Screening,establishment Of Risk Factor Prediction Nomogram Model And Mdixon Quant And ~1H-MRS Of Stroke Related Sarcopenia Patients’Thigh

Part Ⅰ:Screening for stroke-related sarcopeniaObjective:The proportion of Stroke patients in the rehabilitation department accounts for about 21-69%[1].We found that some Stroke patients with paraplegics,healthy sides,or even whole body muscle mass decreased with decreased muscle strength,resulting in stroke-related sarcopenia(SRS),referred to as Stroke sarcopenia[2].Compared with patients without sarcopenia,their time in hospital is longer,the incidence of complications is higher,the hospitalization cost is higher,the rehabilitation effect is not ideal,and the recovery is slower[3].Although there is an independent ICD-10-CM code for this disease,there is no code for this disease in the Diagnosis Related Groups(DRGs)in the digital medical record system in most hospitals,which leads to the inability of medical insurance to pay for the examination and treatment of this disease,and the lack of doctors’ understanding of this disease,Sarcopenia related guidelines or consensus do not have standardized,effective and unified diagnosis and treatment methods,and skeletal muscle imaging features are unclear[4],resulting in long-term neglect.Patients older than 70 years may have been accompanied by primary sarcopenia before stroke[5],resulting in significantly longer recovery time and poor treatment effect.Therefore,early detection,diagnosis and treatment of stroke sarcopenia are very important.The purpoe of this study is to explore an accurate,simple and effective screening tool to clarify its optimal diagnostic cut-off value,formulate the best clinical rehabilitation treatment plan for stroke patients,improve their rehabilitation efficacy,reduce complications,reduce total treatment costs,and ultimately benefit patients.Methods:A single-center prospective cross-sectional study design was used to collect 501 patients with stroke who were admitted to the Rehabilitation Department of hospital from January 2020 to January 2022,and their disease duration ranged from 2 weeks to 6 months.Four trained researchers performed SARC-F scale,Ishii score,calf circumference(CC)measurement and maximum value,bioelectrical impedance body composition analyzer(Bioelectrical impedance)within 24 hours after admission Limb skeletal muscle mass index was measured by analysis,BIA,and grip strength was measured by dynamometer.According to the 2019 Asian Working Group on Sarcopenia Published by the consensus of the diagnostic criteria for the gold standard,calculate SARC-F scale,Ishii score,CC.compared with the gold standard in the diagnosis of pairing four tables,including true positive and false positive,negative,false negatives in the number of patients,calculation of Specific degrees,Sensitivity,positive predictive value,negative predictive value,positive likelihood ratio and negative likelihood ratio,Kappa value,receiver operating characteristic curve(ROC)was drawn to calculate the highest Youden index,obtain the best cutoff value and relevant Sensitivity and Specificity,and the area under the ROC curve AUC.Results:Calf circumference(CC)measurement include the Sensitivity(Sen)Specificity(Spe)and positive predictive value of SRS screening Value(PPV),negative predictive value(NPV),positive likelihood ratio(PLR),negative likelihood ratio(NPV)Ratio(NLR),accuracy(AC),Area Under ROC Curve(AUC)and Kappa values were 92.3%,46.8%,55.2%,89.5%,8.34,0.1,65.7%,0.85,0.72.respectively.The best cutoff value(COV)is 31cm;After gender stratification analysis,the Sen,Spe,PPV,NPV,PLR,NLR,AC,AUC,Kappa and COV of CC screening SRS in male patients were 90.4%,77.5%.74%,91.9%,18,0.27,82.8%,0.83,0.74,31cm,respectively.The Sen,Spe,PPV,NPV,PLR,NLR,AC,AUC,Kappa and COV of SRS in CC screening of female patients were 84.2%,81.8%,80%,85.7%,4.64,0.2,82.9%,0.8,0.66 and 30cm,respectively.The Sen,Spe,PPV,NPV,PLR,NLR,AC,AUC,Kappa and COV of SRS screened by SARC-F were 99.5%,7.2%,43.2%,95,5%,1.6,0.06,50.3%,0.73,0.31,5,respectively.The Sen,Spe,PPV,NPV,PLR,NLR,AC,AUC,Kappa and COV of SRS screening by Ishii score were 94.2%,49.1%,56.8%,92.3%,2.3,0.05,67.9%,0.78,0.55,118,respectively.The Sen,Spe,PPV,NPV,PLR,NLR,AC,AUC,Kappa and COV of SRS in male patients were 97.6%,48.3%,66.7%,97.2%,2.5,0.06,60.5%,0.8,0.5,118,respectively.The Sen,Spe,PPV,NPV,PLR,NLR,AC.AUC,Kappa and COV values of SRS in female patients screened by Ishii score were 