【摘要翻译】腔隙性脑梗死认知缺损症候学初探
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腔隙性脑梗死认知缺损症候学初探
研究目的
选择腔隙性脑梗死和腔隙性脑梗死认知缺损患者，比较研究LI与LI认知缺损的中医证侯特点及证类分布特征
在此基础上探讨LI认知缺损的病因病机，寻找导致Li认知缺损的危险因素，为建立LI认知缺损中医防治方案提供客观依据
研究方法
全部观察患者均为东方医院门诊和住院病人。按照公认的中医，西医诊断标准，结合辅助量表，制定纳入，排除标准，筛选LI认知缺损观察组30例，LI不伴认知缺损对照组30例，采取病例对照研究，对性别，年龄，高血压等因素进行分析，同时进行量表评分和证候学观察，制定并采用统一的病例报告表。依据标准分别为：①腔隙性脑梗塞的诊断标准参照1995 年中华医学会第四次全国脑血管病学术会议修订的《各类脑血管疾病诊断要点》；②按照DSM-Ⅳ结合CDR量表评定除外痴呆诊断；③认知功能综合评定参照简易精神检查量表（MMSE）；④社会功能活动及日常生活能力各亚项损害评定参照Blessed评定量表（BBS）和全面衰退量表（GDS）；⑤神经功能缺损程度的评价标准参照美国国立卫生研究院卒中量表NIHSS；⑥界定血管源性认知缺损参照Hachinski缺血指数；⑦中医证候观察依据制定的统一LI认知缺损证候学科研观察表。
以上临床及实验研究数据均应用SPSS12.0 统计学软件进行分析
结果
在临床观察期间收录门诊病人观察组30例，对照组30例，共60例。对两组患者观察结果进行数据处理，得出以下研究结果：
LI认知缺损发病情况显示：男女比例约1；1，以70～79 岁发病率最高（70.83%），60～69岁发病的也不少，其次为80～89 岁。腔隙性脑梗死后出现认知缺损时间平均为42.84月，其中最长180月，最短0.33月，绝大部分出现在LI后50个月以内，可突然起病，也可以隐袭起病，进程多呈阶段样加重。既往多伴有高血压病。LI认知缺损Hachinski缺血指数均大于7分，符合血管源性认知缺损的界定值。观察组NIHSS量表评分与对照组无显著性差异，而HAMA评分有显著性差异，MMSE，BBS评分则有非常显著性差异。
单发性LI与多发性LI约1：1，腔梗好发部位以基底节最为常见，其次累及放射冠，丘脑，脑叶。即使单发的腔隙性脑梗死也可造成认知缺损，大部分病灶（87.5％）体积小于10ml。病灶右侧组与病灶左侧组或病灶两侧组比较，MMSE量表中注意力和计算力评分值均有显著性差异。文盲组与中学或以上组比较，在定向力，注意和计算力两项得分有显著性差异；小学组和中学或以上组比较，语言评分值有显著性差异。
观察组与对照组单因素分析显示：年龄，病灶距额极距离有显著性差异。观察组与对照组多因素分析显示：LI认知缺损的发病主要与年龄，文化程度相关，其中与文化程度负相关。结果与多数研究结论一致。
4，LI认知缺损核心症状主要为神情呆滞，表情淡漠，反应迟钝，善忘，思维缓慢，理解力差，言辞贫乏或颠倒，担心忧虑，失算，寡言少语，嗜睡，肢体笨拙，步履蹒跚，缺乏兴趣，注意力不集中，与对照组有显著性差异。观察组中各类证候特征性症状例数出现总数均超过30例，以火证和肝肾阴虚证为著。观察组各类证候特征性症状例数高于对照组，实证以痰，瘀证差异明显，风，火证例数接近；虚证差异均较明显。
结论
单发或多发的腔隙性脑梗死均可造成认知缺损，大部分病灶体积小于10ml。这种认知缺损临床表现相对较轻，呈单发或数项组合认知缺损，同时工作及生活能力受到不同程度影响，多伴有轻度的抑郁症状，与腔隙性脑梗死不伴认知缺损明显不同。
单因素分析表明年龄，病灶距额极距离是LI认知缺损发病的危险因素，多因素分析表明LI认知缺损的发病主要与年龄，文化程度相关，其中与文化程度负相关。而LI是否处于优势半球，患者文化程度的不同，导致MMSE损害亚项不同。
LI认知缺损核心症状以神情呆滞，表情淡漠，反应迟钝，善忘，思维缓慢，理解力差，言辞贫乏或颠倒，担心忧虑，失算，寡言少语，嗜睡，肢体笨拙，步履蹒跚，缺乏兴趣，注意力不集中为主，与对照组明显不同，可以用于本病的诊断。LI认知缺损病机复杂，虚实并见，虚证涉及肝脾肾，以肾虚为主，实证以风火痰证为标。 LI认知缺损与中风证类表现相对一致，有共同的体质因素。而肾虚，痰瘀内阻与中风后是否出现认知缺损密切相关。
Elementary Probes into the Symptomatology of Lacunar Infarction Cognitive Impairment
1.Study Objective
Selecting the patients with LI (Lacunar Infarction) and LI Cognitive Impairment, contrast researches are studied with the characters and distributing features of the Traditional Chinese Medicine（TCM） syndromes of LI and LI Cognitive Impairment.
