic stroke, CS)的应用价值。方法 收集2017年1月-2018年12月在郑州市第一人民医院神经内科住院的诊断为隐源性脑卒中且已完善cTCD 检查23例患者; 根据cTCD表现分为阳性组、阴性组,比较2组患者的一般资料和影像学特点; 应用RoPE量表对cTCD阳性患者进行评估,分析其与cTCD阳性率、分流量的相关性。结果 cTCD阳性组70%CS患者累及后循环、10.0%累及前循环、10%前后循环均受累; cTCD阴性组15.4%CS患者累及后循环、53.8%累及前循环、30.7%累及前后循环,其中累及后循环与cTCD阳性呈正相关(r=0.555,P<0.05)。cTCD阳性组80.0%CS患者累及皮层、10.0%累及深部、10.0%为混合性; cTCD阴性组23.1%CS患者累及皮层、30.75%累及深部、46.2%患者为混合性,其中累及皮层与cTCD阳性呈正相关(r=0.565,P<0.05)。cTCD阳性组吸烟10%,cTCD阴性组吸烟76.9%,吸烟与cTCD阳性呈负相关(r=-0.664,P<0.05)。cTCD阳性组男性患者占50%,cTCD阴性组男性患者占92.3%,性别与cTCD阳性呈负相关(r=-0.478,P<0.05)。其它因素高血压病、糖尿病、高脂血症及既往脑卒中病史与cTCD阳性之间未发现明确相关性(P>0.05)。RoPE评分与cTCD阳性率的相关性分析显示二者呈显著正相关(r=0.918,P=0.01)。cTCD阳性患者RLS分流量与RoPE评分的相关性分析显示二者呈显著正相关(r=0.894,P=0.000)。结论 发泡试验(cTCD)阳性患者临床易累及皮层和后循环供血区; RoPE量表联合cTCD可用于国内CS病因的筛查。     

伴卵圆孔未闭的隐源性脑卒中的临床表现及影像学特征

目的 探讨伴卵圆孔未闭(Patent foramen oval,PFO)的隐源性脑卒中(Cryptogenic stroke, CS)的临床表现及影像学特征。方法 收集2014年11月-2019年6月在华中科技大学同济医院神经内科住院确诊为PFO的患者,筛选出122例存在隐源性脑卒中患者,根据头颈血管影像学检查表现将其分为主动脉弓斑块(Aortic arch atheroma, AAA)合并PFO组、轻度动脉硬化(Mild atherosclerosis, MSA)合并PFO组及单纯PFO组,比较3组的一般临床资料及影像学特点。结果 与AAA合并PFO组及MSA合并PFO比较,单纯PFO组患者年龄更小,吸烟史、高血压病史及既往脑卒中病史比例更低,反常性风险栓塞评分量表(Risk of paradoxical embolism, RoPE)数值更高(P<0.05)。影像学上AAA合并PFO组患者与MAS合并PFO组及单纯PFO组比较,其梗死灶数量更多,小病灶及累及两根以上血管和同时累及前后循环的比例更高,而MAS合并PFO组及单纯PFO组中梗死灶数量更少,大病灶及累及单根血管的比例更高(P<0.05); 单纯PFO组病灶分布于后循环的比例高于AAA合并PFO组(χ²=4.854,P=0.028); MAS合并PFO组及单纯PFO组中梗死灶数量、大小、累及的血管情况无明显差异(P>0.05)。结论 PFO引起的反常栓塞及主动脉斑块脱落栓塞可能是引起CS的重要病因,CS患者的梗死灶影像学特点能作为寻找隐源性脑卒中发病机制的线索     

