非线性动力学方法可预警直立倾斜试验中血管迷走性晕厥的发生

doi:10.19723/j.issn.1671-167X.2019.03.009

北京大学学报（医学版） ›› 2019, Vol. 51 ›› Issue (3): 430-438. doi: 10.19723/j.issn.1671-167X.2019.03.009

非线性动力学方法可预警直立倾斜试验中血管迷走性晕厥的发生

李凡¹,王汉斌²,彭清¹,孙云闯¹,张冉²,庞博²,方竞²,张珏^2△(),黄一宁^1△()

^1. 北京大学第一医院神经内科,北京 100034
^2. 北京大学前沿交叉学科研究院,北京 100871

出版日期:2019-06-18 发布日期:2019-06-26
作者简介:张珏,北京大学工学院副教授,博士生导师,北京大学前沿交叉学科研究院生物医学跨学科研究中心博士生导师。长期致力于临床问题驱动的医学工程交叉学科研究。与北京大学第一医院、北京大学人民医院、中国人民解放军总医院、哈佛医学院等多家临床医院密切合作,在磁共振成像、医学图像和信号辅助诊断分析方面取得了多项研究成果,已经有超过70篇相关SCI文章发表,申请国家发明专利19项。目前担任中国食品药品企业质量安全促进会检测技术委员会副主任委员。
在医学信号分析领域,针对睡眠过程中生理信号,提出了多尺度分析的动态特征挖掘方法,为呼吸暂停患者夜间呼吸事件和心血管事件预警提供了有价值的参考, 相关研究结果多次在睡眠医学的顶级杂志 Sleep Medicine发表,并首次提出了经颅直流电刺激改善老年人平衡功能的新有效治疗手段,为制定康复处方提供了工具和思路。
2014年获得教育部高等学校科学研究优秀成果科技进步二等奖;2012年获得国家体育总局颁发的第30届奥运科技攻关与科技服务项目贡献二等奖。|黄一宁,北京大学第一医院神经科主任。1987年毕业于中国协和医科大学获硕士学位。1984年至2002年在北京协和医院神经科工作,2003年调任现职。长期不间断地在临床第一线工作,见识广博,经验丰富,并且精通于神经系统疾病常用的检测手段,如神经电生理、神经超声、神经影像学等专业技术,擅长于神经系统急症重症疾病和疑难疾病的诊治,特别是在脑血管病诊断和治疗上有很深的造诣。
2001年以来,牵头开展了多个国家重大科研项目,如国家十五攻关项目、国家十五攻关专项、卫生部临床重大专项、国家十一五重大专项,以及国家自然基金、首都发展基金、中德合作中心项目等。在国际顶级专业杂志如the Lancet Neurology、 Neurology、 Stroke等发表多篇文章。现任中华神经科分会常委、脑血管病学组副组长、亚洲急性卒中专家组(ASAP)成员。他精通英文,熟悉法文,与国际临床神经病学界有广泛联系。曾被德国乌尔姆大学、法兰克福歌德大学、德国哥廷根大学、德国萨拉大学、香港中文大学等聘为客座教授、访问教授或访问学者。

Prediction of syncope with nonlinear dynamic analysis during head-up tilt in vasovagal syncope patients

Fan LI¹,Han-bin WANG²,Qing PENG¹,Yun-chuang SUN¹,Ran ZHANG²,Bo PANG²,Jing FANG²,Jue ZHANG^2△(),Yi-ning HUANG^1△()

^1. Department of Neurology, Peking University First Hospital, Beijing 100034, China
^2. Academy of Advanced Interdisciplinary Study, Peking University, Beijing 100871, China

Online:2019-06-18 Published:2019-06-26

摘要/Abstract

摘要： 目的量化评价血管迷走性晕厥血压下降过程中的脑血流自动调节功能,用于在晕厥相关症状出现前预测其发生。方法选取20位直立倾斜试验证实的血管迷走性晕厥患者,另选取20名正常对照者。所有被试在直立倾斜试验前都要平卧30 min,同时使用TCD 2 MHz Doppler监测探头监测双侧大脑中动脉血流速度,心电监护监测心率,使用连续每搏血压监测指端无创连续血压。在进行10 min基线数据采集后,被试继续进行70°直立倾斜试验,每位被试至少直立30 min,或在30 min内出现晕厥发作或晕厥前兆时或当被试出现突发血压下降≥20 mmHg时终止检查。利用多模态血流血压分析(multimodal pressure-flow analysis,MMPF)的非线性动力学方法对不同时相的脑血流自动调节功能进行分析。利用信号分析的方法将脑血流信号记录中的重搏切迹深度量化测量,定义新的预测参数晕厥指数(syncope index,SI)用于评估血压变化时的脑血管张力。结果病例组在血管迷走性晕厥发生时的晕厥指数与倾斜试验开始时的基线数值相比存在明显下降(0.16±0.10 vs. 0.27±0.10,P<0.01), 而对照组在倾斜试验结束时的晕厥指数与倾斜试验开始时的基线数值相比差异无统计学意义。对于血管迷走性晕厥组的患者,在晕厥发生前3 min,搏动指数与基线数据相比未见明显变化(P>0.05),但晕厥指数已出现明显下降(0.23±0.07 vs.0.29±0.07,P<0.01)。结论当血管迷走性晕厥发生时脑血流动态调节功能衰竭,小血管张力的丧失与脑血流自动调节功能的丧失是相关的;晕厥指数可以作为提前预测血管迷走性晕厥发生的一个有用的参数。

