目的 对比分析隐源性脑卒中（CS）合并大小不同分流量的右向左分流（RLS）患者的临床和影像学特点，对其脑卒中发病机制进行推断和总结。 方法 对2012年4月至2022年7月就诊于福建医科大学附属第一医院神经内科、年龄18~65岁的急性缺血性脑卒中患者，根据脑梗死病因TOAST分型标准，对评估为CS的患者行增强经颅多普勒超声（cTCD）检查，将其中有RLS的患者（RLSⅠ~Ⅳ级）分为大分流组（平静呼吸或Valsalva动作后出现Ⅲ~Ⅳ级的RLS）和小分流组（平静呼吸或Valsalva动作后出现Ⅰ~Ⅱ级的RLS），通过卡方检验、Fisher精确概率法、单因素方差分析比较两组之间临床资料及神经影像学特点，并进一步采用Spearman相关分析和多因素Logistic回归分析明确影响RLS的相关因素，推测RLS相关脑卒中的发病机制。 结果 最终将共计167例经cTCD检查有RLS的CS患者纳入本研究，男女比例88∶79，发病年龄（45。27±9。02）岁。大分流组92例（55。1%），发病年龄（45。61±9。32）岁，其中男性35例（38。0%），合并高血压病者9例（9。8%），有吸烟史者18例（19。6%），反常性栓塞风险量表（RoPE）评分为（7。08±0。12）分。小分流组75例（44。9%），发病年龄（44。85±8。68）岁，其中男性53例（70。7%），合并高血压病者29例（38。7%），有吸烟史者31例（41。3%），RoPE评分为（6。20±0。14）分。大分流组男性比例显著低于小分流组（χ2=17。640，P<0。001），有高血压病（χ2=19。611，P<0。001）及吸烟史（χ2=9。443，P<0。01）的比例显著低于小分流组，RoPE评分大于小分流组（F=21。580，P<0。001）。全部6例肺动静脉瘘患者（6。5%，6/92）都在大分流组，小分流组无肺动静脉瘘患者（P<0。05）。两组患者在发病年龄，合并高脂血症、糖尿病，既往脑卒中/短暂性脑缺血发作史，脑卒中家族史方面差异均无统计学意义（均P>0。05）。多因素Logistic回归分析结果显示：女性（OR=2。848，95%CI 1。223~6。632，P<0。05）、无高血压病史（OR=3。937，95%CI 1。593~9。727，P<0。01）和大分流显著相关。对两组患者梗死病灶的影像学表现按血管支配及分布进行比较，结果发现：大分流组梗死病灶位于单侧前循环者54例（58。7%），位于后循环者34例（37。0%），没有同时累及双侧前循环者，前后循环均受累者4例（4。3%）；有皮质梗死者31例（33。7%），有皮质下梗死者9例（9。8%），有深部梗死者36例（39。1%），有混合多发梗死者16例（17。4%）。小分流组病灶位于单侧前循环者36例（48。0%），位于后循环者29例（38。7%），位于双侧前循环者4例（5。3%），前后循环均受累者7例（9。3%）；有皮质梗死者7例（9。3%），有皮质下梗死者8例（10。7%），有深部梗死者39例（52。0%），有混合多发梗死者21例（28。0%）。Logistic回归分析结果显示：皮质梗死灶和大分流显著相关（OR=5。981，95%CI 1。882~19。007，P<0。01），其余病灶分布特征两组差异均无统计学意义（均P>0。05）。 结论 cTCD显示有RLS的CS 患者中，大分流组女性、无合并高血压病者更多，RoPE评分更高，梗死病灶更多见于皮质，推测大的分流与脑卒中的相关性较高，脑卒中合并大的RLS患者的发病机制为栓塞的可能性较大。而小分流组男性、合并高血压者更多，提示脑卒中合并小的RLS患者，动脉粥样硬化更可能为其发病机制。 Objective To investigate the clinical and imaging characteristics of patients with cryptogenic stroke with different right-to-left shunt (RLS) and possible mechanisms。 Methods Acute ischemic stroke patients aged 18-65 years， who admitted to the Department of Neurology， the First Affiliated Hospital of Fujian Medical University from April 2012 to July 2022， were etiologically classified according to the TOAST criteria。 Cryptogenic stroke patients further underwent contrast-enhanced transcranial Doppler (cTCD) examination。 Patients with RLS (RLS grade Ⅰ-Ⅳ) were divided into large shunt group (RLS grade Ⅲ-Ⅳ， under normal breathing or after Valsalva manoeuvre) and small shunt group (RLS grade Ⅰ-Ⅱ， under normal breathing or after Valsalva manoeuvre)。 The chi-square test，Fisher's exact probability method and one-way analysis of variance were used to compare clinical and neuroimaging data between the 2 groups。 And the RLS related factors as well as mechanisms of RLS-related stroke were further discussed through Spearman correlation and multiple Logistic regression analysis。 Results A total of 167 cryptogenic stroke patients with RLS were included in this study。 The male to female ratio was 88∶79。 The onest age was (45。27±9。02) years。 In the large shunt group， there were 92 patients (55。1%) with onset age of (45。61±9。32) years。 In this group， 35 patients (38。0%) were males， 9 (9。8%) had hypertension， and 18 (19。6%) had smoking history the Risk of Paradoxical Embolism (RoPE) score was 7。08±0。12。 In the small shunt group， there were 75 patients (44。9%) with onest age of (44。85±8。68) years。 In this group， 53 patients (70。7%) were males， 29 (38。7%) had hypertension， and 31 (41。3%) had smoking history the RoPE score was 6。20±0。14。 Males (χ2=17。640， P<0。001) as well as hypertension (χ2=19。611， P<0。001) and smoking history (χ2=9。443， P<0。01) were significantly less common in the large shunt group than in the small shunt group， while the RoPE score in the large shunt group was higher than that in the small shunt group (F=21。580， P<0。001)。 