The basis of the pathogen of the LI Cognitive Impairment will be discussed to find the risk factors of the causes of the disease so as to provide objective foundations to establish a prevention and treatment scheme through the use of TCM.
2.Study Methods
All the patients observed are at clinic and hospital in Dongfang Hospital. According to the established diagnosis standards of TCM and Western Medicine, acceptance and exclusion standards are formulated in combination with accessorial scales. 30 cases of the observation group with LI Cognitive Impairment and 30 cases of the contrast group without Cognitive Impairment were filtered to have an analysis on the factors such as gender，age and hypertension by adopting case contrast study, and at the same time the assessment score of scales and symptomatic observation were given to establish and adopt uniform case-report tables. The standards of the foundation are the following:
① The diagnosis standards of the LI references to the amended book of The Outlines of Various Cerebral Vascular Diseases in the Fourth National Academic Conference about cerebral vascular diseases by the China Medical Committee in 1995.②According to the assessment of the DSM-Ⅳ in combination with CDR scale except from the diagnosis of the dementia .③The general assessment of the cognitive functions references to the MMSE(Mental Examination Scale ) .④All kinds of the sub-item assessment of social functional activities and daily life ability references to BBS of the Blessed and the GDS(General Depression Scale).⑤The assessment standards of the degree of the nervous functional deficiency references to the NIHSS(National Institutes of Health Stroke Scale)in U.S. ⑥.Defining the cognitive impairment of vessel pathogen references to the ischemia index of the Hachinski.⑦.the symptomatology observation in TCM lay on the basis of the formulated uniform observation tables of the scientific research on the symptomatology of LI Cognitive Impairment.
All the above data of the clinical and experimental research were analyzed with the application of the SPSS12.0 statistics software.
3.Results
The admitted clinic patients during the clinical observation phase were 60 cases in number including 30 cases in the observation group and 30 cases in the contrast group. Research results were achieved as the following through data processing of the observation outcome of the two group patients.
The incident conditions of LI Cognitive Impairment show that with the ratio 1:1 of men to women, the incidence rate is highest in the ages of 70 ～90 , not low in the ages of 60 ～69, and secondarily is the ages of 80 ～ 90.The average time for the occurrence of LI Cognitive Impairment is 42.84 months, in which the longest is 180 months and the shortest is 0.33month,most of which took place within 50 months after LI; The onset may be sudden or insidious with periodic aggravation, and always accompanied by hypertension in his case history. The ischemia index of the cognitive impairment is more than 7, which is in accordance with the boundary value of the cognitive deficits of vessel pathogen. In the observation group the NIHSS assessment score isn’t different from the contrast group; The difference is significant in the HAMA and especially significant in the MMSE and BBS.
With the ratio 1:1 of Mono- LI to Poly- LI, the most predilection sites of LI are the basal section, secondarily is the coroma radiata, the thalamus and the cerebral lobe. Even the Mono-LI may cause cognitive impairment but the volume of most focus （87.5％）is less than 10ml.Compared with the left group or the bilateral groups of the focus, the right focus group has remarkable difference in the assessment score of attention ability and calculation ability in MMSE. Compared with the group in middle school or above, the illiteracy group has significant difference in the ability of direction ，attention and calculation. Compared with the group in middle school or above, the elementary school group is significantly different in the linguistic ability.
Single factor analysis for the observation group and the contrast group shows that the age and the distance from the focus to the frontal polar have remarkable difference. Multiple factors analysis in the observation group and the contrast group shows that the onset of LI Cognitive Impairment is mainly related to age and civilization degree with negative relation to civilization degree. The results are consistent to many research conclusions.