关键词: 血管迷走性晕厥, 脑血流自动调节, 非线性动力学

Abstract: Objective: To quantify the relationship between cerebral blood flow velocity and peripheral blood pressure during hypotension period, aiming to predict the brain hypotension before symptomatic occurrence.Methods: Twenty vasovagal syncope (VVS) patients who had a previous clinical history were selected in groups and 20 pair-matched control subjects underwent 70° tilt-up test. The subjects remained supine for 30 minutes before recordings when Doppler probes, electrodes and Finapres device were prepared. After continuous baseline recordings for 10 min, the subjects underwent head up tilt (HUT) test (70°), and were standing upright for 30 minutes or until syncope was imminent. For ethical reasons, the subjects were turned back to supine position immediately after SBP dropped to ≥20 mmHg, when their consciousness persisted. The point of syncope was synchronized for all the subjects by the point SBP reached the minima. Their beat-to-beat blood pressures (BP) were recorded continuously and bilateral middle cerebral artery (MCA) flow velocities were obtained with two 2 MHz Doppler probes from a transcranial Doppler ultrasonography (TCD) system. A nonlinear dynamic method——multimodal pressure flow (MMPF) analysis was introduced to access cerebral autoregulation during different time intervals. We introduced a new indicator——syncope index (SI), which was extracted from blood flow velocity (BFV) signal to evaluate the variation of cerebral vascular tension, and could reflect the deepness of dicrotic notch in BFV signal. Results: Compared with the syncope index of the baseline value at the beginning of the tilt test, SI in VVS group showed significantly lower when the VVS occurred (0.16±0.10 vs.0.27±0.10,P<0.01),while there was no significant difference in syncope index between the control group at the end of the tilt test and the baseline value at the beginning of the tilt test. For those VVS patients, pulse index and resistance index had no significant change. Syncope index decreased significantly 3 minutes before the point of syncope (0.23±0.07 vs.0.29±0.07,P<0.01).Conclusion: Dynamic regulation is exhausted when vasovagal syncope occurred. Tension decrease of small vessels could have some relationship with loss of the cerebral autoregulation capability. The proposed syncope index could be a useful parameter in predicting syncope of VVS patients since it decreased significantly up to 3 minutes earlier from the point of syncope.

Key words: Vasovagal syncope, Cerebral autoregulation, Nonlinear dynamics

中图分类号:

R725.4

李凡,王汉斌,彭清,孙云闯,张冉,庞博,方竞,张珏,黄一宁. 非线性动力学方法可预警直立倾斜试验中血管迷走性晕厥的发生[J]. 北京大学学报（医学版）, 2019, 51(3): 430-438.

Fan LI,Han-bin WANG,Qing PENG,Yun-chuang SUN,Ran ZHANG,Bo PANG,Jing FANG,Jue ZHANG,Yi-ning HUANG. Prediction of syncope with nonlinear dynamic analysis during head-up tilt in vasovagal syncope patients[J]. Journal of Peking University(Health Sciences), 2019, 51(3): 430-438.

