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中华脑血管病杂志(电子版)

中华脑血管病杂志(电子版) ›› 2024, Vol. 18 ›› Issue (04) : 317 -322. doi: 10.11817/j.issn.1673-9248.2024.04.004

论著

颈动脉狭窄处剪切率对高同型半胱氨酸血症患者脑梗死的预测价值
刘焕亮1, 崔慧娟1, 曹慧1, 付源1,†()   
  1. 1. 150001　哈尔滨，哈尔滨医科大学附属第四医院神经内科
  • 收稿日期:2023-10-23 出版日期:2024-08-01
  • 通信作者: 付源
  • 基金资助:
    黑龙江省自然科学基金(LH2021H036)

The predictive value of shear rate at carotid stenosis for cerebral infarction in patients with hyperhomocysteinemia

Huanliang Liu1, Huijuan Cui1, Hui Cao1, Yuan Fu1,†()   

  1. 1. Department of Neurology, the Fourth Affiliated Hospital of Harbin Medical University, Harbin 150001, China
  • Received:2023-10-23 Published:2024-08-01
  • Corresponding author: Yuan Fu
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引用本文：

刘焕亮, 崔慧娟, 曹慧, 付源. 颈动脉狭窄处剪切率对高同型半胱氨酸血症患者脑梗死的预测价值[J]. 中华脑血管病杂志(电子版), 2024, 18(04): 317-322.

Huanliang Liu, Huijuan Cui, Hui Cao, Yuan Fu. The predictive value of shear rate at carotid stenosis for cerebral infarction in patients with hyperhomocysteinemia[J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2024, 18(04): 317-322.

目的

探讨颈动脉狭窄处剪切率对高同型半胱氨酸血症（HHcy）患者脑梗死结局的预测价值。

方法

回顾性纳入2020年12月至2022年12月哈尔滨医科大学附属第四医院神经内科收治的HHcy伴颈动脉狭窄患者237例。根据是否发生脑梗死事件将患者分为脑梗死结局组（150例）及非脑梗死结局组（87例），收集2组患者临床指标及超声参数的数据。采用单因素分析方法（独立样本t检验、Mann-Whitney U检验和Pearson χ2检验）比较2组上述参数的差异，采用多因素Logistic回归分析脑梗死结局的独立危险因素，应用受试者操作特征（ROC）曲线评价相关指标对脑梗死结局的诊断价值。

结果

与非脑梗死结局组比较，脑梗死结局组的血清Hcy水平[（29.39±17.49）μmol/L vs（24.51±10.08）μmol/L]、狭窄处收缩期峰值流速（PSV）[（422.92±138.63）cm/s vs（312.87±98.27）cm/s]、不稳定斑块比例（37.3% vs 9.2%）和剪切率[11 254.76（8800.00，15 700.00）s-1vs 5511.11（4600.00，6720.00）s-1]均较高，狭窄处内径[0.15（0.12，0.19）cm vs 0.22（0.19，0.28）cm]较小，差异具有统计学意义（t=-2.384，P=0.018；t=-6.513，P<0.001；χ2=22.117，P<0.001；Z=-12.625，P<0.001；Z=-8.233，P<0.001）。多因素Logistic回归分析显示，不稳定斑块（OR=5.450，95%CI：2.438~12.186，P<0.001）、狭窄处PSV（OR=1.010，95%CI：1.006~1.013，P<0.001）、剪切率（OR=1.003，95%CI：1.002~1.005，P<0.001)）是患者发生脑梗死结局的危险因素。狭窄处PSV、剪切率对患者脑梗死结局有较高的诊断效能，狭窄处PSV、剪切率的截断值分别取328 cm/s和7800 s-1时，对患者脑梗死结局有最佳预测价值，且剪切率的诊断效能优于狭窄处PSV（ROC曲线下面积：0.992 vs 0.754，Z=7.577，P<0.001）。

结论

不稳定斑块、狭窄处PSV、剪切率是HHcy伴颈动脉狭窄患者脑梗死结局的危险因素。其中，剪切率对患者发生脑梗死结局具有最佳预测价值，可作为预测患者发生脑梗死事件的量化指标。

关键词: 剪切率, 高同型半胱氨酸血症, 颈动脉狭窄, 脑梗死
Objective

To investigate the predictive value of shear rate at carotid artery stenosis for the outcome of cerebral infarction in patients with hyperhomocysteinemia (HHcy).

Methods

A total of 237 patients with HHcy and carotid artery stenosis, admitted to the Department of Neurology, the Fourth Affiliated Hospital of Harbin Medical University from December 2020 to December 2022, were retrospectively enrolled. The patients were divided into the cerebral infarction outcome group and the non-cerebral infarction outcome group, based on the presence or absence of cerebral infarction events. Data of clinical indicators and ultrasound parameters for the two groups were collected. Univariate analysis (independent sample t-test, Mann-Whitney U test and Pearson χ2 test) was used to compare the differences in the aforementioned parameters between the two groups. Multivariate Logistic regression was used to analyze the independent risk factors of cerebral infarction outcome. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of relevant indicators for cerebral infarction outcomes.

