动脉瘤性蛛网膜下腔出血早期认知功能减退的临床研究

Cognitive decline after acute aneurysm subarachnoid hemorrhage

目的观察动脉瘤性蛛网膜下腔出血(subarachnoid hemorrhage,SAH)患者早期认知功能减退的发生率并探讨其发生的危险因素。方法回顾性分析2016年1月至2020年8月在福建省立医院就诊的195例动脉瘤性SAH并急诊行血管内介入栓塞治疗患者的临床资料,按照术后2周简易精神状态检查(Mini-Mental State Examination,MMSE)评定结果,分为认知功能减退组(n=40)与认知功能正常组(n=155),比较两组患者性别、年龄、高血压、糖尿病、吸烟、血脂、尿酸、肌酐、抽搐表现、心肌损伤、超敏C反应蛋白(high-sensitivity C-reactive protein,hs-CRP)、格拉斯哥昏迷量表(Glasgow coma scale,GCS)、Hunt-Hess分级、术前出血巴罗神经学研究所(Barrow Neurological Institute,BNI)评分、蛛网膜下腔出血早期脑水肿评分(Subarachnoid hemorrhage early brain edema scale,SEBES)、术前脑积水、术前改良Rankin评分(modified Rankin scale,mRS)、动脉瘤位置、动脉瘤大小、介入栓塞手术方式、是否脑脊液引流、合并甲状腺机能低下、脑血管痉挛、迟发性脑梗死等指标并进行比较,应用单因素、多因素Logistic 回归分析蛛网膜下腔出血出现早期认知功能下降的危险性因素。结果单因素分析显示:认知功能减退组患者年龄、尿酸、肌酐水平高于认知功能正常组,差异有统计学意义(P<0.05)。与认知功能正常组相比,认知功能减退组在合并hs-CRP升高、抽搐、肌钙蛋白升高等临床表现、脑功能损伤评分高(Hunt-Hess分级≥3级、GCS评分≥8分、术前出血BNI评分≥3分、早期脑水肿SEBES评分≥3分)、出现围手术期并发症(术前脑积水、术前mRS评分>3分、脑血管痉挛、合并迟发性脑梗死)方面可能性更高,差异有统计学意义(P<0.05)。多因素分析示高龄(OR=7.990,95%CI:1.021~1.121,P=0.005)、高尿酸(OR=4.059,95%CI:1.000~1.011,P=0.044)、早期脑水肿SEBES评分高(OR=7.072,95%CI:2.344~277.908,P=0.008)、术后超声经颅多普勒超声(transcranial Doppler,TCD)提示脑血管痉挛(OR=8.064,95%CI:2.100~57.244,P=0.005)、合并迟发性脑梗死(OR=5.118,95%CI:1.173~9.238,P=0.024)是动脉瘤性SAH行介入栓塞术后发生早期认知功能下降的独立危险因素。结论建议对aSAH合并高龄、高尿酸、脑水肿严重、继发脑血管痉挛及迟发性脑梗死的患者进行动态的神经心理学评估,早期识别认知功能减退并积极干预。

Objective To explore the risk factors of early cognitive decline after aneurysmal subarachnoid hemorrhage(aSAH)and to evaluate its correlation with clinical data.Methods This study included 195 patients with aSAH who were hospitalized in neurological ward from Jan 2016 to Aug 2020.According to the performance on Mini-Mental State Examination(MMSE)two weeks after surgery,they were divided into cognitive impairment group(n=40)and cognitive normal group(n=155).The index of gender,age,smoking,hypertension,diabetes,hyperlipidemia,uric acid,creatinine,epilepsy,myocardial injury,high-sensitivity C-reactive protein(hs-CRP),Glasgow coma scale(GCS)score,Hunt-Hess classification,Barrow Neurological Institute(BNI)scale,subarachnoid hemorrhage early brain edema scale(SEBES),preoperative hydrocephalus,preoperative modified Rankin scale(mRS),aneurysm location,aneurysm size,method of operation,lumbar puncture,hypothyroidism,cerebral vasospasm,delayed cerebral infarction were collected and Logistic regression was used to compared to find out the risk factors.Results The age,uric acid and creatinine levels of patients in the cognitive impairment group were higher than those in the normal cognitive function group,and the difference was statistically significant(P<0.05).Compared with normal cognitive function group,the cognitive impairment group had clinical manifestations such as elevated hs-CRP,convulsions,and elevated troponin,and had a higher brain damage score(Hunt-Hess grade≥3,GCS score≥8,preoperative bleeding BNI scale≥3,early brain edema SEBES≥3).The possibility of perioperative complications such as preoperative hydrocephalus,preoperative mRS score>3,and cerebral vasospasm comorbid with delayed cerebral infarction is also higher in the cognitive impairment group.The differences were statistically significant(P<0.05).Multivariate Logistic regression analysis indicated that:old age(OR=7.990,95%CI:1.021-1.121,P=0.005),high level of uric acid(OR=4.059,95%CI:1.000-1.011,P=0.044),high SEBES(OR=7.072,95%CI:2.344-277.908,P=0.008),cerebral vasospasm detected by postoperative transcranial Doppler ultrasound(OR=8.064,95%CI:2.100-57.244,P=0.005)and delayed cerebral infarction(OR=5.118,95%CI:1.173-9.238,P=0.024)were independent risk factors associated with the onset of cognitive decline.Conclusion It is necessary to follow up cognitive function after subarachnoid hemorrhage,especially for elderly patients with high level of uric acid,high SEBES,cerebral vasospasm and delayed cerebral infarction after surgery.