高分级动脉瘤性蛛网膜下腔出血患者转归的预测因素:单中心病例系列研究

目的 探讨影响高分级动脉瘤性蛛网膜下腔出血(aneurysmal subarachnoid hemorrhage,aSAH)患者转归的预测因素.方法 回顾性分析高分级(Hunt-Hess分级Ⅳ～V级)aSAH患者的临床资料.术后6个月时采用格拉斯哥转归量表(Glasgow Outcome Scale,GOS)进行转归评价,4～5分定义为转归良好,1～3分定义为转归不良.利用单变量分析和多变量logistic回归分析确定影响患者转归的相关因素.结果 共连续纳入96例高级别aSAH患者,男性41例,女性55例;年龄18～80岁,平均(61.2±11.4)岁;Hunt-Hess分级Ⅳ级47例,V级49例;41例行显微手术夹闭,9例行介入栓塞,46例保守治疗.转归良好组32例(33.33％),转归不良组64例(66.67％).单变量分析显示,转归良好组伴有高血压(40.6％对65.6％;x2=6.580,P=0.010)、脑实质出血(50.0％对78.1％0=8.836,P=0.003)、脑室积血或铸型(34.4％对68.8％;x2=10.302,P=0.001)以及脑疝征象(18.8％对45.3％;x2 =6.497,P=0.013)的患者比例显著低于转归不良组,而Hunt-Hess分级Ⅳ级(71.9％对31.7％;x2=10.088,P=0.001)、动脉瘤直径＜10 mm(84.4％对45.3％;x2=13.393,P＜0.001)、动脉瘤位于前交通动脉(53.1％对29.7％;x2=5.000,P=0.025)以及选择积极干预治疗(手术或介入)(93.8％对31.3％;x2 =33.391,P＜0.001)的患者比例则显著高于转归不良组.多变量logistic回归分析表明,高血压优势比(odds ratio,OR)2.326,95％可信区间(confidence interval,CI)3.037 ～ 15.331;P=0.023]以及脑室出血或铸型(OR 3.274,95％ CI2.156 ～5.311;P=0.020)是高级别aSAH患者转归不良的独立危险因素,而选择积极干预治疗(手术或介入)是其独立保护因素(OR 0.04,95％ CI0.003 ～0.565;P=0.017).结论 高级别aSAH患者的预后与高血压、脑室铸型以及治疗方案的选择密切相关.

Predictors of the outcome in patients with poor-grade aneurysmal subarachnoid hemorrhage: a single center case series study

Objeetive To investigate the predictors of the outcome in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH).Methods The clinical data of patients with poor-grade aSAH (Hunt-Hess grade Ⅳ to V) were analyzed retrospectively.The outcome evaluation was conducted with the Glasgow Outcome Scale (GOS) at 6 months after procedure,4 to 5 were defined as good outcome and 1 to 3 were defined as poor outcome.Univariate analysis and multivariate logistic regression analysis were used to identify the factors influencing outcome.Results A total of 96 consecutive patients with poor-grade aSAH were enrolled,including 55 females and 41 males,aged from 18 to 80 years (mean,61.2 ± 11.4 years).The Hunt-Hess grade were Ⅳ in 47 and V in 49 patients.Forty-one patients were treated with microsurgery clipping,46 received conservative treatment.There were 32 patients (33.33％) in the good outcome group and 64 (66.67％)in the poor outcome group.Univariate analysis showed that the proportions of hypertension (40.6％ vs.65.6％;x2 =6.580,P=0.010),parenchymal hemorrhage (50.0％ vs.78.1％;x2 =8.836,P=0.003),and intraventricular hemorrhage or casted ventricles (34.4％vs.68.8％;x2=10.302,P=0.001),and signs of herniation (18.8％ vs.45.3％;x2 =6.497,P=0.013) in the good outcome group were significantly lower than those in the poor outcome group,while the proportions of Hunt-Hess grade Ⅳ (71.9％ vs.31.7％;x2 =10.088,P =0.001),aneurysm diameter ＜ 10 mm (84.4％ vs.45.3％;x2 =13.393,P＜0.001),aneurysms at anterior communicating artery (53.1％ vs.29.7％;x2 =5.000,P =0.025),and active interventional treatment (operation of intervention) (93.8％ vs.31.3 ％;x2 =33.391,P ＜ 0.001) were significantly higher.Multivariate logistic regression analysis showed that hypertension (odds ratio OR] 2.326,95％ confidence interval CI] 3.037-15.331;P =0.023) and ventricular hemorrhage or casted ventricles (OR 3.274,95％ CI 2.156-5.311;P=0.020) were the independent risk factors for poor outcome in patients with poor-grade aSAH,and active interventional treatment was its independent protective factor (OR 0.04,95％ CI 0.003-0.565;P =0.017).Conclusions The prognosis in patients with poor-grade aSAH was closely associated with hypertension,ventricular casting,and treatment regimen.