早期治疗高分级动脉瘤性蛛网膜下腔出血的一年预后因素多中心研究

A multicenter study on the prognostic factors of one year outcomes in patients with poor grade intracranial aneurysm after early treatment

目的探讨早期治疗高分级动脉瘤性蛛网膜下腔出血患者的1年预后，并对可能的预后影响因素进行分析。方法多中心前瞻性临床研究。2010年10月至2013年3月共纳人10家医疗中心早期治疗（72h内）的高分级动脉瘤性蛛网膜下腔出血连续病例203例，男性100例，女性103例。登记患者的临床资料，并在术后12个月进行随访，采用格拉斯哥预后评分评价神经功能预后。将性别、年龄、吸烟与否、呼吸平稳与否、脑疝与否、动脉瘤位置、世界神经外科联盟（WFNS）分级、CTFisher分级、饮酒量、动脉瘤直径、手术方式和手术时机作为可能的预后影响因素，对各变量与预后进行单因素和多因素统计分析，单因素分析采用Wilcoxon秩和检验、Kruskal—WallisH检验和Nemenyi检验，多因素分析采用等级Logistic回归检验。结果WFNS分级Ⅳ级94例，V级109例；头颅CTFisher分级1～2级31例，3～5级172例。单因素统计结果显示，脑疝与否、呼吸平稳与否、WFNS分级、CTFisher分级、动脉瘤位置和治疗方式不同预后组间比较差异有统计学意义。多因素分析结果显示，脑疝（OR=2．535，95％CI：1．204～5．339，P=0．014）、WFNS分级V级（OR=3．728，95％C1：1．972～7．043，P=0．000）、CTFisher分级3～5级（OR=5．641，95％CI：2．032～15．643，P=0．001）、前循环动脉瘤（OR=6．234，95％CI：1．996～19．472，P=0．002）是预后不良的独立影响因素。结论早期积极手术治疗动脉瘤可以改善高分级动脉瘤性蛛网膜下腔出血患者的预后，而脑疝、WFNS分级V级、CTFisher分级3～5级、前循环动脉瘤的患者预后相对较差。

Objectives To explore the one year outcome of subarachnoid hemorrhage （SAH） patients with poor grade intracranial aneurysm who underwent early treatment （within 72 hours）, and to analyze the possible predictors of the prognosis. Methods This clinical study was a prospective, multicenter, observational registry of SAH patients with poor grade intracranial aneurysm. Data pertaining to 203 SAH patients with poor grade intracranial aneurysm between October 2010 and March 2013 from 10 medical centers. There were 100 male and 103 female patients. Neurological outcomes at 12 months after the surgery were measured using the Glasgow Outcome Scale （GOS）. Genders, age, smoke, breath, herniation, aneurysm location, World Federation of Neurosurgical Societies （WFNS） grade, CT Fisher＇s grade, alcohol consumption, aneurysm diameter, surgical procedure and operation time were identified as possible prognostic factors, the association between possible prognostic factors and outcome were analyzed, using univariate and multivariate analysis. Univariate analysis included Wilcoxon rank sum test, Kruskal- Wallis H test and Nemenyi test, multivariate analysis included Logistic regression test. Results Among 203 patients, 94 patients were WFNS grade IV, and 109 patients were WFNS grade V ; 31 patients were CT Fisher＇s grade 1 to 2, 172 patients were CT Fisher＇s grade 3 to 5. Herniation （OR = 2. 535, 95% CI： 1. 204 to 5. 339, P = 0. 014）, WFNS grade V （ OR = 3. 728, 95% CI： 1. 972 to 7. 043, P = 0. 000） , CT Fisher＇s grade 3 to 5 （ OR = 5. 641, 95% CI： 2. 032 to 15. 643, P = 0. 001 ）, and anterior circulation location （OR =6. 234, 95%CI： 1. 996 to 19. 472, P =0. 002） were found to be independent prognostic factors of unfavorable prognosis. Conclusions Early surgical treatment could improve the prognosis of SAH patients with poor-grade-aneurysm. The patients with herniation, WFNS grade V, CT Fisher＇s grade 3 to 5, anterior circulation aneurysms suffered unfavorable prognosis.