经颅多普勒增强实验结合经食管超声鉴别肺动静脉瘘与卵圆孔未闭所致隐源性卒中的研究

目的 探讨经颅多普勒增强实验（contrast transcranial Doppler,cTCD）结合经食管超声（transesophageal echocardiography,TEE）对于鉴别肺动静脉瘘（pulmonary arteriovenous fistula,PAVF）与卵圆孔未闭 （patent foramen ovale,PFO）所致隐源性卒中的意义。 方法 收集4例隐源性卒中患者（PAVF组2例,PFO组2例）的临床资料,行cTCD、TEE检查,比较两组的 检查结果差异。 结果 PAVF组cTCD结果显示患者平静呼吸时即见雨帘样栓子信号,Valsalva动作（Valsalva maneuver, VM）后栓子数量变化不明显;TEE彩色多普勒（color Doppler flow image,CDFI）未见异常,右心声学造 影VM后5个心动周期左房内肺静脉开口处见大量微泡。PFO组cTCD结果显示,一例平静呼吸时可见4 个栓子,VM后雨帘样栓子信号,VM作用消失后第40个心动周期有2个栓子信号。一例平静呼吸时无 栓子信号,VM后可见>50个栓子信号,VM作用消失后无栓子信号。TEECDFI示原发隔继发隔间裂隙左 向右过隔血流,右心声学造影VM后2～3个心动周期卵圆孔附近的左心房内见数个微气泡。 结论 cTCD结合TEE鉴别诊断PFO和PAVF敏感性高,易于操作。二者主要鉴别点在于cTCD平静呼吸时 是否出现大量栓子及是否受VM影响。     

195例正常人右向左分流发生率及特点的 研究

【摘要】
目的 观察正常人不同年龄组右向左分流（right-to-left shunt，RLS）的发生率、分流量、分流类型，
以及比较两个年龄组RLS的特点。
方法 收集接受对比增强经颅多普勒超声（contrast-enhanced transcranial Doppler，cTCD）的正常人群
的临床资料。根据年龄将18～45岁纳入青年组，大于45岁纳入中年组。以肘前静脉注射激活的生理盐
水作为造影剂，结合Valsalva动作，行M模经颅多谱勒超声（power M-mode transcranial Doppler，mpTCD）
监测，诊断RLS并对分流量进行分级，分析不同分流量和分流类型（固有型和潜在型）在研究人群中
的分布特点。
结果 共195例正常人入组，RLS发生率为28.7%，其中小量分流39例（20%）。青年组RLS发生率为
28.9%（39/135），中年组RLS发生率为28.3%（17/60），两组RLS发生率及分流量分布差异无显著性，
且均以小量分流为主。固有型34例（60.7%），潜在型22例（39.3%）。青年组固有型25例（64.0%），潜
在型14例（35.9%）；中年组固有型9例（52.9%），潜在型8例（47.1%）。组间分流类型差异无显著性。
结论 本研究所选人群中RLS发生率约为28.7%，且以小量分流者居多，青年人与中年人RLS发生率、
分流量、分流类型无差异。     

不明原因缺血性卒中患者左心房超声检查特点

【摘要】
目的 探讨不明原因缺血性卒中患者左心房超声检查特点。
方法 连续入选我院不明原因缺血性卒中患者36例,选取同期健康志愿者35例作为对照组,两组均行经胸超声心动图检查,比较两组间左心房大小、面积及左心房射血分数、左心房压力等结构及功能指标。
结果 两组左心房内径、左心房面积均无统计学差异。不明原因缺血性卒中组左心房射血分数低于对照组［（61.13±11.42）% vs （65.15±10.12）%,P=0.043］;左心房压高于对照组［（98.76± 21.89）mmHg vs （75.37± 26.98）mmHg,P=0.0414］;左心房中部血流流速低于对照组［（57.50±4.03）cm/s vs （66.56±10.59）cm/s,P=0.035］。
结论 不明原因缺血性卒中患者存在左心房功能异常。     

