动脉瘤性蛛网膜下腔出血患者显微外科手术治疗的转归及其影响因素

Outcome of microsurgical treatment and its influencing factors in patients with aneurysmal subarachnoid hemorrhage

目的探讨动脉瘤性蛛网膜下腔出血患者显微外科手术治疗的转归及其影响因素。方法回顾性纳入连续的接受早期显微外科手术治疗的动脉瘤性蛛网膜下腔出血患者。出院时采用格拉斯哥转归量表评价患者转归，4～5分定义为转归良好，1～3分定义为转归不良。结果共纳入147例动脉瘤性蛛网膜下腔出血患者，112例患者转归良好（76.2%）。转归良好组与转归不良组术前格拉斯哥昏迷量表（Glasgow Coma Scale, GCS）评分[（12.8±2.8）分对（7.5±3.8）分；t＝7.525，P〈0.001）以及Hunt-Hess分级低（83.0%对31.4%；χ2＝34.318，P〈0.001）、动脉瘤大小（χ2＝9.531，P＝0.009）、术前再出血（6.3%对25.7%；χ2＝8.506，P＝0.003）、术前脑疝（4.5%对40.0%；χ2＝26.846，P〈0.001）、首次CT扫描显示合并脑内血肿（19.6%对48.6%；χ2＝11.449，P＝0.002）和脑室出血（8.9%对40.0%；χ2＝18.846，P〈0.001）的比例差异有统计学意义。多变量logistic回归分析显示，动脉瘤较大[优势比（odds ratio, OR）3.194，95%可信区间（confidence interval, CI）1.458～6.999；P＝0.004]、年龄较大（OR 1.054，95% CI 1.013～1.097；P＝0.010）、术前GCS评分较低（OR 0.539，95% CI 0.410～0.724；P〈0.001）以及术前脑疝（OR 3.633，95% CI 1.039～12.700；P＝0.043）是转归不良的独立影响因素。结论经积极手术治疗，大部分动脉瘤性蛛网膜下腔出血患者转归良好。不过，年龄较老、动脉瘤较大、术前GCS评分较低以及合并脑疝的患者通常转归不良。

ObjectiveTo investigate the outcome of microsurgical treatment and its influencing factors in patients with aneurysmal subarachnoid hemorrhage.MethodsThe consecutive patients with aneurysmal subarachnoid hemorrhage treated with the early or ultra-early microsurgery were enrolled retrospectively. The Glasgow outcome scale （GOS） was used to assess the outcomes of patients at discharge. GOS 4-5 was defined as good outcome, and GOS 1-3 was defined as poor outcome.ResultsA total of 147 patients with aneurysmal subarachnoid hemorrhage were enrolled. One hundred and twelve patients （76.2%） had good outcomes. There were significant differences in the proportions of preoperative Glasgow Coma Scale （GCS） scores （12.8±2.8 vs. 7.5±3.8; t=7.525, P〈0.001）, low Hunt-Hess grade （83.0% vs.31.4%; χ2=34.318, P〈0.001）, size of aneurysm （χ2=9.531, P=0.009）, preoperative rebleeding （6.3% vs.25.7%; χ2=8.506, P=0.003）, preoperative brain herniation （4.5% vs.40.0%; χ2=26.846, P〈0.001）, initial CT scan showing intracerebral hemorrhage （19.6% vs.48.6%; χ2=11.449, P=0.002）, and intraventricular hemorrhage （8.9% vs. 40.0%; χ2=18.846, P〈0.001） between the good outcome group and the poor outcome group. Multivariate logistic regression analysis showed that the larger aneurysm （odds ratio [OR] 3.194, 95%confidence interval [CI] 1.458-6.999; P=0.004）, older age （OR 1.054, 95% CI 1.013-1.097; P=0.010）, lower preoperative GCS score （OR 0.539, 95% CI 0.410-0.724; P〈0.001）, and preoperative brain herniation （OR 3.633, 95% CI 1.039-12.700; P=0.043） were the independent risk factors for poor outcomes.ConclusionsAfter active surgical treatment, most of the patients with aneurysmal subarachnoid hemorrhage have good outcomes, however, patients with older age, larger aneurysms, lower preoperative GCS scores, and preoperative brain herniation usually have poor outcomes.