89.8%.49.3%,55.7%,87.2%,2.1,0.04,66.1%,0.77,0.44,162,respectively.Conclusion:Calf circumference screening has the highest diagnostic efficiency for stroke related sarcopenia,and the best diagnostic value is less than or equal to 31cm in men and less than 30cm in women.This method is simple and easy to implement,and can be popularized in communities,hospitals and nursing homes.It is suitable for early prediction and prevention of stroke patients.Part 2:Nomogram prediction model,proportion and risk factors of stroke related sarcopeniaObjective:SRS diagnosis is mainly based on skeletal muscle mass index and muscle,because of race and region,genetic,diet,measuring tools,such as the diagnostic criteria of different and various countries and regions,the research object(patients,the elderly),location(community,hospital),the prevalence of SRS are different.The prevalence of SRS is about 16.8%-60.3%,with an average of 42%,39%in women and 45%in men,54%in Japan,40%in Korea,38.6%in Chinese Taiwan and 16.8%in the United States[15].The prevalence of stroke within 1 month was 50.4%,and the prevalence of stroke longer than 6 months was 34%[16].The prevalence of SRS diagnosed by AWGS was 50%,and the prevalence of SRS diagnosed by European Working Group on Sarcopenia in Older People(EWGSOP)was 45.5%[17].Clinical studies in Taiwan showed that the prevalence of SRS was 29.9%[18].However,there are few studies on the prevalence of SRS in other regions,but this data is very important for the formulation of relevant medical insurance policies.After stroke,the muscle mass and muscle strength of patients continue to decline,coupled with other comorbidities such as diabetes,chronic bronchitis emphysema and hypertension,leading to a gradual decline in nutritional status and physical function,poor prognosis and significantly increased mortality[19].Therefore,to clarify the proportion of SRS in rehabilitation department is conducive to the early prevention and treatment of SRS in clinical practice.There are many studies on risk factors abroad,and the most clear ones are dysphagia and malnutrition caused by cognitive impairment.Related causes have protein energy reduction,stroke patients after muscle loss of nerve,motor neurons in lower motor neuron inhibitory function,the motor neuron communication interrupt,nerve nutrient transfer fails,the result in hemiplegia patients lie in bed or decreased activity,limb apraxia,protein catabolism strengthen synthetic function decrease,All of these may eventually lead to sarcopenia.Not all stroke patients have associated sarcopenia,and the independent risk factors related to its clinical etiology are still unclear.Basically,there are many foreign studies,but domestic studies are rare.Therefore,we need more accurate and complete understanding of the composition ratio of SRS,etiology and clinically related risk factors.The purpose of this study was to evaluate the constituent ratio and common causes of SRS in rehabilitation department.identify its independent risk factors,and establish a Nomogram prediction model.Methods:A single-center case-control study was conducted to collect 1226 consecutive stroke patients who met the admission criteria in hospital of Kunming Medical University from January 2020 to January 2022.Skeletal muscle mass index(SMI)of extremities was analyzed by BIA and grip strength was measured by a grip meter within 24 hours after admission.According to the 2019 Asian sarcopenia consensus diagnostic criteria,all patients were divided into sarcopenia and non-sarcopenia groups.The proportion of patients was determined,and their age,gender,course of disease,recovery time,nature of work,type of stroke,walking ability,and nasogastric tube induration time were recorded.During hospitalization,whether there was cognitive impairment,aphasia,pneumonia,comorbidities of diabetes mellitus and hypertension,gout,fracture history,weight,height,BMI,fasting blood glucose,insulin,albumin and hemoglobin,insulin growth factor IGF-1,25-OHD and other examinations.The differences between the two groups of variables were determined by t-test for normal continuous measurement data,rank sum test for non-normal continuous measurement data,and chi-square test for count data.The variables with statistically significant differences were analyzed by multivariate logistic regression to identify their independent risk factors.The Nomogram prediction model was established using R language and verified by