程 燕,鐘 平
(安徽醫(yī)科大學(xué)附屬宿州醫(yī)院神經(jīng)內(nèi)科,安徽 宿州 234000)
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動(dòng)脈瘤性蛛網(wǎng)膜下腔出血患者早期手術(shù)與臨床轉(zhuǎn)歸的相關(guān)性研究
程燕,鐘平
(安徽醫(yī)科大學(xué)附屬宿州醫(yī)院神經(jīng)內(nèi)科,安徽 宿州234000)
摘要:目的 探討動(dòng)脈瘤性蛛網(wǎng)膜下腔出血(aSAH)患者早期手術(shù)與臨床轉(zhuǎn)歸的相關(guān)性。方法回顧性納入該院接受血管介入手術(shù)或開(kāi)顱動(dòng)脈瘤夾閉術(shù)治療的aSAH住院患者,收集其人口統(tǒng)計(jì)學(xué)和臨床資料。采用改良Rankin量表(mRS)評(píng)價(jià)患者6個(gè)月后的轉(zhuǎn)歸。采用單變量及多變量Logistic回歸分析確定影響aSAH患者臨床轉(zhuǎn)歸的危險(xiǎn)因素。結(jié)果共納入aSAH患者84例,其中24例接受早期手術(shù),60例接受晚期手術(shù);58例轉(zhuǎn)歸良好,26例轉(zhuǎn)歸不良。單變量分析顯示早期手術(shù)組6個(gè)月時(shí)轉(zhuǎn)歸良好率(87.50% vs 61.67%;χ2=5.353,P=0.021)高于晚期手術(shù)組。轉(zhuǎn)歸良好組與轉(zhuǎn)歸不良組相比,入院時(shí)收縮壓高(t=-3.268;P=0.002)、腦血管痙攣(15.52% vs 57.69%;χ2=15.647,P<0.001)、再出血(12.07% vs 46.15%;χ2=11.916,P=0.001)、腦積水(17.24% vs 50.00%;χ2=9.689,P=0.002)、晚期手術(shù)(63.79% vs 88.46%;χ2=5.353,P=0.021)、Fisher分級(jí)3~4級(jí)(17.24% vs 61.54%;χ2=16.483,P<0.001)和Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)(20.69% vs 53.85%;χ2=9.235,P=0.002)是aSAH患者轉(zhuǎn)歸不良的危險(xiǎn)因素。多變量Logistic回歸分析顯示腦血管痙攣(OR=3.28,95%CI=1.18~10.23;P=0.037)、晚期手術(shù)(OR=2.26,95%CI=1.21~3.89;P=0.028)、Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)(OR=3.42,95%CI=1.28~8.65;P=0.013)是aSAH患者轉(zhuǎn)歸不良的可能獨(dú)立危險(xiǎn)因素。結(jié)論 腦血管痙攣、晚期手術(shù)和Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)是aSAH患者臨床轉(zhuǎn)歸不良的獨(dú)立危險(xiǎn)因素;早期手術(shù)可改善aSAH患者的臨床轉(zhuǎn)歸。
關(guān)鍵詞:蛛網(wǎng)膜下腔出血;動(dòng)脈瘤;危險(xiǎn)因素;手術(shù)時(shí)機(jī);治療結(jié)果
動(dòng)脈瘤性蛛網(wǎng)膜下腔出血(aneurysmalsubarachnoidhemorrhage,aSAH)是一種極度危害健康的疾病,發(fā)病率和死亡率極高[1]。其臨床轉(zhuǎn)歸受多種可控制和不可控制因素影響,可控制因素包括手術(shù)干預(yù)治療和內(nèi)科管理措施。近年來(lái)研究顯示早期手術(shù)可減少aSAH患者再出血的風(fēng)險(xiǎn)和改善患者預(yù)后[2-3]。但是,Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)的aSAH患者病情較重且常伴有高度腦腫脹[4],早期手術(shù)仍然會(huì)導(dǎo)致高發(fā)病率及死亡率[5]。因此,明確aSAH患者早期(3d內(nèi))或晚期病情穩(wěn)定后手術(shù),何者臨床轉(zhuǎn)歸更好至關(guān)重要。這項(xiàng)回顧性研究通過(guò)分析影響aSAH患者預(yù)后的危險(xiǎn)因素,旨在為臨床選擇最佳的手術(shù)時(shí)機(jī)提供依據(jù)。
1對(duì)象和方法
1.1研究對(duì)象 采用回顧性研究方法,連續(xù)性收集2010年1月—2015年1月安徽醫(yī)科大學(xué)附屬宿州醫(yī)院aSAH住院患者。納入標(biāo)準(zhǔn):(1)顱腦CT及CTA或DSA證實(shí)為aSAH;(2)所有患者均行血管介入手術(shù)或開(kāi)顱動(dòng)脈瘤夾閉術(shù)治療,并且手術(shù)基本成功;(3)年齡20~75歲;(4)臨床資料完整者。排除標(biāo)準(zhǔn):(1)外傷后假性動(dòng)脈瘤患者;(2)動(dòng)靜脈畸形合并動(dòng)脈瘤;(3)煙霧病合并動(dòng)脈瘤;(4)其他原因不明的蛛網(wǎng)膜下腔出血。
