The Analysis Of Risk Factors And Early Prognosis For Acute Cerebral Infarction Patients With Intracranial Unruptured Aneurysms

Part 1 Analysis of risk factors for acute cerebral infarction patients with intracranial unruptured aneurysmsBackground and objective:Intracranial aneurysms are due to abnormal expansion of intracranial artery walls,which are different in shape,including cystic,fusiform or irregular.With the rapid renewal of neuroimaging techniques,more and more intracranial unruptured aneurysms have been found.Although cerebral angiography is the gold standard for the diagnosis of intracranial aneurysms,magnetic resonance angiography,especially 3D-TOF-MRA,has been studied with the advantages of easy operation and no trauma,which have been found to be similar to that of DSA.The rate is considered to be the first choice for screening intracranial aneurysms in the population.Intracranial unruptured aneurysms can be found in healthy persons or in patients with other central nervous system diseases such as acute cerebral infarction receiving magnetic resonance imaging(MRI)or angiography(MRA).Although the risk of rupture of most intracranial aneurysms is low and there are no special symptoms in clinical,the subarachnoid hemorrhage(SAH)caused by a few ruptured aneurysms is fatal and its mortality rate is up to 30%-50%.Therefore,it is of positive clinical significance to pay attention to the screening of intracranial unbreakable aneurysms.The history of the natural development of intracranial aneurysms is not completely clear.There are few studies on acute cerebral infarction with intracranial unruptured aneurysms.Small sample studies found that the combined incidence of two of the intracranial aneurysms is between 3.7%-6.6%,obviously higher than that of the general population,and the reason is unclear.There are many common risk factors for intracranial unruptured aneurysms in ACI patients.There is still a lack of a large sample of incidence and risk factors between two comorbidities.The aim of this study was to review the baseline data of unruptured aneurysms in ACI patients in our Center for the lastest 8 years and analyz the incidence of intracranial unruptured aneurysms in ACI patients and the risk factors of two comorbidities.Method:This study was a retrospective cross-sectional study.The hospitalized patients diagnosed with ACI were enrolled affiliated hospitai of yangzhou university from January 2009 to August 2017.Criteria for entry:(1)age:20-90 years;(2)the first or again stroke patients;(3)the patients were admitted to hospital after the symptoms of 24 hours;(4)the diagnosis of cerebral infarction was in line with the diagnostic criteria of acute cerebral infarction and transient ischemic attack;(5)the skull MRI and 3D-TOF-MRA were completed within 72h.Exclusion criteria:(1)a history of subarachnoid hemorrhage,brain trauma,intracranial hemorrhage,infection,and intracranial space occupying;(2)severe diseases of the other organs of the whole body or unstable life signs,which can not be completed by magnetic resonance or DSA angiography in time;(3)patients with incomplete clinical materials are not complete.The imaging diagnosis of all intracranial unruptured aneurysms is based on the 3D-TOF-MRA examination.If the patients have completed the DSA cerebral angiography during the hospitalization,the latter is the criterion.According to the results of MRI or 3D-TOF-MRA or DSA examination,ACI patients were divided into 2 groups,A group:ACI did not combine with intracranial unruptured aneurysm;group B:ACI combined with intracranial unruptured aneurysm.Baseline materials including age,sex,smoking,drinking,past hypertension,diabetes,hyperlipidemia,coronary heart disease,cerebral infarction,cerebral hemorrhage,tumor,and head trauma were completed.The difference of baseline data between two groups and the possible risk factors of comorbidity between the two groups were statistically analyzed.Statistical methods:SPSS22.0 was used for sorting and analysis.The measurement data were expressed in the form of mean standard deviation(x±s).When the variance of the group was homogeneous,the independent sample t test was used to analyze.When the variance between the groups was not homogeneous,the t‘test was used to correct the degree of freedom;the count data was expressed in the form of frequency,the