Results

Compared with the non-cerebral infarction outcome group, the serum Hcy level [(29.39±17.49) μmol/L vs (24.51±10.08) μmol/L], the peak systolic velocity (PSV) at the stenosis [(422.92±138.63) cm/s vs (312.87±98.27) cm/s], the unstable plaque ratio (37.3% vs 9.2%), and shear rate [11 254.76 (8800.00, 15 700.00) s-1vs 5511.11 (4600.00, 6720.00) s-1] were higher. The inner diameter of stenosis [0.15 (0.12, 0.19) cm vs 0.22 (0.19, 0.28) cm] was smaller, and the difference was statistically significant (t=-2.384, P=0.018; t=-6.513, P<0.001; χ2=22.117, P<0.001; Z=-12.625, P<0.001; Z=-8.233, P<0.001). Multivariate Logistic regression analysis showed that unstable plaque (OR=5.450, 95%CI: 2.438-12.186, P<0.001), PSV at stenosis (OR=1.010, 95%CI: 1.006-1.013, P <0.001) and shear rate (OR=1.003, 95%CI: 1.002-1.005, P<0.001) were the risk factors for the outcome of cerebral infarction. PSV and the shear rate at the stenosis have significant diagnostic efficacy for the outcome of cerebral infarction in patients. When the cut-off values of PSV and shear rate at the stenosis are 328 cm/s and 7800 s-1, respectively, they have the best predictive value for the outcome of cerebral infarction in patients, and the diagnostic efficacy of shear rate is significantly better than that of PSV at the stenosis (area under ROC curve: 0.992 vs 0.754, Z=7.577, P<0.001).

Conclusion

Unstable plaque, PSV at stenosis, and shear rate are risk factors for cerebral infarction outcome in HHcy patients with carotid artery stenosis. Among them, the shear rate demonstrates the greatest predictive value for the outcome of cerebral infarction. It can be used as a quantitative indicator to predict the occurrence of cerebral infarction these patients.

Key words: Shear rate, Hyperhomocysteinemia, Severe carotid stenosis, Cerebral infarction
表1 HHcy伴颈动脉狭窄不同结局组患者临床资料的比较
临床资料 非脑梗死结局组（n=87） 脑梗死结局组（n=150） 统计值 P值
年龄（岁，） 68.94±9.11 68.85±9.15 t=0.078 0.938
性别[例（%）] χ2=0.449 0.503
男 67（77.0） 121（80.7）
女 20（23.0） 29（19.3）
高血压史[例（%）] 32（36.8） 72（48.0） χ2=2.814 0.093
心房颤动史[例（%）] 15（17.2） 34（22.7） χ2=0.988 0.320
吸烟史[例（%）] 16（18.4） 38（25.3） χ2=1.509 0.219
体质量指数（kg/m2，） 23.82±3.52 23.05±2.91 t=1.802 0.073
血糖（mmol/L，） 6.11±2.57 6.17±2.00 t=-0.213 0.831
总胆固醇（mmol/L，） 4.88±1.26 5.01±1.19 t=-0.814 0.416
甘油三酯（mmol/L，） 1.76±1.07 1.78±1.34 t=-0.088 0.930
高密度脂蛋白（mmol/L，） 1.07±0.24 1.05±0.22 t=0.832 0.406
低密度脂蛋白（mmol/L，） 2.97±0.98 3.14±0.98 t=-1.302 0.194
血清Hcy（μmol/L，） 24.51±10.08 29.39±17.49 t=-2.384 0.018
狭窄血管[例（%）] χ2=0.055 0.814
颈内动脉 30（34.5） 54（36.0）
颈动脉球部 57（65.5） 96（64.0）
狭窄部位[例（%）] χ2=0.045 0.832
左侧 43（49.4） 72（48.0）
右侧 44（50.6） 78（52.0）
狭窄处PSV（cm/s，） 312.87±98.27 422.92±138.63 t=-6.513 <0.001
狭窄处内径[cm，M（QR）] 0.22（0.19，0.28） 0.15（0.12，0.19） Z=-8.233 <0.001
不稳定斑块[例（%）] χ2=22.117 <0.001
有 8（9.2） 56（37.3）
无 79（90.8） 94（62.7）
剪切率[s-1，M（QR）] 5511.11（4600.00，6720.00） 11 254.76（8800.00，15 700.00） Z=-12.625 <0.001
表2 HHcy伴颈动脉狭窄患者脑梗死结局的独立危险因素分析
因素 B值 SE值 Wald值 P值 OR值 95%CI
同型半胱氨酸（μmol/L） 0.018 0.011 2.874 0.090 1.019 0.997~1.041
不稳定斑块 1.696 0.411 17.059 <0.001 5.450 2.438~12.186
狭窄处内径（cm） -2.329 1.248 3.486 0.062 0.097 0.008~1.123
狭窄处PSV（cm/s） 0.010 0.002 27.353 <0.001 1.010 1.006~1.013
剪切率（s-1） 0.003 0.001 19.836 <0.001 1.003 1.002~1.005
图1 狭窄处收缩期峰值流速及剪切率预测脑梗死的受试者操作特征曲线
表3 狭窄处PSV及剪切率对脑梗死结局的诊断效能
指标 AUC 95%CI P值 截断值 敏感度（%） 特异度（%）
狭窄处PSV（cm/s） 0.754 0.694~0.808 <0.001 328 71.33 63.22
剪切率（s-1） 0.992 0.971~0.999 <0.001 7800 94.00 97.70
不稳定斑块 0.641 0.571~0.711 <0.001 NA 62.67 90.80
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