K-fold.Results:Among 1226 stroke patients,592 had sarcopenia,and Proportion(PR)was 48.3%.There were 874 male patients,PR was 71.3%,and 567 SRS patients,PR was 64.9%.There were 352 female patients(PR=28.7%)and 185 SRS patients(PR=52.6%).There were 1072 married patients,PR was 83.7%;In 652 patients with cerebral hemorrhage,PR was 53%,and PR of SRS was 48%.The PR of mental labor was 55.0%and that of SRS was 50.3%.There were 590 patients with a history of coma,PR was 48.1%,SRS PR was 56.9%;There were 568 smoking patients,PR was 46.3%,SRS PR was 44.6%;There were 440 patients with alcoholism,PR was 35.9%,and PR of SRS was 45%.Most of the patients with stroke occurred in temporal lobe and basal ganglia(946.PR was 77.2%),and 306 patients in parietal lobe(PR was 27.7%).320 patients had pneumonia,PR was 26.1%,SRS PR was 34.8%;The PR of 566 patients with diabetes was 46.1%,and the PR of SRS was 50.3%.718 patients had undergone cerebrovascular interventional therapy.PR was 58.6%,SRS PR was 54.1%;A total of 480 patients were able to walk,with a PR of 39.2%and a PR of 24.3%for SRS.SRS is more important than non-stroke-related stroke sarcopenia,component ratio is high,single NSRS in patients with male rate is high,light weight,age,history of coma rate high,rehabilitation treatment time is short,high rate of tracheotomy,college diploma is more,the CC small and low strength,mental work than low,took place in the temporal lobe basal ganglia region is more high,cerebrovascular intervention treatment,ICU stay time is long,pneumonia rate is high,the walking exercise capacity decreased,low albumin,small white balls ratio,low creatine,uric acid,low red blood cell,hemoglobin,low albumin,had been in risk of cognitive impairment,difficulty swallowing and low incidence of aphasia,high triglycerides,low iron,low serum calcium and cholinesterase and high lactate dehydrogenase,creatine kinase low,insulin and insulin C,IGF-1 low.There were significant differences in feeding tube placement time,BMI,limb and trunk skeletal muscle mass,fat percentage,basal metabolism,mineral and phase Angle,and trunk water content(p<0.05).The correlation analysis between these factors and the occurrence of sarcopenia showed that the muscle mass of extremities was strongly negatively correlated with sarcopenia.especially the muscle mass of right lower extremities(r=-0.62,p<0.05).It was negatively correlated with basal metabolic rate(r=-0.61,p<0.05),and negatively correlated with body weight and BMI(r=-0.47,p<0.05).It was highly negatively correlated with upper limb circumference(r=-0.6,p<0.05),moderately negatively correlated with muscle strength(r=-0.3,p<0.05).completely negatively correlated with calf circumference(r=-0.81,p<0.05).and positively correlated with placement of nasal feeding tube(r=0.36,p<0.05).Logistic regression analysis showed that right calf circumference and rehabilitation time were protective factors for sarcopenia(OR0.11.95%CI 0.06-0.18.OR0.99,95%CI 0.91-0.997)and decreased muscle strength(OR13.64,95%CI 0.91-0.997).95%CI 2.68-69.4).smoking(OR3.4,95%CI 1.3-8.8),lesion location in frontal/basal ganglia(ORI.8,95%CI 2.2-27.3),diabetes mellitus(OR2.6,95%CI 1.1-6.1).aphasia(OR3.2,95%CI 1.2-8.1),cognitive impairment(OR1.7,95%CI 1.21-2.52),dysphagia(OR1.51,95%CI 1.06-2.2),nasal feeding tube placement(OR1.01,95%CI 1.005-1.016),coma(OR1.47,95%CI 1.002-2.15),pneumonia(OR=1.6,95%CI)1.02-2.42)is an independent risk factor for stroke sarcopenia.Conclusion:About half of stroke patients in rehabilitation department suffer from SRS,and the probability of male patients is much higher than female patients.The age of onset of female patients is concentrated in 70 years old,which is 10 years older than male patients on average.The independent risk factors for SRS were older age,decreased muscle strength,smoking,stroke lesion located in frontal lobe and basal ganglia,diabetes mellitus,aphasia,cognitive impairment,dysphagia,nasogastric tube placement,coma,pneumonia.The protective factors of stroke sarcopenia were longer rehabilitation time,greater BMI and body weight.The Nomogram prediction model can well predict stroke related sarcopenia,and the actual consistency with the prediction of SRS is high,with a C-index of 0.76.Part 3:Characteristics of mDixon Quant and 1H-MRS of thigh skeletal muscle in stroke-related sarcopeniaObjective:There are three types of direct skeletal muscle injury,including myocyte edema and fibrosis,fatty infiltration,and large