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参考文献 22

[1]	Peter N . Cerebral blood flow, heart rate, and blood pressure patterns during the tilt test in common orthostatic syndromes[J]. Neuroscience J, 2016,2016:6127340.
[2]	Shen WK, Sheldon RS, Benditt DG , et al. 2017 ACC/AHA/HRS Guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J]. Circulation, 2017,136(5):e60-e122.
[3]	Brignole M , Moya A, de Lange FJ, et al. 2018 ESC guidelines for the diagnosis and management of syncope[J]. Eur Heart, 2018,39(21):1883-1948. doi: 10.1093/eurheartj/ehy037
[4]	Victor C, Satish R . Confounders of vasovagal syncope: orthostatic hypotension[J]. Cardiol Clin, 2013,31(1):89-100. doi: 10.1016/j.ccl.2012.09.003
[5]	Gommer ED, Shijaku E, Mess WH , et al. Dynamic cerebral autoregulation: different signal processing methods without influence on results and reproducibility[J]. Med Biol Eng Comput, 2010,48(12):1243-1250. doi: 10.1007/s11517-010-0706-y
[6]	Hu K, Peng CK, Huang NE , et al. Altered phase interactions between spontaneous BP and flow fluctuations in type 2 diabetes mellitus: nonlinear assessment of cerebral autoregulation[J]. Physica A, 2008,387(10):2279-2292. doi: 10.1016/j.physa.2007.11.052
[7]	Lo MT, Novak V, Peng CK , et al. Nonlinear phase interaction between nonstationary signals: a comparison study of methods based on Hilbert-Huang and fourier transforms[J]. Phys Rev E Stat Nonlin Soft Matter Phys, 2009,79(6 Pt 1):61924. doi: 10.1103/PhysRevE.79.061924
[8]	Men-Tzung L, Kun H, Yanhui L , et al. Multimodal pressure-flow analysis: application of Hilbert-Huang transform in cerebral blood flow regulation[J]. EURASIP J Adv Signal Process, 2008,2008:785243. doi: 10.1155/2008/785243
[9]	Tiecks FP, Lam AM, Aaslid R , et al. Comparison of static and dynamic cerebral autoregulation measurements[J]. Stroke, 1995,26:1014-1019. doi: 10.1161/01.STR.26.6.1014
[10]	Grubb BP, Gerard G, Roush K , et al. Cerebral vasoconstriction during head-upright tilt-induced vasovagal syncope. A paradoxic and unexpected response[J]. Circulation 1991,84(3):1157-1164. doi: 10.1161/01.CIR.84.3.1157
[11]	Albina G, Cisneros L F, Laiño R , et al. Transcranial Doppler monitoring during head upright tilt table testing in patients with suspected neurocardiogenic syncope[J]. Europace, 2004,6(1):63-69. doi: 10.1016/j.eupc.2003.09.009
[12]	Furukawa T . Role of head-up tilt table testing in patients with syncope or transient loss of consciousness[J]. J Arrhythm, 2017,33(6):568-571. doi: 10.1016/j.joa.2017.08.002
[13]	Carey BJ, Manktelow BN, Panerai R , et al. Cerebral autoregulatory responses to head-up tilt in normal subjects and patients with recurrent vasovagal syncope[J]. Circulation, 2001,104(8):898-902. doi: 10.1161/hc3301.094908
[14]	Subudhi AW, Panerai RB, Roach RC . Acute hypoxia impairs dynamic cerebral autoregulation: results from two independent techniques[J]. J Appl Physiol, 2009,107(4):1165-1171. doi: 10.1152/japplphysiol.00498.2009
[15]	Schondorf R, Stein R, Roberts R , et al. Dynamic cerebral autoregulation is preserved in neurally mediated syncope[J]. Eur J Appl Physiol, 2001,91(5):2493-2502. doi: 10.1152/jappl.2001.91.6.2493
[16]	Krishnamurthy S, Wang X, Bhakta D , et al. Dynamic cardiorespiratory interaction during head-up tilt-mediated presyncope[J]. Am J Physiol Heart Circ Physiol, 2004,287(6):2510-2517. doi: 10.1152/ajpheart.00485.2004
[17]	Wang KW, Chang HH, Hsu CC , et al. Extractions of steady-state auditory evoked fields in normal subjects and tinnitus patients using complementary ensemble empirical mode decomposition[J]. Biomed Eng Online, 2015,14:72. doi: 10.1186/s12938-015-0062-0
[18]	Bondar RL, Kassam MS, Stein F , et al. Simultaneous cerebrovascular and cardiovascular responses during presyncope[J]. Stroke, 1995,26(10):1794-1800. doi: 10.1161/01.STR.26.10.1794
[19]	Schondorf R, Benoit J, Wein T . Cerebrovascular and cardiovascular measurements during neurally mediated syncope induced by head-up tilt[J]. Stroke, 1997,28(8):1564-1568. doi: 10.1161/01.STR.28.8.1564
[20]	Van Lieshout JJ, Wieling W, Karemaker JM , et al. Syncope, cerebral perfusion, and oxygenation[J]. J Appl Physiol, 2003,94(3):833-848 doi: 10.1152/japplphysiol.00260.2002
[21]	Bor-Seng-Shu E, Kita WS, Figueiredo EG , et al. Cerebral hemodynamics: concepts of clinical importance[J]. Arq Neuropsiquiatr, 2012,70(5):352-356. doi: 10.1590/S0004-282X2012000500009
[22]	Sweeney MD, Ayyadurai S, Zlokovic BV . Pericytes of the neurovascular unit: key functions and signaling pathways[J]. Nat Neurosci, 2016,19(6):771-783.

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Parameter	Patients	Control group	P
Number of subjects, n	20	20	NA
Age/years	39±12 (19-59)	37±19 (21-76)	0.71
Systolic blood pressure/mmHg	127±19	116±24	0.10
Diastolic blood pressure/ mmHg	75±13	68±13	0.08
Heart rate/(/min)	72±10	68±10	0.32
Mean blood flow velocity/(cm/s)	59±11	58±16	0.77

Patients	Different time points in tilt test
Patients	d	e	f	g
BP-BFV phase shift degree	59.6±20.6	20. 9±17.4^#	21.0±12.3^#	12.9±9.9^#
Syncope index	0.29±0.07	0.23±0.07^*	0.19±0.09^#	0.16±0.10^#
Pulse index	0.81±0.14	0.85±0.13	0.84±0.11	0.89±0.13^*
Resistance index	0.52±0.05	0.54±0.05	0.54±0.04	0.55±0.05^*

非线性动力学方法可预警直立倾斜试验中血管迷走性晕厥的发生

Prediction of syncope with nonlinear dynamic analysis during head-up tilt in vasovagal syncope patients

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