卵圆孔未闭分流量、解剖特点与隐源性脑卒中影像学特点的相关性

目的 探讨卵圆孔未闭(Patent foramen oval,PFO)分流量、解剖特点与隐源性脑卒中(Cryptogenic stroke, CS)影像学特点的相关性。方法 收集2012年8月-2020年12月在大连市中心医院神经内科住院的急性隐源性脑卒中患者110例,所有患者进行头部弥散成像(Diffuse weighted imaging,DWI)、磁共振成像(Magnetic resonance imaging,MRI)、磁共振血管成像(Magnetic resonance angiography,MRA)或头颈部CT血管成像(Computed tomography angiography,CTA)、动态心电图、颈动脉超声及心脏超声等检查排除其他病因; 分别根据经颅多普勒超声发泡试验(Contrast-enhanced transcranial doppler,cTCD)阳性分型、cTCD确定右向左分流(Right-to-left shunt,RLS)量及经食道超声(transesophageal echocardiography,TEE)检查的PFO不同解剖特点,即行cTCD确定RLS量和PFO分型,TEE检查确定存在PFO及观察并测量其解剖结构,分析隐源性脑卒中的病灶分布、部位及数量是否有差异。结果 共入组110例,男64例(58.1%),平均年龄(42±11)岁,根据cTCD常规阳性和Valsalva动作阳性将PFO分为固有型组(53例)和潜在型组(57例),2组性别、年龄、高血压病、糖尿病、脑卒中或TIA病史及ROPE评分均无明显差异(P>0.05)。cTCD显示RLS中小量组(栓子量≤25个)50例(45.5%),大量组60例(54.5%)。TEE检查静息状态下PFO直径(1.5±1.1)mm,PFO的平均长度(9.4±2.7)mm,长隧道型(PFO长度>8 mm)52例(47.2%),有过隔血流78例(70.9%)。头DWI显示梗死灶累及前循环供血区49例(44.5%),后循环供血区36例(32.7%),前后循环供血区25例(22.7%),单侧72例(65.4%),双侧38例(34.5%),皮层15例(13.6%),皮层下14例(12.7%),深部16例(14.5%),皮层+皮层下41例(37.2%),皮层、皮层下+深部24例(21.8%),单一梗死51例(46.3%),多发梗死59例(53.6%)。PFO固有型组(53例)和PFO潜在型组(57例)脑梗死灶分布、部位和数量均无明显差异(P>0.05),PFO固有型组患者脑梗死灶多见于半卵圆、侧脑室旁21例(39.6%); PFO潜在型组患者的脑梗死灶多见于脑干、小脑23例(40.3%)。中小量RLS组(栓子量≤25个,50例)和大量RLS组(栓子量>25个,60例)脑梗死灶分布、部位和数量均无明显差异(P>0.05)。长隧道型(>8 mm,52例)和非长隧道型(≤8 mm,26例)脑梗死灶分布、部位和数量均无明显差异(P>0.05)。无过隔血流(32例)和有过隔血流(78例)脑梗死灶分布、部位和数量均无明显差异(P>0.05)。小PFO(PFO直径<2 mm)组(54例)和中大PFO(PFO直径≥2 mm)组(24例)梗死灶分布(P=0.006)和梗死灶数量(P=0.027)均有明显差异; 小PFO组患者脑梗死灶常见于前循环供血区(48.1%)、单侧(72.2%)及单一梗死灶(55.5%); 中大PFO组患者脑梗死灶以前后循环供血区(41.6%)、双侧(58.3%)、多发梗死灶(70.8%)多见。结论 小PFO组的脑梗死灶在影像学上分布以前循环供血区、单侧、单一病灶多见; 中大PFO组的脑梗死灶以前后循环供血区、双侧、多发梗死灶多见; PFO大小与PFO相关的隐源性脑卒中梗死灶的分布及数量有关。PFO固有型患者的脑梗死灶多见于前循环供血区,其中梗死部位以皮层下多见; PFO潜在型患者的脑梗死灶多见于后循环供血区。     

下腔静脉加压法与Valsalva动作在提高卵圆孔未闭检出率中的对比研究

目的 探讨下腔静脉加压法与Valsalva动作在经食道超声心动图(Transesophageal echocardiography,TEE)对卵圆孔未闭(Patent foramen ovale,PFO)检出率中的差异。方法 回顾性分析手术证实的PFO患者114例,包括对比增强经颅多普勒超声(Contrast-enhanced transcranial Doppler ultrasonography,c-TCD)少量右向左分流(Right-to-left shunt,RLS)(n=51)组、中量RLS(n=37)组、大量RLS(n=26)组,记录常规TEE超声、Valsalva动作配合下TEE检查、PFO封堵术前无痛TEE下下腔静脉加压检测,分析3组房间隔右向左一过性分流信号发生率的不同和其它临床因素在3组间的差异。结果 3组身体质量指数(Body mass index,BMI)、高血压病、高脂血症及冠心病的比例无明显差异(P>0.05); 大量RLS组患者年龄明显小于少量RLS及中量RLS组(P<0.05)。少量RLS及中量RLS组患者Valsalva动作和下腔静脉加压后较常规TEE下PFO的显示率均有提高(P<0.01); 大量RLS组患者Valsalva动作和下腔静脉加压后PFO显示率改变不明显(P>0.05)。结论 大量RLS患者较少量及中量RLS患者的年龄小,更容易早期出现临床症状; 下腔静脉加压法可以替代Valsalva动作提高TEE超声对PFO的检出率。     