The core symptoms of LI Cognitive Impairment mainly are dull look, indifferent expression, blunt reaction, bad memory, slow thinking, poor understanding, absent or reversal speech, anxiety and worry, incapable calculation taciturn words, indulgence in sleep, awkward extremities, teeter step, lack of interest, and abstracted attention, which is greatly different from the contrast group. The occurrence cases with characteristic symptoms in various syndromes are all more than 30 in number in the observation group with the domain of the Fire syndrome and the asthenia syndrome of the liver and the kidney. The occurrence cases of various characteristic symptoms in the observation group are higher than the contrast group, in which the difference between the Phlegm syndrome and stagnation syndrome in sthenia syndrome is significant while the cases are adjacent between the Cold syndrome and Fire syndrome, but the difference of all syndromes in the asthenia syndrome is significant.
4. Conclusion
The Mono- LI or Poly- LI can result in cognitive impairment with the less than 10ml volume of the most focus. The clinical manifestations of cognitive impairment are relatively slight with the presentation of single or multiple combinations, at the same time it will bring about different impacts on the ability of work and life mostly accompanied by slight depression symptoms, which is significantly different from LI without Cognitive Impairment
Single factor analysis shows that age and the distance from the focus to the frontal polar are the risk factors for LI Cognitive Impairment, while multiple factors analysis shows that the onset of the LI Cognitive Impairment is mainly related to age and civilization degree with negative relations to civilization degree. Whether LI lies in the dominant hemisphere or not, different civilization degree will result in the difference of the sub-items of the MMSE impairment.
The core symptoms of the LI Cognitive Impairment mainly are dull look indifferent expression, blunt reaction ，bad memory，slow thinking ，poor understanding ，absent or reversal speech ，anxiety and worry，incapable calculation taciturn words，indulgence in sleep ，awkward extremities ，teeter step，lack of interest，abstracted attention, which is significantly different from the contrast group and can be used to give diagnosis to the disease. The pathogen of LI Cognitive Impairment is very complicated with the concurrence of sthenia syndrome and asthenia syndrome, in which the sthenia syndrome involves the liver the spleen and the kidney while the Virtual Kidney is the main pathogen ,and the Wind syndrome，Fire syndrome，phlegm syndrome are the presentations of the sthenia syndrome. With common constitutional factor, the manifestations of LI Cognitive Impairment are relatively consistent to the apoplexy-like syndrome, while the Virtual Kidney and Phlegm Retardarce inside is mainly related to the occurrence of cognitive impairment after stroke.
研究目的
选择腔隙性脑梗死和腔隙性脑梗死认知缺损患者，比较研究LI与LI认知缺损的中医证侯特点及证类分布特征
在此基础上探讨LI认知缺损的病因病机，寻找导致Li认知缺损的危险因素，为建立LI认知缺损中医防治方案提供客观依据
研究方法
全部观察患者均为东方医院门诊和住院病人。按照公认的中医，西医诊断标准，结合辅助量表，制定纳入，排除标准，筛选LI认知缺损观察组30例，LI不伴认知缺损对照组30例，采取病例对照研究，对性别，年龄，高血压等因素进行分析，同时进行量表评分和证候学观察，制定并采用统一的病例报告表。依据标准分别为：①腔隙性脑梗塞的诊断标准参照1995 年中华医学会第四次全国脑血管病学术会议修订的《各类脑血管疾病诊断要点》；②按照DSM-Ⅳ结合CDR量表评定除外痴呆诊断；③认知功能综合评定参照简易精神检查量表（MMSE）；④社会功能活动及日常生活能力各亚项损害评定参照Blessed评定量表（BBS）和全面衰退量表（GDS）；⑤神经功能缺损程度的评价标准参照美国国立卫生研究院卒中量表NIHSS；⑥界定血管源性认知缺损参照Hachinski缺血指数；⑦中医证候观察依据制定的统一LI认知缺损证候学科研观察表。
以上临床及实验研究数据均应用SPSS12.0 统计学软件进行分析
结果