All 6 pulmonary arteriovenous fistula cases (6。5%， 6/92) belonged to the large shunt group。 There was no pulmonary arteriovenous fistula patient in the small shunt group (P<0。05)。 There were no statistically significant differences in age of onset， hyperlipidemia， diabetes， previous stroke/transient ischemic attack， or family history of stroke between the 2 groups (all P>0。05)。 Multiple Logistic regression analysis showed that female (OR=2。848， 95%CI 1。223-6。632，P<0。05) and no history of hypertension (OR=3。937， 95%CI 1。593-9。727， P<0。01) were significantly associated with large shunt。 The neuroimaging features were analyzed through comparing offending vessels as well as spatial distribution of lesions between the 2 groups。 Results showed that infarct location of 54 cases (58。7%) was in the unilateral anterior circulation area， 34 cases (37。0%) in the posterior circulation area， no case in the bilateral anterior circulation area， and both of anterior and posterior circulation areas were involved in 4 cases (4。3%) in the large shunt group。 Of all the large shunt group patients， 31 (33。7%) had cortical infarcts， 9 (9。8%) had subcortical infarcts， 36 (39。1%) had deep infarcts， and 16 (17。4%) had mixed multiple infarcts。 In the small shunt group， infarct location of 36 cases (48。0%) was in the unilateral anterior circulation area， 29 cases (38。7%) in the posterior circulation area， 4 cases (5。3%) in the bilateral anterior circulation area， and both of anterior and posterior circulation areas were involved in 7 cases (9。3%)。 Of all the small shunt group patients， 7 (9。3%) had cortical infarcts， 8 (10。7%) had subcortical infarcts， 39 (52。0%) had deep infarcts， and 21 (28。0%) had mixed multiple infarcts。 Logistic regression analysis showed that cortical infarction was associated with large shunt (OR=5。981，95%CI 1。882-19。007，P<0。01)， and there was no statistically significant difference in other types of infarction distribution between the 2 groups (all P>0。05)。 Conclusions Among cryptogenic stroke patients with RLS， large shunt was more common in females， patients with no history of hypertension， and those with higher RoPE score as well as more cortical infarction， suggesting that there was a strong link between stroke and large RLS， which revealed the underlying mechanism of embolism in patients with stroke and large RLS。 In the small shunt group， there were more males and hypertensive patients， suggesting atherosclerosis was more likely involved in pathogenic mechanism of stroke patients with small RLS。
Clinical and imaging characteristics of cryptogenic stroke combined with right-to-left shunt
Objective To investigate the clinical and imaging characteristics of patients with cryptogenic stroke with different right-to-left shunt (RLS) and possible mechanisms. Methods Acute ischemic stroke patients aged 18-65 years, who admitted to the Department of Neurology, the First Affiliated Hospital of Fujian Medical University from April 2012 to July 2022, were etiologically classified according to the TOAST criteria. Cryptogenic stroke patients further underwent contrast-enhanced transcranial Doppler (cTCD) examination. Patients with RLS (RLS grade Ⅰ-Ⅳ) were divided into large shunt group (RLS grade Ⅲ-Ⅳ, under normal breathing or after Valsalva manoeuvre) and small shunt group (RLS grade Ⅰ-Ⅱ, under normal breathing or after Valsalva manoeuvre). The chi-square test,Fisher's exact probability method and one-way analysis of variance were used to compare clinical and neuroimaging data between the 2 groups. And the RLS related factors as well as mechanisms of RLS-related stroke