Paradoxical brain embolism]

Although paradoxical brain embolism result in the right-to-left shunt (RLS) is very important etiology of ischemic stroke especially in young adults, the detailed characteristics of them in Japan remain unknown. In collected clinical data for 7,245 acute stroke patients, patent foramen ovale (PFO) were more frequent in the young patients group (n = 1,584) than in the non-young patients group (n = 5,661) (0.7% vs. 1.2%, p = 0. 07). The frequency of PFO was rare than that of previously reported. Suspected reason is that the limited patients were underwent transesophageal echocardiography (TEE). The golden standard to detect RLS is contrast-enhanced TEE, and standardization of procedure is the most important factor. In our hospital, positive rate of RLS was risen up to 21.9% from 8.8% by standardization. In the patients with RLS in our hospital, the definite and probable criteria of paradoxical brain embolism were fulfilled only in 7.7% and 38.5%, respectively. If patients have any other risk factors (e.g. venous thrombus, cardiac source of embolism), to prevent recurrent stroke associated with RLS they must be underwent anticoagulation and correctly controlled by PT-INR. And if patients have no other risk factors, PICCS study confirmed that there was no difference of recurrence rate between anticoagulation and aspirin therapy.     

Cryptogenic stroke and patent foramen ovale: clinical clues to paradoxical embolism

BACKGROUND: Patent foramen ovale (PFO) is an independent risk factor for cerebral infarction. Since ~25% of the population have a PFO, the simple association of PFO with stroke is not enough to establish the diagnosis of paradoxical embolism. We evaluated possible clinical clues to the diagnosis of paradoxical embolism. METHODS: Among patients with cryptogenic ischemic stroke (CS) who were investigated for a right-to-left shunt (RLS), we compared clinical, coagulation and biochemical parameters in patients with PFO versus without PFO. RESULTS: Among 1689 new patients referred for TIA/non-disabling stroke between 2001 and 2007, 175 with cryptogenic stroke (CS) were investigated for RLS by transcranial Doppler (TCD) bubble studies; 89 (5.5%) with positive TCD had a PFO confirmed by TEE. In multivariate logistic regression, a history of DVT or pulmonary embolism (OR, 4.39; 95% CI, 1.23-15.69; p=0.023), prolonged travel (OR, 8.77; 95% CI, 1.775-43.3; p=0.008) , migraine (OR, 2.30: 95% CI, 1.07-4.92; p=0.031), a Valsalva maneuver preceding the onset of focal neurological symptoms (OR, 3.33; 95% CI, 1.15-9.64; p=0.026) and waking up with stroke/TIA (OR, 4.53, 95% CI, 1.26-16.2; p=0.018) were independently associated with PFO-associated cerebrovascular events. Patients with PFO had higher plasma total homocysteine levels than patients without PFO (8.9+/-3 versus 7.9+/-2.6 micromol/L respectively; p=0.021). CONCLUSIONS: A history of DVT or pulmonary embolism, migraine, recent prolonged travel, sleep apnea, waking up with TIA or stroke or a Valsalva maneuver preceding the event are clinical clues to the diagnosis of paradoxical embolism among patients with CS.     