在临床观察期间收录门诊病人观察组30例，对照组30例，共60例。对两组患者观察结果进行数据处理，得出以下研究结果：
LI认知缺损发病情况显示：男女比例约1；1，以70～79 岁发病率最高（70.83%），60～69岁发病的也不少，其次为80～89 岁。腔隙性脑梗死后出现认知缺损时间平均为42.84月，其中最长180月，最短0.33月，绝大部分出现在LI后50个月以内，可突然起病，也可以隐袭起病，进程多呈阶段样加重。既往多伴有高血压病。LI认知缺损Hachinski缺血指数均大于7分，符合血管源性认知缺损的界定值。观察组NIHSS量表评分与对照组无显著性差异，而HAMA评分有显著性差异，MMSE，BBS评分则有非常显著性差异。
单发性LI与多发性LI约1：1，腔梗好发部位以基底节最为常见，其次累及放射冠，丘脑，脑叶。即使单发的腔隙性脑梗死也可造成认知缺损，大部分病灶（87.5％）体积小于10ml。病灶右侧组与病灶左侧组或病灶两侧组比较，MMSE量表中注意力和计算力评分值均有显著性差异。文盲组与中学或以上组比较，在定向力，注意和计算力两项得分有显著性差异；小学组和中学或以上组比较，语言评分值有显著性差异。
观察组与对照组单因素分析显示：年龄，病灶距额极距离有显著性差异。观察组与对照组多因素分析显示：LI认知缺损的发病主要与年龄，文化程度相关，其中与文化程度负相关。结果与多数研究结论一致。
4，LI认知缺损核心症状主要为神情呆滞，表情淡漠，反应迟钝，善忘，思维缓慢，理解力差，言辞贫乏或颠倒，担心忧虑，失算，寡言少语，嗜睡，肢体笨拙，步履蹒跚，缺乏兴趣，注意力不集中，与对照组有显著性差异。观察组中各类证候特征性症状例数出现总数均超过30例，以火证和肝肾阴虚证为著。观察组各类证候特征性症状例数高于对照组，实证以痰，瘀证差异明显，风，火证例数接近；虚证差异均较明显。
结论
单发或多发的腔隙性脑梗死均可造成认知缺损，大部分病灶体积小于10ml。这种认知缺损临床表现相对较轻，呈单发或数项组合认知缺损，同时工作及生活能力受到不同程度影响，多伴有轻度的抑郁症状，与腔隙性脑梗死不伴认知缺损明显不同。
单因素分析表明年龄，病灶距额极距离是LI认知缺损发病的危险因素，多因素分析表明LI认知缺损的发病主要与年龄，文化程度相关，其中与文化程度负相关。而LI是否处于优势半球，患者文化程度的不同，导致MMSE损害亚项不同。
LI认知缺损核心症状以神情呆滞，表情淡漠，反应迟钝，善忘，思维缓慢，理解力差，言辞贫乏或颠倒，担心忧虑，失算，寡言少语，嗜睡，肢体笨拙，步履蹒跚，缺乏兴趣，注意力不集中为主，与对照组明显不同，可以用于本病的诊断。LI认知缺损病机复杂，虚实并见，虚证涉及肝脾肾，以肾虚为主，实证以风火痰证为标。 LI认知缺损与中风证类表现相对一致，有共同的体质因素。而肾虚，痰瘀内阻与中风后是否出现认知缺损密切相关。
Elementary Probes into the Symptomatology of Lacunar Infarction Cognitive Impairment
1.Study Objective
Selecting the patients with LI (Lacunar Infarction) and LI Cognitive Impairment, contrast researches are studied with the characters and distributing features of the Traditional Chinese Medicine（TCM） syndromes of LI and LI Cognitive Impairment.
The basis of the pathogen of the LI Cognitive Impairment will be discussed to find the risk factors of the causes of the disease so as to provide objective foundations to establish a prevention and treatment scheme through the use of TCM.
2.Study Methods
All the patients observed are at clinic and hospital in Dongfang Hospital. According to the established diagnosis standards of TCM and Western Medicine, acceptance and exclusion standards are formulated in combination with accessorial scales. 30 cases of the observation group with LI Cognitive Impairment and 30 cases of the contrast group without Cognitive Impairment were filtered to have an analysis on the factors such as gender，age and hypertension by adopting case contrast study, and at the same time the assessment score of scales and symptomatic observation were given to establish and adopt uniform case-report tables. The standards of the foundation are the following:
① The diagnosis standards of the LI references to the amended book of The Outlines of Various Cerebral Vascular Diseases in the Fourth National Academic Conference about cerebral vascular diseases by the China Medical Committee in 1995.②According to the assessment of the DSM-Ⅳ in combination with CDR scale except from the diagnosis of the dementia .③The general assessment of the cognitive functions references to the MMSE(Mental Examination Scale ) .④All kinds of the sub-item assessment of social functional activities and daily life ability references to BBS of the Blessed and the GDS(General Depression Scale).⑤The assessment standards of the degree of the nervous functional deficiency references to the NIHSS(National Institutes of Health Stroke Scale)in U.S. ⑥.Defining the cognitive impairment of vessel pathogen references to the ischemia index of the Hachinski.⑦.the symptomatology observation in TCM lay on the basis of the formulated uniform observation tables of the scientific research on the symptomatology of LI Cognitive Impairment.