were further discussed through Spearman correlation and multiple Logistic regression analysis. Results A total of 167 cryptogenic stroke patients with RLS were included in this study. The male to female ratio was 88∶79. The onest age was (45.27±9.02) years. In the large shunt group, there were 92 patients (55.1%) with onset age of (45.61±9.32) years. In this group, 35 patients (38.0%) were males, 9 (9.8%) had hypertension, and 18 (19.6%) had smoking history the Risk of Paradoxical Embolism (RoPE) score was 7.08±0.12. In the small shunt group, there were 75 patients (44.9%) with onest age of (44.85±8.68) years. In this group, 53 patients (70.7%) were males, 29 (38.7%) had hypertension, and 31 (41.3%) had smoking history the RoPE score was 6.20±0.14. Males (χ2=17.640, P<0.001) as well as hypertension (χ2=19.611, P<0.001) and smoking history (χ2=9.443, P<0.01) were significantly less common in the large shunt group than in the small shunt group, while the RoPE score in the large shunt group was higher than that in the small shunt group (F=21.580, P<0.001). All 6 pulmonary arteriovenous fistula cases (6.5%, 6/92) belonged to the large shunt group. There was no pulmonary arteriovenous fistula patient in the small shunt group (P<0.05). There were no statistically significant differences in age of onset, hyperlipidemia, diabetes, previous stroke/transient ischemic attack, or family history of stroke between the 2 groups (all P>0.05). Multiple Logistic regression analysis showed that female (OR=2.848, 95%CI 1.223-6.632,P<0.05) and no history of hypertension (OR=3.937, 95%CI 1.593-9.727, P<0.01) were significantly associated with large shunt. The neuroimaging features were analyzed through comparing offending vessels as well as spatial distribution of lesions between the 2 groups. Results showed that infarct location of 54 cases (58.7%) was in the unilateral anterior circulation area, 34 cases (37.0%) in the posterior circulation area, no case in the bilateral anterior circulation area, and both of anterior and posterior circulation areas were involved in 4 cases (4.3%) in the large shunt group. Of all the large shunt group patients, 31 (33.7%) had cortical infarcts, 9 (9.8%) had subcortical infarcts, 36 (39.1%) had deep infarcts, and 16 (17.4%) had mixed multiple infarcts. In the small shunt group, infarct location of 36 cases (48.0%) was in the unilateral anterior circulation area, 29 cases (38.7%) in the posterior circulation area, 4 cases (5.3%) in the bilateral anterior circulation area, and both of anterior and posterior circulation areas were involved in 7 cases (9.3%). Of all the small shunt group patients, 7 (9.3%) had cortical infarcts, 8 (10.7%) had subcortical infarcts, 39 (52.0%) had deep infarcts, and 21 (28.0%) had mixed multiple infarcts. Logistic regression analysis showed that cortical infarction was associated with large shunt (OR=5.981,95%CI 1.882-19.007,P<0.01), and there was no statistically significant difference in other types of infarction distribution between the 2 groups (all P>0.05). Conclusions Among cryptogenic stroke patients with RLS, large shunt was more common in females, patients with no history of hypertension, and those with higher RoPE score as well as more cortical infarction, suggesting that there was a strong link between stroke and large RLS, which revealed the underlying mechanism of embolism in patients with stroke and large RLS. In the small shunt group, there were more males and hypertensive patients, suggesting atherosclerosis was more likely involved in pathogenic mechanism of stroke patients with small RLS.
万方数据