area injury.The imaging findings of skeletal muscle denervation injury caused by nerve and vascular deprivation showed different degrees of muscle atrophy.On T1WI and T2WI,the muscle signal of the injured side was higher than that of the healthy side,and the transverse diameter of the cross-sectional muscle was reduced,while the long diameter of the muscle was not significantly changed.MRI showed that the muscle fibers of skeletal muscle were tapering,fat hyperintensity shadow appeared in the muscle and the muscle was significantly tapering and atrophic with the progression of the lesion.However,there is a lack of clear quantitative research on the quantitative and qualitative changes of skeletal muscle in SRS patients,whether there are denervation changes such as myocyte edema or intermuscular fat infiltration,and what is the rule of fat mass change.For the imaging characteristics of skeletal muscle in sarcopenia,CT or quantitative Q-CT is mainly used to measure the changes of muscle fiber cells and interstitial components in foreign countries,and there is a lack of MRI and quantitative MRI related studies.The purpose of this study was to analyze the changes of body composition and MRI characteristics of thigh skeletal muscle in patients with stroke sarcopenia,to determine the changes of thigh skeletal muscle fat percentage and muscle fiber inside and outside fat content in patients with stroke sarcopenia by mDixon Quant and 1H-MRS,and to clarify its correlation with clinical laboratory tests.To clarify the changes of the main muscle components and the main influencing factors.Methods:A single-center case-control study design was used.According to the 1:1 ratio of body weight and BMI between the case group and the control group,40 non-sarcopenia group,40 sarcopenia group,and 40 normal control group who were admitted to hospital from January 2020 to January 2022 and met the inclusion criteria within 6 months of stroke course were collected.The relevant demographic data were recorded,and laboratory tests were performed for fasting blood glucose,insulin,albumin and hemoglobin.IGF-1,blood lipids,glucagon and 25-OHD.T2WI/T1WI MRI and mDixon Quant MRI were performed in all three groups.The midpoint of rectus femoris muscle was selected as the Region of interest(ROIs)at the mid-thigh level for 1H-MRS scanning.Image J software was used to delineate the anterolateral muscle groups including vastus lateralis,rectus femoris,vastus intermedius and vastus medialis at the middle level of the thigh.The posterior muscle group included biceps femoris.semitendinosus and semimembranosus muscles.The medial muscle group includes the area of adductor,adductor magnus,gracilis and sartorius.The areas of subcutaneous fat,subfascial fat and intermuscular fat were also delineated.The degree of fat infiltration was assessed by visual Goutillar score at the level of the middle thigh on T1WI.After mDixon Quant MRI scan,the region of interest(ROI10mm)at the central level of each muscle was selected on the fat image to show the muscle fat fraction.The Lip1/Lip2 wave peak and the area under the curve measured by 1H-MRS represent the relative and absolute content of fat in and out of cells,respectively.Then the muscle area,fat fraction,relative and absolute fat content of the three groups were analyzed by ANOVA or non-parametric test to obtain the differences among the three groups.Then the correlation between muscle fat fraction,extracellular/intracellular fat content and clinical laboratory data was analyzed,and the correlation coefficient between the two was obtained.To identify the characteristics of changes in muscle fat content in patients with sarcopenia,and to find out laboratory tests that can be used as markers,so as to facilitate clinical prediction of the occurrence of sarcopenia.Results:In the normal control group(aged 30-60 years),there was no significant difference in the percentage fat of thigh skeletal muscle between men and women with body weight matched with BMI(p>0.05).Eleven skeletal muscles in the middle layer of thigh were divided into three groups:anterolateral group and posterolateral group.There was no significant difference in the percentage of muscle fat in ipsilateral anterolateral thigh group,medial thigh group and posterior thigh group in normal control group(p>0.05).There was no significant difference in the percentage of muscle fat between the anterolateral and medial thigh groups,but the