动脉瘤性蛛网膜下腔出血的手术时机与心肌损伤的临床研究

The Clinical Study of Surgical Timing and Myocardial Injury in Patients with Aneurysmal Subarachnoid Hemorrhage

目的探讨动脉瘤性蛛网膜下腔出血(a SAH)的不同手术时机对继发性心肌损伤(SMI)的影响。方法回顾性分析2017年4月至2019年4月住院治疗的107例a SAH患者的临床资料,所有患者均行开颅动脉瘤颈夹闭手术,按照手术时间分为早期手术组48例(发病时间≤72 h手术)和延迟手术组59例(发病时间>72 h手术)。检测两组的心肌肌钙蛋白I(cTnI)、脑利钠肽(BNP)、血浆去甲肾上腺素(NE)及肾上腺素(E)水平,使用心脏彩色多普勒超声监测左室舒张末期内径(LVEDD)和左室射血分数(LVEF),并分析SMI的发生率和预后。结果在早期手术组中,血浆cTnI、BNP、NE及E在发病3 d达到峰值,然后逐渐下降,而延迟手术组血浆cTnI、BNP、NE及E在发病5 d达到峰值。在发病3 d早期手术组的LVEDD增大,LVEF降低,然后逐渐恢复正常,而延迟手术组LVEDD在发病5 d达到峰值,LVEF达到谷值。在发病3 d、5 d、7 d,早期手术组的血浆cTnI、BNP、NE及E均低于延迟手术组,早期手术组的LVEDD均小于延迟手术组,并且LVEF均大于延迟手术组(均P<0.05)。延迟手术组的SMI发生率(38.98%)大于早期手术组(20.83%)(P<0.05)。早期手术组的GOS评分(4.19±0.79)分高于延迟手术组(3.80±0.62)分,并且预后良好率(77.08%)高于延迟手术组(57.63%)(均P<0.05)。结论 a SAH的早期手术治疗可减弱患者交感神经兴奋,降低儿茶酚胺水平,减少SMI的发生率,有助于改善患者的预后,进一步提高临床疗效。

Objective To investigate the effect of different surgical timing on secondary myocardial injury(SMI) in patients with aneurysmal subarachnoid hemorrhage(a SAH).Methods The clinical data of 107 patients with a SAH hospitalized from April 2017 to April 2019 were retrospectively analyzed.All the patients underwent craniotomy aneurysm neck clipping surgery,and were divided into early operation group(onset time ≤72 hours,n = 48) and delayed operation group(onset time > 72 hours,n =59) according to the operation time.Cardiac troponin I(cTnI),brain natriuretic peptide(BNP),plasma norepinephrine(NE) and adrenaline(E) levels were measured in both groups.Left ventricular ejection fraction(LVEF) and left ventricular end-diastolic diameter(LVEDD) were measured by cardiac color doppler ultrasonography,and the incidence of SMI and prognosis were analyzed.Results In the early operation group,plasma cTnI,BNP,NE and E peaked at 3 th day after onset,and then decreased gradually.Plasma cTnI,BNP,NE and E in the delayed operation group peaked at 5 th day after onset.LVEDD increased and LVEF decreased in the early operation group at 3 th day after onset,and then gradually returned to normal. LVEDD reached the peak and LVEF reached the valley in the delayed operation group at 5 th day after onset.At 3 days,5 days and 7 days after onset,the plasma cTnI,BNP,NE and E of the early operation group were lower than those of the delayed operation group,the LVEDD of the early operation group was lower than that of the delayed operation group,and the LVEF was higher compared with the delayed operation group(all P<0. 05).The incidence of SMI in the delayed operation group(38. 98%) was higher than that(20. 83%) in the early operation group(P<0. 05).The GOS score of the early operation group[(4. 19±0. 79) scores]were higher compared with the delayed operation group[(3. 80±0. 62) scores],and the good prognosis rate(77. 08%) was higher than that(57. 63%) of the delayed operation group(all P<0. 05).Conclusion The early surgical treatment of a SAH can reduce the sympathetic excitation of patients,reduce the level of catecholamine,and decrease the incidence of SMI,so as to improve the prognosis of patients and the clinical efficacy much further.