1.2資料收集根據(jù)手術(shù)時(shí)間,分為早期手術(shù)組(<72h)和晚期手術(shù)組(≥72h)。全面收集可能影響aSAH患者臨床轉(zhuǎn)歸的詳細(xì)資料:(1)人口統(tǒng)計(jì)學(xué)資料:性別、年齡;(2)既往史:吸煙、飲酒、高血壓、糖尿病、冠心??;(3)入院時(shí)收縮壓及舒張壓,Hunt-Hess分級(jí)、Fisher分級(jí);(4)手術(shù)方式和手術(shù)時(shí)機(jī);(5)并發(fā)癥:腦出血、腦血管痙攣、腦積水、肺部感染等;(6)動(dòng)脈瘤大小和位置。
1.3評(píng)價(jià)指標(biāo)采用改良Rankin量表(modifiedRankinScale,mRS)評(píng)估患者的臨床轉(zhuǎn)歸,根據(jù)臨床轉(zhuǎn)歸情況分為轉(zhuǎn)歸良好組(mRS≤2分)和轉(zhuǎn)歸不良組(mRS>2分),隨訪時(shí)間為出院6個(gè)月后。
2結(jié)果
研究期間共納入aSAH患者93例,失訪9例,最終有84例患者納入分析。其中男性36例,女性48例,平均年齡(58.88±9.846)歲。位于前循環(huán)有55例,后循環(huán)有29例;Hunt-Hess分級(jí):I~Ⅲ級(jí)58例,Ⅳ~Ⅴ級(jí)26例;Fisher分級(jí):1~2級(jí)58例,3~4級(jí)26例。24例接受早期手術(shù),60例接受晚期手術(shù);58例轉(zhuǎn)歸良好,26例轉(zhuǎn)歸不良。
2.1早期手術(shù)組與晚期手術(shù)組人口統(tǒng)計(jì)學(xué)、臨床資料及轉(zhuǎn)歸良好率比較單變量分析顯示早期手術(shù)組年齡、性別、Fisher分級(jí)3~4級(jí)和Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)、再出血、腦積水、腦血管痙攣與晚期手術(shù)組比較均無(wú)統(tǒng)計(jì)學(xué)差異,但早期手術(shù)組6個(gè)月時(shí)轉(zhuǎn)歸良好率(87.5%vs61.67%;χ2=5.353,P=0.021)顯著高于晚期手術(shù)組,差異具有統(tǒng)計(jì)學(xué)意義,見(jiàn)表1。
表1 早期手術(shù)組與晚期手術(shù)組人口統(tǒng)計(jì)學(xué)和臨床資料比較
2.2轉(zhuǎn)歸良好組與轉(zhuǎn)歸不良組人口統(tǒng)計(jì)學(xué)和臨床資料比較單因素分析顯示入院時(shí)收縮壓高(t=-3.268;P=0.002)、腦血管痙攣(15.52%vs57.69%;χ2=15.647,P<0.001)、再出血(12.07%vs46.15%;χ2=11.916,P=0.001)、腦積水(17.24%vs50.00%;χ2=9.689,P=0.002)、晚期手術(shù)(63.79%vs88.46%;χ2=5.353,P=0.021)、Fisher分級(jí)3~4級(jí)(17.24%vs61.54%;χ2=16.483,P<0.001)和Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)(20.69%vs53.85%;χ2=9.235,P=0.002)在兩組之間有統(tǒng)計(jì)學(xué)差異,是aSAH患者轉(zhuǎn)歸不良的危險(xiǎn)因素,而吸煙、飲酒、高血壓病史、動(dòng)脈瘤大小和位置、手術(shù)方式在兩組之間無(wú)統(tǒng)計(jì)學(xué)差異,見(jiàn)表2。
表2 轉(zhuǎn)歸良好組與轉(zhuǎn)歸不良組人口統(tǒng)計(jì)學(xué)和臨床資料比較
2.3aSAH患者臨床轉(zhuǎn)歸不良的獨(dú)立危險(xiǎn)因素將“2.2”節(jié)單因素分析中P<0.1的因素納入至多變量Logistic回歸分析,顯示腦血管痙攣(OR=3.28,95%CI=1.18~10.23;P=0.037)、晚期手術(shù)(OR=2.26,95%CI=1.21~3.89;P=0.028)、Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)(OR 3.42,95%CI 1.28~8.65;P=0.013)是aSAH患者轉(zhuǎn)歸不良的獨(dú)立危險(xiǎn)因素,見(jiàn)表3。
表3 aSAH患者臨床轉(zhuǎn)歸不良的多變量Logistic回歸分析
3討論
