颅内破裂动脉瘤被误诊的危险因素分析

Risk factors for misdiagnosis of ruptured intracranial aneurysms

目的探讨导致颅内破裂动脉瘤被误诊的危险因素。方法选择南华大学附属第二医院神经外科自2014年10月至2020年10月收治的606例颅内破裂动脉瘤患者进入研究,根据入院时是否被误诊分为误诊组(n=35)及非误诊组(n=571),比较2组患者一般临床资料并采用多因素Logistic回归分析明确导致患者被误诊的独立影响因素,根据回归模型绘制受试者工作特征(ROC)曲线评估不同因素对误诊的预测价值。比较2组患者动脉瘤再破裂情况及不同预后。结果2组患者改良Fisher分级、首诊科室、动脉瘤直径、医院级别、首诊医生接受宣教情况差异均有统计学意义(P<0.05)。多因素Logistic回归分析显示改良Fisher分级0~Ⅱ级(OR=12.284,95%CI:5.397~27.958,P=0.000)、动脉瘤直径≥10 mm(OR=2.871,95%CI:1.276~6.456,P=0.011)、首诊非神经内外科(OR=9.279,95%CI:4.019~21.420,P=0.001)、首诊医生未接受宣教(OR=2.907,95%CI:1.258~6.721,P=0.013)是颅内破裂动脉瘤被误诊的独立危险因素;其中首诊非神经内外科及改良Fisher分级0~Ⅱ级的ROC曲线下面积分别为0.747、0.754,对颅内破裂动脉瘤被误诊有一定的预测作用。误诊组、非误诊组患者动脉瘤再破裂发生率分别为37.1%、5.3%,出院时预后不良(改良Rankin量表评分>2分)率分别为42.9%、22.6%,差异有统计学意义(P<0.05)。结论首诊非神经内外科、改良Fisher分级0~Ⅱ级、直径≥10 mm及首诊医生未接受宣教的颅内破裂动脉瘤患者容更容易被误诊;加强对各级医院非神经内外科医护人员关于动脉瘤破裂的专业宣教可降低误诊率。

Objective To explore the risk factors for misdiagnosis of ruptured intracranial aneurysm.Methods A total of 606 patients with ruptured intracranial aneurysms,admitted to our hospital from October 2014 to October 2020,were enrolled in our study;these patients were divided into two groups according to whether they were initially misdiagnosed:misdiagnosis group(n=35)and non-misdiagnosis group(n=571).The general clinical data of patients from the two groups were compared;multivariate Logistic regression was used to identify the independent influencing factors for misdiagnosis.Receiver operating characteristic(ROC)curve was drawn according to the regression model to evaluate the predictive value of different factors for misdiagnosis.The re-rupture of aneurysms and different prognoses were compared between the two groups.Results There were significant differences in Fisher grading,primarily visited departments,aneurysm diameters,hospital levels,and propaganda and education situation of the first visited doctors between the 2 groups(P<0.05).Multivariate Logistic regression analysis showed that the independent factors for misdiagnosis of ruptured intracranial aneurysms were as follows:modified Fisher grading 0-II(OR=12.284,95%CI:5.397-27.958,P=0.000);aneurysm diameter≥10 mm(OR=2.871,95%CI:1.276-6.456,P=0.011),not neurology or neurosurgery as primarily visited departments(OR=9.279,95%CI:4.019-21.420,P=0.001),and first visited doctor not receiving propaganda and education(OR=2.907,95%CI:1.258-6.721,P=0.013);area under the ROC curve of not neurology or neurosurgery as primarily visited departments and modified Fisher grading 0-II were 0.747 and 0.754,which had good predictive value in the misdiagnosis of ruptured intracranial aneurysm.Re-ruptured aneurysms occurred in 37.1%patients from the misdiagnosis group and 5.3%patients from the non-misdiagnosis group,with significant difference(P<0.05);and the proportion of patients with poor prognosis at discharge(modified Rankin scale scores>2)was 42.9%in the misdiagnosis group and 22.6%in the non-misdiagnosis group,with significant difference(P<0.05).Conclusion Patients with modified Fisher grading 0-II,without neurology or neurosurgery as primarily visited departments and with aneurysm≥10 mm,and patients whose first visited doctor not receiving professional education of spontaneous subarachnoid hemorrhage have high risks of misdiagnosis of ruptured intracranial aneurysm;strengthening the professional education of spontaneous subarachnoid hemorrhage for doctors from non-neurology or neurosurgery departments of hospital at different levels may reduce the misdiagnosis rate.