臺灣博碩士論文加值系統

頸動脈狹窄是造成急性缺血性腦中風的隱形殺手。頸動脈狹窄可能會使得頸動脈竇壁的扭曲變形，進而影響心血管自主神經功能的受損。本研究目的是探討急性期與亞急性期的急性缺血性中風病人，頸動脈狹窄的對自主神經功能的影響。經由腦部的電腦斷層掃描影像顯示及神經專科醫師判斷，確認175人為第一次急性缺血腦中風，住院期間皆進行彩色頸動脈複合式超音波檢查，評估病人頸動脈狹窄程度，並於症狀發生<7天內(急性期)、症狀發生10-14天(亞急性期)安排兩次的自主神經功能檢查。另外有對照組為7位健康人自願參加的受試者。病人出院後，在中風後第1、3、6、及12個月會電話訪問追蹤，評估其腦中風的殘疾失能狀況及評估其日常生活活動能力。急性缺血性腦中風病人頸動脈狹窄程度分為三組(≧50%, ＜50%, no stenosis)，與對照組無頸動脈狹窄健康人比較，連續性平均收縮壓與平均動脈壓在急性期平躺休息、姿勢改變、傾斜後躺下來皆有明顯的差異；連續性平均舒張壓在急性期平躺休息、傾斜後躺下來，有明顯的差異；脈搏壓在姿勢改變，有顯著的差異。無頸動脈狹窄的缺血性腦中風病人在急性期與亞急性期比較，連續性平均血壓(收縮壓、平均動脈壓)與脈搏壓在平躺休息時有顯著的差異。＜50%頸動脈狹窄的缺血性腦中風病人在急性期與亞急性期比較，不管在平躺休息、或姿勢改變、傾斜後躺下來，連續性平均血壓(收縮壓、舒張壓、平均動脈壓)、與脈搏壓的變化皆有明顯的差異。≧50%頸動脈狹窄的缺血性腦中風病人在急性期與亞急性期比較，連續性平血壓(收縮壓、舒張壓、平均動脈壓)在姿勢改變有顯著的差異。對不同的頸動脈狹窄的急性缺血性腦中風病人與健康成年人相比，連續性平均血壓(收縮壓、舒張壓、平均動脈壓)與脈搏壓都有顯著的差異，但心律變異性與感壓反射敏感度無顯著的差異。嚴重頸動脈狹窄的急性缺血性腦中風病人與輕微中度頸動脈狹窄及無頸動脈狹窄比較，預後結果較差。缺血性腦中風病人的預後以Barthel Index分組，不管在急性期或亞急性期的各項血壓、脈搏壓、心律變異性-交感神經與迷走神經的平衡(LF/HF)，各種姿勢的測量，預後差與預後好比較，皆無顯著的差異。唯有感壓反射敏感度(BRS)在亞急性期的姿勢改變時，預後差的BRS較預後好明顯較低。經多變數邏輯斯迴歸分析，年齡高(p < 0.001)，中風較嚴重(NIHSS, p <0.001)，有糖尿病 (p = 0.024)為預後差的獨立影響因子，而非頸動脈狹窄的嚴重程度。

Carotid stenosis may distort carotid sinus wall, and cause the damage of cardiovascular autonomic nerve function. The aim of the study is to investigate the autonomic nerve function in patients with ischemic stroke in the acute and subacute phases with varying degrees of carotid stenosis. 175 people were diagnosed as acute ischemic stroke for the first time based on examination of brain computed tomography (CT) image and clinical examination by neurologists. Color-coded Carotid Duplex Sonography examination were carried out on these patients to assess the degree of carotid artery stenosis during their hospitalization. The autonomic nerve function tests were performed onset of the occurrence of symptoms < 7 days (acute phase), and of 10-14 days (subacute period). Seven healthy volunteers participated in the study served as the control group. Telephone interviews followed after the patients were discharged at the first, third, sixth, and 12th month to assess their disability status of stroke and the activities of daily living. Patients were divided into three groups based on carotid artery stenosis as ≧50%, <50%, and no stenosis. The results showed that compared with control group, the sBP and mBP measurements taken with patients lying down, tilting, and lying down again were higher in the three stroke groups in the acute phases. The dBP measurements taken with subjects lying down, and lying down again after tilting in the acute phases were also higher in the three stroke groups than that of control group. The PP measurements taken with subjects tilting were higher in the three groups of stroke patients than that of the control group in the acute phase.The measurements of sBP, dBP, mBP, and PP with patients of lying down, tilting, and lying down after lying in the group with <50% stenosis were different between values taken in the acute phase and those in subacute phase. The sBP, dBP, mBP values taken with patients tilting in the group with ≧ 50% stenosis were different in acute and subacute phase. Compared with healthy adults, acute ischemic stroke patients with different degree of carotid stenosis were higher in sBP, dBP, mBP, and PP values, but no difference shown in HRV and BRS values. Acute ischemic stroke in patients of severe carotid stenosis had poorer prognosis, compared with mild-moderate carotid stenosis and no carotid stenosis. Using Barthel Index as the prognosis index, measurements of sBP, dBP, mBP and PP, and LF/HF in the acute and subacute phases, whether lying postural changes, or lying down, showed no significant difference in acute and subacute phase between poor and good prognosis groups. Patients with lower BRS values taken with posture changes of in the subacute phase had poorer prognosis. With stepwise multiple logistic regression, Age (p < 0.001), NIHSS (p < 0.001) and DM (p = 0.024) were shown to be independent predictors of poor prognosis (Barthel index≦60).

目 錄
論文審定書………………………………………………………….…….. i
誌謝………………………………………………………….……………..ii
中文摘要………………………………………………………….…….....iii
英文摘要………………………………………..………………………....v
目錄……………………………………………………….…………….... vii
圖次與表次……………………………………………………….……….viii
縮寫表………………………………………..…………………………....ix
緒論………………………………………………………........................1
自主神經系統………………………………………............................ 2
心律變異性及心律變異性分析……………………………….………...3
感壓反射敏感度………………………………………..........................6
研究目的.…………………………………………..................................7
材料與方法……………………………………………............................8
結果……………………………………………......................................11
討論……………………………………………………...........................17
結論與未來研究……………………………………………....................18
參考文獻……………………………………………………….……........19

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