aSAH患者的死亡率及致殘率極高,因此,早期及時(shí)處理破裂的動(dòng)脈瘤對(duì)改善aSAH患者的臨床預(yù)后至關(guān)重要。目前主要的外科治療方法包括開(kāi)顱夾閉術(shù)和介入栓塞術(shù)兩種。關(guān)于手術(shù)時(shí)機(jī)與aSAH患者臨床預(yù)后關(guān)系之間的研究仍然存在爭(zhēng)議。過(guò)去,考慮到腦血管痙攣的因素,對(duì)于Hunt-Hess分級(jí)Ⅲ級(jí)以上的aSAH患者建議2周后行手術(shù)治療,故多數(shù)患者喪失了治療的手術(shù)時(shí)機(jī),1年后死亡率明顯增加[6]。目前,大多數(shù)學(xué)者認(rèn)為Hunt-Hess分級(jí)Ⅰ~Ⅲ級(jí)的aSAH患者應(yīng)在72 h內(nèi)行手術(shù)治療,避免動(dòng)脈瘤再次破裂出血危及生命。然而,Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)的aSAH患者比Hunt-Hess分級(jí)Ⅰ~Ⅲ級(jí)的患者更易出現(xiàn)再出血和腦血管痙攣[7],即使經(jīng)過(guò)嚴(yán)格評(píng)估后早期手術(shù)可能會(huì)改善其預(yù)后,但仍然具有很高的發(fā)病率和病死率[8]。
本研究通過(guò)回顧性分析發(fā)現(xiàn)早期手術(shù)組6個(gè)月時(shí)臨床轉(zhuǎn)歸良好率明顯高于晚期手術(shù)組,且發(fā)現(xiàn)除腦血管痙攣和Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)之外,晚期手術(shù)也是aSAH患者臨床轉(zhuǎn)歸不良的獨(dú)立危險(xiǎn)因素。近年來(lái),隨著血管內(nèi)治療的發(fā)展,即使分級(jí)高的aSAH患者,若早期行介入手術(shù)并及時(shí)處理并發(fā)癥,仍可獲得良好的治療效果[9]。Siddiq等[10]通過(guò)對(duì)全國(guó)aSAH住院患者進(jìn)行分析發(fā)現(xiàn)在48 h內(nèi)行手術(shù)治療可明顯改善患者預(yù)后。Phillips等[11]研究發(fā)現(xiàn)對(duì)于大部分分級(jí)低的患者早期手術(shù)特別是24 h內(nèi)手術(shù)可改善其臨床預(yù)后。薛彥忠等[12]通過(guò)對(duì)aSAH患者早期栓塞治療的療效及并發(fā)癥分析發(fā)現(xiàn)早期(3 d內(nèi)) 的介入治療可使90%的患者達(dá)到治療目的,即使是Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)患者也可預(yù)防再出血及減少并發(fā)癥的發(fā)生,改善預(yù)后。以上研究與本研究一致。早期手術(shù)可改善aSAH患者臨床預(yù)后的主要原因可能是避免了再出血對(duì)腦的損傷,能及時(shí)清除蛛網(wǎng)膜下腔的凝血塊,減少并發(fā)癥的發(fā)生。
腦血管痙攣是aSAH主要并發(fā)癥之一,其可引起遲發(fā)性的神經(jīng)功能缺損,導(dǎo)致腦不可逆的損傷。已有相當(dāng)數(shù)量的研究顯示[13-14]腦血管痙攣可增加患者的致殘率及致死率,是aSAH預(yù)后不良的獨(dú)立危險(xiǎn)因素。本研究也發(fā)現(xiàn)腦血管痙攣是aSAH患者臨床轉(zhuǎn)歸不良的獨(dú)立危險(xiǎn)因素。然而,早期手術(shù)組與晚期手術(shù)組腦積水、腦血管痙攣之間無(wú)統(tǒng)計(jì)學(xué)意義,可能的原因是動(dòng)脈瘤手術(shù)后,臨床上積極治療并發(fā)癥有關(guān)。例如,早期行腰椎穿刺和腰大池引流促進(jìn)腦脊液循環(huán),緩解急性腦積水,阻止其向慢性腦積水發(fā)展,特別是早期行腰大池持續(xù)引流術(shù),該法能充分引流血性腦脊液,阻斷積血造成的繼發(fā)性損害,能有效減少腦血管痙攣等并發(fā)癥,改善患者預(yù)后。本研究尚未發(fā)現(xiàn)手術(shù)方式與患者臨床預(yù)后有關(guān),可能與樣本量少有關(guān)。
綜上,可知早期手術(shù)可改善aSAH患者的臨床轉(zhuǎn)歸。臨床實(shí)踐中,即使Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)的患者也可考慮早期手術(shù)。本研究存在一些不足之處,如樣本量偏少,為回顧性研究;且大多數(shù)患者為Ⅰ~Ⅲ級(jí)。因此,需要進(jìn)一步大樣本研究來(lái)明確aSAH患者的手術(shù)時(shí)機(jī),特別是對(duì)于Hunt-Hess分級(jí)Ⅳ~Ⅴ級(jí)的病例。
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doi:10.3969/j.issn.1009-6469.2015.12.025
