脑出血后继发性脑水肿的形成、发展及影响因素研究

【摘要】
目的 研究急性脑出血（intracerebral hemorrhage，ICH）患者继发性脑水肿的相关因素及对ICH患者预后的影响。
方法 本研究为前瞻性研究，连续收集发病24 h内的ICH住院患者51例。患者到院时收集临床基线信息、完成实验室检查和常规头颅平扫计算机断层扫描（computed tomography，CT）以评价基线脑水肿情况。发病（12±2）d行常规头颅平扫CT及CT血管成像一站式检查，以完成高峰期水肿情况及脑血管系统评价。分别在就诊、出院和发病后90 d进行神经功能评价。
结果 在51例入组患者中，基底节区出血36例，丘脑出血7例，脑叶出血8例。本研究发现初始水肿体积（V初始水肿）与初始血肿体积（V初始血肿）正相关（r=0.799，P＜0.001）；初始水肿指数（EI初始）与服用抗血小板药物负相关（r=－2.456，P=0.014）。高峰期水肿体积（V高峰水肿）与V初始水肿（r=0.720，P＜0.001）、V初始血肿（r=0.779，P＜0.001）和高峰期血肿体积（V高峰血肿）（r=0.788，P＜0.001）呈正相关；高峰期水肿指数（EI高峰）与EI初始正相关（r=0.357，P=0.010）。本组患者中V初始水肿与就诊ICH功能预后量表（Functional Outcome after ICH，FUNC）评分（r=-0.355，P=0.011）、格拉斯哥昏迷量表（Glasgow Coma Scale，GCS）评分（r=－0.419，P=0.002）、原始脑出血量表（the Original ICH Scale，oICH）评分（r=0.364，P=0.009）、出院（r=0.520，P＜0.001）及发病后90 d（r=0.481，P＜0.001）改良Rankin量表（modified Rankin Scale，mRS）评分以及出院时美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）评分（r=0.526，P＜0.001）相关；V高峰水肿与就诊时NIHSS评分（r=0.455，P=0.001）、FUNC评分（r=－0.327，P=0.019）、GCS评分（r=－0.436，P=0.001）、出院（r=0.564，P＜0.001）及发病后90 d（r=0.590，P＜0.001）mRS评分以及出院时NIHSS评分（r=0.541，P＜0.001）相关。
结论 ICH患者存在继发性脑水肿，初始水肿严重程度与初始血肿体积、既往应用抗血小板药物等因素相关，高峰期水肿严重程度与初始水肿、血肿体积，高峰血肿体积以及初始水肿指数等因素相关。ICH患者急性期疾病严重程度和90 d预后与初始和高峰期脑水肿体积相关。

Nature History and Predictive Factors of Perihematomal Edema after IntracerebralHemorrhage

Objective To evaluate the nature history of perihematomal edema （PHE） in intracerebral hemorrhage （ICH） patients using X-ray computed tomography （CT）, to analyze the predictive factors of the severity of initial and peak PHE, and to explore the relationship between PHE and clinical outcome. Methods It was a retrospective study of consecutive patients with ICH admitted to Beijing Tiantan Hospital from October 2009 to November 2011. Medical records, laboratory data, and CT scan were performed at admission. On （12±2） days after ICH, CT angiography and venography were given to analyze peak edema and cerebral vascular system. Neurologic assessments were performed at admission, patient discharge and 3 months after ICH. Results Among 51 patients enrolled, there were 36 cases of basal ganglia hemorrhage, 7 cases of thalamus hemorrhage and 8 cases of lobar hemorrhage. According to our study, baselinehematoma volume was the only correlation factor of baseline edema volume （r=0.799, P〈 0.001） and antiplatelet use on admission is associated with more severe relative baseline edema （r=--2.456, P=0.014）. Peak edema volume had a positive correlation with both baseline edema （r=0.720, P 〈0.001） and hematoma volume and peak hematoma volume （r=0.788, P〈0.001）. Peak edema index is only related with baseline edema index （t=0.357, P=-0.010）. This study revealed significant relationship between the baseline/peak edema volume and acute clinical deterioration/modified Rankin Scale （mRS） and National Institutes of Health Stroke Scale （NIHSS） on discharge and 90 days of onset, but failed to find correlations between baseline/peak edema index and clinical outcomes. Conclusion Antiplatelet use on admission is associated with more severe relative baseline edema. Acute clinical deterioration and long-term functional outcome after ICH are only correlated to initial absolute PHE severity.