右向左分流相关隐源性脑卒中的临床特点及病因的探讨

Clinical Characteristics and Etiology of Cryptogenic Stroke with Right-to-Left Shunt

摘要: 目的：探讨右向左分流(right-to-left shunt, RLS)相关隐源性脑卒中(cryptogenic stroke, CS)患者的临床特点及引起卒中的可能机制。方法：收集2018年10月至2020年9月于我院神经内科住院并根据TOAST (Trial of Org 10172 in Acute Stroke Treatment)分型诊断为CS的患者。所有CS患者均行经颅多普勒发泡试验检查，根据有无RLS，分为RLS+组和RLS−组。比较两组人口学特征、脑血管病危险因素、血小板及凝血功能，心脏的结构与功能等方面的特点。结果：共纳入111例CS患者，RLS+组55例，RLS−组56例。血管病危险因素方面，RLS+组高血压、糖尿病及高血脂比例更少(P < 0.05)，而合并偏头痛、卒中、短暂性脑缺血发作(transit ischemic attack, TIA)及下肢深静脉血栓比例更多(P < 0.05)。血小板及凝血功能方面，RLS+组平均血小板体积(11.34 ± 1.34 vs 10.29 ± 0.82, P < 0.001)、D-二聚体含量(965.27 ± 1609.90 vs 320.54 ± 175.38, P = 0.004)均显著高于RLS−组。心脏结构与功能方面，RLS+组左房前后径(4.03 ± 0.40 vs 3.69 ± 0.34, P < 0.001)、肺动脉收缩压(30.82 ± 7.31 vs 28.48 ± 4.14, P = 0.040)均大于RLS−组。结论：伴RLS的CS患者血管病危险因素少见，但偏头痛、卒中、TIA、下肢深静脉血栓及肺动脉高压病史多见。伴RLS的CS发病可能与RLS患者存在血小板活化、血液高凝、左房扩大有关。

Abstract: Objective: To explore the clinic characteristics and pathogenesis of cryptogenic stroke (CS) patients with right-to-left shunt (RLS). Methods: Patients admitted to the Department of Neurology of our hospital from October 2018 to September 2020 and diagnosed as CS according to TOAST classification were enrolled. All CS patients were examined by contrast-enhanced transcranial Doppler test, and were divided into RLS+ group and RLS− group according to the existence of RLS. Demographic characteristics, risk factors of vascular disease, platelet function, coagulation function, structure and function of heart were compared between two groups. Results: A total of 111 CS patients were enrolled, 55 patients in RLS+ group and 56 patients in RLS− group. In terms of risk factors of vascular disease, RLS+ group had less prevalence of hypertension, diabetes and hyperlipidemia (P < 0.05), but more prevalence of migraine, stroke, transit ischemic attack (TIA) and lower limb venous thrombosis (P < 0.05). In terms of platelet and coagulation function, the average platelet volume (11.34 ± 1.34 vs 10.29 ± 0.82, P < 0.001) and D-Dimer content (965.27 ± 1609.90 vs 320.54 ± 175.38, P = 0.004) were higher in the RLS+ group than the RLS− group. In terms of the structure and function of the heart, left atrial diameter (4.03 ± 0.40 vs 3.69 ± 0.34, P < 0.001) and pulmonary arterial systolic pressure (30.82 ± 7.31 vs 28.48 ± 4.14, P = 0.040) were higher in the RLS+ group than the RLS− group. Conclusions: Risk factors for vascular disease are rare in CS patients with RLS, but a history of migraine, stroke, TIA, deep venous thrombosis in the lower extremities, and pulmonary arterial hypertension is more common. The incidence of CS with RLS may be related to platelet activation, blood hypercoagul ability and left atrial enlargement in patients with RLS.