动脉血乳酸水平在动脉瘤性蛛网膜下腔出血中的临床意义

Clinical significance of arterial lactic acid level in patients with aneurysmal subarachnoid hemorrhage

目的探讨动脉血乳酸水平在动脉瘤性蛛网膜下腔出血(aSAH)中的临床意义。方法回顾性分析2018年1—10月首都医科大学宣武医院神经外科收治的166例aSAH患者的临床资料。其中责任动脉瘤位于前循环136例,位于后循环30例;经开颅手术夹闭治疗57例,血管内治疗99例,血管内治疗+手术夹闭治疗2例,仅内科保守治疗8例。根据入重症监护室72 h内最高血乳酸水平分为乳酸正常组(血乳酸≤2.2 mmol/L)和乳酸增高组(血乳酸>2.2 mmol/L)。采用格拉斯哥预后评分(GOS)评估患者的预后,1~3分为预后不良,4~5分为预后良好。比较两组入院Hunt-Hess分级、责任动脉瘤部位、并发症的发生及预后等的差异。采用单因素和多因素logistic回归分析法评估影响aSAH患者预后的危险因素。结果166例患者中,54例(32.5%)出现乳酸增高。乳酸正常组(112例)与乳酸增高组在基础疾病、责任动脉瘤部位及治疗方式方面的差异均无统计学意义(均P>0.05)。两组入院Hunt-Hess分级的差异有统计学意义(P<0.001);乳酸增高组脑血管痉挛、迟发性脑缺血(DCI)、低白蛋白血症及贫血的发生率均高于乳酸正常组,差异均有统计学意义(均P<0.05);乳酸增高组出院及随访时预后不良患者的比例均高于乳酸正常组,差异均有统计学意义(均P<0.001)。单因素分析结果显示,入院Hunt-Hess分级、脑血管痉挛、DCI、低白蛋白血症、贫血、动脉血乳酸水平是影响aSAH患者预后的临床因素(均P<0.05)。多因素logistic回归分析结果显示,入院Hunt-Hess分级≥Ⅲ级(OR=4.424,95%CI:1.029~19.025,P=0.046)、脑血管痉挛(OR=4.140,95%CI:1.197~14.326,P=0.025)、低白蛋白血症(OR=5.385,95%CI:1.142~25.396,P=0.033)、贫血(OR=8.341,95%CI:1.579~44.051,P=0.012)及动脉血乳酸水平升高(OR=7.997,95%CI:2.313~27.651,P=0.001)是影响aSAH患者预后的独立危险因素。结论aSAH患者急性期动脉血乳酸水平可能与入院Hunt-Hess分级、脑血管痉挛、DCI等并发症的发生有关;动脉血乳酸水平升高是影响aSAH患者预后的危险因素,或可作为aSAH严重程度及预后的一个生物学标志物。

Objective To investigate the role of arterial lactic acid level in patients with aneurysmal subarachnoid hemorrhage(aSAH).Methods A retrospective study was conducted on the clinical data of 166 patients with aSAH admitted to Neurosurgery Department of Xuanwu Hospital,Capital Medical University from January 2018 to October 2018.Among them,the aneurysm responsible for aSAH were located in the anterior circulation in 136 cases,and in the posterior circulation in 30 cases.Craniotomy and surgical clipping were performed in 57 cases,intravascular intervention treatment in 99 cases,intravascular intervention therapy plus surgical clipping in 2 cases,and conservative treatment of medication in only 8 cases.According to the highest blood lactic acid level within 72 h post admission to intensive care unit,the normal lactic acid group(blood lactic acid≤2.2 mmol/L)and elevated lactic acid group(blood lactic acid>2.2 mmol/L)were divided.The Glasgow Outcome Scale(GOS)was used to assess the patient′s outcome:1-3 as poor and 4-5 as good.Between the 2 groups,the differences in the Hunt-Hess grade at admission,location of aneurysm responsible for aSAH,occurrence of complications and outcome were compared.The risk factors affecting the prognosis of aSAH patients were evaluated by using univariate and multivariate logistic regression analysis.Results Of the 166 patients,54(32.5%)showed elevated level of lactic acid,and the differences in underlying diseases,location of aneurysm responsible for aSAH and treatment methods were not statistically significant(all P>0.05).The difference between elevated lactic acid group and normal lactic acid group in the Hunt-Hess grade at admission was significant(P<0.001).The incidences of cerebrovascular spasms,delayed cerebral ischemia(DCI),hypoalbuminemia and anemia in the elevated lactic acid group were higher than those in the normal lactic acid group,and the differences were statistically significant(all P<0.05).The results of univariate analysis showed that the Hunt-Hess grade at admission,cerebrovascular spasms,DCI,hypoalbuminemia,anemia,the level of arterial blood lactic acid were the clinical factors that affected the prognosis of aSAH patients(all P<0.05).Multivariate logistic regression analysis results showed that the Hunt-Hess grade at admission(OR=4.424,95%CI:1.029-19.025,P=0.046),cerebrovascular spasms(OR=4.140,95%CI:1.197-14.326,P=0.025),hypoalbuminemia(OR=5.385,95%CI:1.142-25.396,P=0.033),anemia(OR=8.341,95%CI:1.579-44.051,P=0.012)and arterial blood lactic acid level(OR=7.997,95%CI:2.313-27.651,P=0.001)were the independent influencing factors for the prognosis of aSAH patients.Conclusion The arterial lactic acid level post aSAH may be related to the Hunt-Hess grade at admission,complications such as cerebral vasospasm and DCI,and might be a risk factor that affects the prognosis of patients with aSAH,might be able to serve as a biomarker of aSAH severity and prognosis.