group was compared with the chi square test;the influence factors of the aneurysm and the prognosis of the patients The multiple factor Logistic regression model was used in the analysis.The test level is a =0.05.Results:The study ultimately met the inclusion criteria of ACI in 3641 patients,2188 males(60.09%),1453 females(39.91%),and the average age was(68.15±11.42)years.There were 3404 cases(93.49%)in group A,and 237 cases(6.51%)in group B.The single factor analysis of two groups of baseline data showed that there were significant differences in sex,age,smoking and high blood pressure among the two groups,in group B(P=0.008),age(P<0.001),smoking(P=0.025),and hypertension(P=0.023)higher than that in group A.With intracranial aneurysms as the dependent variable,the P<0.1 factors as independent variables(including age,sex,smoking,hypertension,TOAST)were included in the multiple factor logistic regression model.The results showed that women[odds ratio OR=1.691,95%confidence interval,CI 1.249-2.29 0;P=0.001],indicating that the risk of intracranial aneurysms in women was 1.691 times higher than that of men;age[OR=1.023,95%CI 1.010-1.036,P<0.001],indicating that the risk of intracranial aneurysms at 10 years of age increased by 1.023 times;smoking[OR=1.942,95%CI 1.413-2.670],indicating the risk of intracranial aneurysm in smokers with ACI patients.The sex was 1.942 times higher,and hypertension[OR=1.539,95%CI 1.025-2.309,P=0.037],indicating that the risk of intracranial aneurysms in patients without hypertension was 1.539 times higher than those without hypertension.Conclution:The incidence of aneurysms in acute cerebral infarction patients is 6.5%.Women,age,smoking and hypertension are high risk factors of intracranial aneurysms in patients with acute cerebral infarction.Part2:The effects of intracranial unruptured aneurysm on the early prognosis of patients with acute cerebral infarctionBackground and object:The natural history of intracranial aneurysms is not fully understood.There is no definite way to identify which intracranial ruptured aneurysms are prone to rupture.Some studies suggest that subarachnoid hemorrhage occurs shortly after acute cerebral infarction events.It is caused by the reshaping of the aneurysm wall in the infarct area,the migration of thrombus after antithrombotic therapy,the occurrence of subarachnoid hemorrhage resulting from the rupture of secondary aneurysm,and the eventual outcome of the patient’s prognosis.The guidelines for early management of acute cerebral infarction recommend intravenous thrombolytic time windows of 4.5 hours.The latest extensive clinical studies and early management guidelines for acute cerebral infarction in 2018 AHA/ASA establish the effectiveness of intravascular interventional therapy for acute cerebral infarction,which is the most beneficial treatment for patients.The safety of thrombolytic therapy for ruptured aneurysms is not unified.Intracranial aneurysm is listed as a contraindication to intravenous thrombolysis,because the risk of aneurysm rupture and bleeding will be increased after intravenous thrombolysis,so the risk of bleeding after combined thrombolytic therapy and the current guidelines rACIe that most clinicians are for patients with acute cerebral infarction with intracranial aneurysms.Conservative therapies including thrombolytic therapy and anti thrombolysis were used.Some studies also suggest that intravenous thrombolytic therapy has no significant increase in the risk of bleeding in patients with acute stroke without intracranial aneurysm.Previous studies are mostly small sample clinical observational studies.The following defects are found in the study of the clinical interaction between the three cases:(1)whether the therapy of acute cerebral infarction including intravascular interventional therapy,venous thrombolysis,anticoagulant and antiplatelet therapy,will increase the risk of rupture of intracranial aneurysms and the prognosis of patients;(2)whether intracranial unruptured aneurysms affect the recurrence rate of ischemic and hemorrhagic stroke in patients with acute cerebral infarction,and(3)the lack of different treatment methods for acute cerebral infarction patients in a randomized controlled clinical study of post effects.The purpose of this study is to investigate whether intracranial aneurysms have an impact