percentage of muscle fat in the posterior left group was higher than that in the right side(p<0.05).There was no significant difference in the percentage of muscle fat in ipsilateral stroke patients(p>0.05).The percentage of thigh skeletal muscle fat in paraplegics group was higher than that in healthy group,but the difference was not statistically significant(p>0.05).The percentage of thigh skeletal muscle fat in paraplegia patients was higher than that in healthy patients(p<0.05).The percentage of fat in thigh skeletal muscle of normal control group.stroke non-sarcopenia group and stroke related sarcopenia group increased gradually,and the difference was statistically significant(p<0.05).Pairwise comparison showed that the percentage of fat in sarcopenia group and normal control group was significantly higher,and the difference was statistically significant(p<0.05).The percentage of fat in sarcopenia group was slightly higher than that in non-sarcopenia group,and the difference was not statistically significant(p>0.05).The percentage of muscle fat in the posterior group of sarcopenia group was higher than that in the medial group and the anterolateral group,and the difference was statistically significant(p<0.05).The cross-sectional area of thigh skeletal muscle in normal control group,stroke non-sarcopenia group and stroke sarcopenia group decreased gradually,and the difference was statistically significant(p<0.05).The cross-sectional area of thigh muscle in sarcopenia group was significantly smaller than that in normal control group(p<0.05).The intermuscular fat area of normal control group,stroke non sarcopenia group and stroke related sarcopenia group increased gradually,and the difference was statistically significant(p<0.05).The muscle fat area of sarcopenia group was significantly higher than that of normal control group(p<0.05).In the normal control group(aged 30-60 years),there was no significant difference in fat percentage of thigh rectus femoris muscle between men and women when body weight was close to BMI(p>0.05).The interskeletal muscle and intra/extracellular fat content of normal control group,stroke non-sarcopenia group and stroke sarcopenia group increased gradually,and the differences were statistically significant(p<0.05).Compared with the normal control group,the sarcopenia group had significantly higher intermuscle and extracellular/intracellular fat content(p<0.05).The ratio of extracellular fat content in skeletal muscle to intracellular fat content in normal control group was 4-10(p<0.05),and the difference was statistically significant.In sarcopenia group,the increase of intracellular fat content was higher than that of extracellular fat content,and the ratio of extracellular fat content to intracellular fat content was less than 4.and the difference was statistically significant(p<0.05).Conclusion:The MRI characteristics of the middle thigh skeletal muscle in stroke related sarcopenia patients showed that the cross-sectional area of the thigh skeletal muscle was significantly smaller than that of the healthy side.The area of skeletal muscle in midthigh of sarcopenia group was significantly smaller than that of normal control group.In sarcopenia group,the reduction of skeletal muscle area in the middle thigh was as follows:the reduction of muscle cross-sectional area in the posterior group was greater than that in the anterolateral group and the reduction of muscle cross-sectional area in the medial group.Hypodermic fat,subfascial fat and intermuscular fat of thigh were significantly higher than those of healthy side.The skeletal muscle subcutaneous fat,subfascial fat and intermuscular fat increased gradually in the normal control group,non-sarcopenia group and sarcopenia group.The subcutaneous fat,subfascial fat and intermuscular fat of the thigh in sarcopenia group were significantly higher than those in normal control group.The mDixon Quant MRI features of stroke sarcopenia are significantly higher percentage of skeletal muscle fat in the middle thigh,and the peak values and area under the curve of Lip1 and Lip2 in 1H-MRS are increased.The percentage of muscle fat in mDixon Quant response was correlated with the intracellular fat content in Lipl area under the curve.Increased muscle fiber intracellular fat content is the main feature of stroke sarcopenia,and the ratio of extracellular fat content to intracellular fat content is less than 4,with a normal range of 4-10.