(收稿日期:2015-07-29,修回日期:2015-08-14)
Correlation of early surgery and clinical outcomes in patients
with aneurysmal subarachnoid hemorrhage
CHENG Yan, ZHONG Ping
(Department of Neurology, Suzhou Hospital Affiliated to Anhui Medical University,
Suzhou, Anhui234000,China)
Abstract:ObjectiveTo explore the correlation between early surgery and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage(aSAH). MethodsInpatients with aSAH were enrolled retrospectively accepted endovascular interventional therapy or aneurysm clipping. Their demographic and clinical data were collected.Clinical outcomes were assessed by modified Rankin scale(mRs) at 6 months. Univariate and multivariate logistic regression analysis were performed to determine the risk factors that influenced clinical outcomes of patients with aSAH. Results84 patients with aSAH were included. 24 patients underwent early surgery, 60 patients delayed surgery. 58 patients had good outcome and 26 patients had poor outcome. Univariate analysis showed that good outcome rate at 6 months (87.50% vs 61.67%;χ2=5.353,P=0.021) of the early surgery was higher than that of the delayed surgery. High systolic blood pressure(t=-3.268;P=0.002), cerebral vasospasm(15.52% vs 57.69%;χ2=15.647,P<0.001), rebleeding(12.07% vs 46.15%;χ2=11.916,P=0.001), hydrocephalus(17.24% vs 50.00%;χ2=9.689,P=0.002),delayed surgery(63.79% vs 88.46%;χ2=5.353,P=0.021), Fisher grade 3 to 4(17.24% vs 61.54%;χ2=16.483,P<0.001) and Hunt-Hess grade IV to V(20.69% vs 53.85%;χ2=9.235,P=0.002) were the risk factors for patients with poor outcome. Multivariate logistic regression analysis showed that cerebral vasospasm(OR 3.28,95%CI 1.18~10.23;P=0.037), delayed surgery(OR 2.26,95%CI 1.21~3.89;P=0.028), Hunt-Hess grade IV to V(OR 3.42,95%CI 1.28~8.65;P=0.013) were the risk factors for patients with poor outcome. ConclusionCerebral vasospasm, delayed surgery, Hunt-Hess grade IV to V are independent risk factors for poor clinical outcomes of patients with aSAH. Early surgery may improve the clinical outcomes for patients with aSAH.
Key words:ubarachnoid hemorrhage;aneurysmal;risk factor;surgical timing;treatment outcome