on the early prognosis of acute cerebral infarction,and to explore the related risk factors that affect the early prognosis,so as to provide a basis for further clinical study.Method:Criteria for entry:the same as the first part;the exclusion criteria:the first part of the first part 1,the addition of article the 4th in the exclusion criteria,that is,the death in 7d after the onset or the follow-up of the patients who have completed the onset of 3months is regarded as a shedding case.The first part of the same method to complete the patient’s head MRI-3D-TOF-MRA examination,by two senior professional titles of MRI qualified doctors to complete intracranial unruptured aneurysm imaging diagnosis,if the group of patients with DSA cerebral angiography,then the following.Exclusion criteria:(1)irregular shape,multiple lobes or spindle shape;(2)traumatic or fungal infection of the aneurysm;(3)dissecting aneurysm;(4)aneurysm of the epidural;(5)an aneurysm with unclear development;(6)combined cerebrovascular malformations.According to the size of intracranial aneurysms,intracranial aneurysms was divided into less than 3mm,3-5mm,5mm-7mm,7mm-10mm,or more 10mm,and the position distribution of intracranial aneurysms,ICA(internal carotid artery),ACOA(anterior cerebral artery ACA,anterior communicating artery ACoA),MCA(middle cerebral artery),PCOA(posterior cerebral artery PCA,posterior communicating artery),and vertebral basilar artery(vertebral basilar artery)).According to the TOAST standard classification were divided the patients into the large atherosclerotic type(LAA),the arteriole occlusion(SAA),the cardiac cerebral embolism(CE),and the other types by the neurosurgeon.The baseline National Institutes of Health Stroke Scale(NIHSS)score immediately after admission.The functional prognosis of 90 days after stroke was followed up by outpatient,telephone and hospitalization,and the patients were estimated by the improved Rankin scale(mRS)90 days later,and all the patients were grouped,including the good prognosis group(mRS 0-2 score)and the poor prognosis group(mRS 3-6 score).Result:The study ultimately met the inclusion criteria of ACI in 3641 patients,2188 males(60.01%),1453 females(39.99%),and the average age was(68.15±11.423)years,237 cases of intracranial unruptured aneurysms conformed to the inclusion criteria,according to the distribution of aneurysm position:ICA(internal carotid artery),ACOA(anterior cerebral artery ACA,anterior communicating artery ACoA),MCA(middle cerebral artery),PCOA(posterior cerebral artery PCA,posterior communicating artery PCoA),and VB(vertebral basilar artery),of which ICA184 cases(77.63%)ACOA22(9.28%),MCA18(7.59%),PCOA11(4.64%),and VB12(5.06%);according to the size of the aneurysm,there were 171 cases(72.16%),43(18.14%),14(5.91%),8(3.37%),1 cases(0.43%),according to the size of the aneurysm,and the number of aneurysms was divided into a single number of aneurysms.There were 212 cases(89.45%)and 25 cases(10.55%)of aneurysms and multiple aneurysms.Of the 3917 patients with ACI,3641 cases were followed up with 3months,276 cases were dropped,the rate of abscission was 8.20%.2346 cases(64.43%)had good prognosis and 1295 cases(35.57%)had poor prognosis.The prognosis of patients with poor prognosis and poor prognosis showed age(P=0.001),diabetes(P=0.002),brain.Infarction(P<0.001),baseline NIHSS score(P<0.001)had statistical significance.There was no statistical difference between the group of intracranial aneurysms(P=0.967)and the group with poor prognosis.There was no significant correlation with the position,size and number of intracranial aneurysms,treatment and TOAST typing.After the Logistic regression analysis,we found the age[OR=1.009,95%CI 1.003-1.016,P=0.003],combined with diabetes mellitus[OR=1.235,95%CI 1.076-1.418,P=0.003],the previous a history of cerebral infarction[95%CI 1.020-1.054,P<0.001]had significant correlation with the adverse outcome of patients with ACI combined with intracranial unruptured aneurysms.Conclution:The presence of intracranial aneurysms has no significant impact on the prognosis of acute stroke patients,including the location and size of the aneurysm,as well as the different treatments.Age,diabetes,the previous a history of cerebral infarction and baseline NIHSS score are the high risk factors for early prognosis in acute stroke patients.