卵圆孔未闭相关性卒中的诊治研究进展

卵圆孔未闭（patent f oramen o vale,PFO）与卒中发病有明显的关联。应利用卒中高风险 PFO解剖学特征、卒中影像特征及反常栓塞风险量表等,经多科综合评估,选择患者最适合的治疗方 案。多数现有研究及指南支持对于卒中高风险PFO患者,首选PFO封堵术加术后长期抗血小板治疗;单 独抗凝治疗与单独抗血小板治疗在预防卒中复发上同效。     

Lesion patterns in patients with cryptogenic stroke with and without right-to-left-shunt

Background and purpose:  Despite numerous studies, the role of patent foramen ovale (PFO) as a risk factor for stroke due to paradoxical embolism is still controversial. On the assumption that specific lesion patterns, in particular multiple acute ischaemic lesions on diffusion-weighted magnetic resonance imaging, indicate a cardioembolic origin, we compared the MRI findings in stroke patients with right-to-left shunt (RLS) and those without.
Methods:  The records of 486 patients with diagnosis of cerebral ischaemia were reviewed. For detection of RLS, contrast-enhanced transcranial Doppler (c-TCD) was carried out in all patients. An MRI scan of the brain was performed in all patients. Affected vascular territories were divided into anterior cerebral artery, middle cerebral artery, vertebrobasilar artery system including posterior cerebral artery, brain stem and cerebellar stroke, and strokes occurring in more than one territory.
Results:  We did not find a specific difference in neuroradiological lesion patterns in patients with RLS compared with patients without RLS. In particular, 23 of 165 patients (13.9%) with RLS showed multiple ischaemic lesions on MRI in comparison with 45 of 321 patients (14.0%) without RLS ( P  = 0.98). These findings also applied for the subgroup of cryptogenic strokes with and without RLS.
Conclusion:  We found no association between an ischaemic lesion pattern that is considered as being typical for stroke due to cardiac embolism and the existence of PFO. Therefore, our findings do not provide any support for the common theory of paradoxical embolism as a major cause of stroke in PFO carriers.     

Almost Perfect Concordance Between Simultaneous Transcranial Doppler and Transesophageal Echocardiography in the Quantification of Right-to-Left Shunts

BACKGROUND AND PURPOSE: Transesophageal echocardiography (TEE) and transcranial Doppler (TCD) are the methods of choice to study patent foramen ovale (PFO), but there are discrepancies between the 2 concerning PFO detection. No study has analyzed right-to-left shunt (RLS) quantification concordance. The 2 methods are carried out in different hemodynamic states, and the Valsalva maneuver (VM) required in each also differs. The authors compared PFO detection and concordance of RLS quantification classifications performing the 2 studies simultaneously. METHODS: The authors prospectively included consecutive stroke patients undergoing TEE and applied the TCD protocol of the Consensus Conference. Echocardiographic PFO was diagnosed when at least 3 microbubbles (MBs) were detected in the left atrium within 3 heartbeats after opacification of the right atrium. RLS quantification was (1) TCD: minimum (1-10 MBs), moderate (11-25 MBs), and massive (>25 MBs) and (2) TEE: small (3-10 MBs), moderate (11-30 MBs), and large (>30 MBs). Statistics: contingency tables (chi(2) and K test). Results. The authors studied 110 patients whose mean age was 56.7 +/- 12.1 years, and 60.9% were men. PFO was detected at the first VM in 30% of patients with TCD and in 31.8% with TEE. At the second VM, both methods detected the same patients (32.7%). RLS was minimum (14), moderate (5), and massive (17) in TCD and small (13), moderate (3), and large (20) in TEE. There was an almost perfect concordance in RLS quantification (K = 0.928, P = .001), with only 4 discrepancies. CONCLUSIONS: Simultaneous study with TCD and TEE showed an almost perfect concordance in PFO detection and RLS quantification.     

卵圆孔未闭的治疗和反常栓塞风险量表临床应用研究进展

卒中已成为我国居民的第一位死亡原因,经全面检查仍无法找到明确病因的称之为隐源 性卒中（cryptogenic stroke,CS）,而卵圆孔未闭（patent foramen ovale,PFO）引起的反常栓塞是导致CS 最可能的原因。近几年对合并PFO的CS选择何种治疗方法一直存在争议,同时一种可以预测反常栓塞 的最新量表,即反常栓塞风险量表（risk of paradoxical embolism,RoPE）也成为国内外很多学者研究的 热点,本文对目前PFO治疗的研究以及RoPE在PFO中的临床应用进行综述。