All the above data of the clinical and experimental research were analyzed with the application of the SPSS12.0 statistics software.
3.Results
The admitted clinic patients during the clinical observation phase were 60 cases in number including 30 cases in the observation group and 30 cases in the contrast group. Research results were achieved as the following through data processing of the observation outcome of the two group patients.
The incident conditions of LI Cognitive Impairment show that with the ratio 1:1 of men to women, the incidence rate is highest in the ages of 70 ～90 , not low in the ages of 60 ～69, and secondarily is the ages of 80 ～ 90.The average time for the occurrence of LI Cognitive Impairment is 42.84 months, in which the longest is 180 months and the shortest is 0.33month,most of which took place within 50 months after LI; The onset may be sudden or insidious with periodic aggravation, and always accompanied by hypertension in his case history. The ischemia index of the cognitive impairment is more than 7, which is in accordance with the boundary value of the cognitive deficits of vessel pathogen. In the observation group the NIHSS assessment score isn’t different from the contrast group; The difference is significant in the HAMA and especially significant in the MMSE and BBS.
With the ratio 1:1 of Mono- LI to Poly- LI, the most predilection sites of LI are the basal section, secondarily is the coroma radiata, the thalamus and the cerebral lobe. Even the Mono-LI may cause cognitive impairment but the volume of most focus （87.5％）is less than 10ml.Compared with the left group or the bilateral groups of the focus, the right focus group has remarkable difference in the assessment score of attention ability and calculation ability in MMSE. Compared with the group in middle school or above, the illiteracy group has significant difference in the ability of direction ，attention and calculation. Compared with the group in middle school or above, the elementary school group is significantly different in the linguistic ability.
Single factor analysis for the observation group and the contrast group shows that the age and the distance from the focus to the frontal polar have remarkable difference. Multiple factors analysis in the observation group and the contrast group shows that the onset of LI Cognitive Impairment is mainly related to age and civilization degree with negative relation to civilization degree. The results are consistent to many research conclusions.
The core symptoms of LI Cognitive Impairment mainly are dull look, indifferent expression, blunt reaction, bad memory, slow thinking, poor understanding, absent or reversal speech, anxiety and worry, incapable calculation taciturn words, indulgence in sleep, awkward extremities, teeter step, lack of interest, and abstracted attention, which is greatly different from the contrast group. The occurrence cases with characteristic symptoms in various syndromes are all more than 30 in number in the observation group with the domain of the Fire syndrome and the asthenia syndrome of the liver and the kidney. The occurrence cases of various characteristic symptoms in the observation group are higher than the contrast group, in which the difference between the Phlegm syndrome and stagnation syndrome in sthenia syndrome is significant while the cases are adjacent between the Cold syndrome and Fire syndrome, but the difference of all syndromes in the asthenia syndrome is significant.
4. Conclusion
The Mono- LI or Poly- LI can result in cognitive impairment with the less than 10ml volume of the most focus. The clinical manifestations of cognitive impairment are relatively slight with the presentation of single or multiple combinations, at the same time it will bring about different impacts on the ability of work and life mostly accompanied by slight depression symptoms, which is significantly different from LI without Cognitive Impairment
Single factor analysis shows that age and the distance from the focus to the frontal polar are the risk factors for LI Cognitive Impairment, while multiple factors analysis shows that the onset of the LI Cognitive Impairment is mainly related to age and civilization degree with negative relations to civilization degree. Whether LI lies in the dominant hemisphere or not, different civilization degree will result in the difference of the sub-items of the MMSE impairment.
The core symptoms of the LI Cognitive Impairment mainly are dull look indifferent expression, blunt reaction ，bad memory，slow thinking ，poor understanding ，absent or reversal speech ，anxiety and worry，incapable calculation taciturn words，indulgence in sleep ，awkward extremities ，teeter step，lack of interest，abstracted attention, which is significantly different from the contrast group and can be used to give diagnosis to the disease. The pathogen of LI Cognitive Impairment is very complicated with the concurrence of sthenia syndrome and asthenia syndrome, in which the sthenia syndrome involves the liver the spleen and the kidney while the Virtual Kidney is the main pathogen ,and the Wind syndrome，Fire syndrome，phlegm syndrome are the presentations of the sthenia syndrome. With common constitutional factor, the manifestations of LI Cognitive Impairment are relatively consistent to the apoplexy-like syndrome, while the Virtual Kidney and Phlegm Retardarce inside is mainly related to the occurrence of cognitive impairment after stroke.
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