微创术联合rt-PA或尿激酶治疗自发性幕上脑出血的疗效

Alteplase vs.urokinase treatment after minimally invasive surgery for spontaneous intracerebral hemorrhage:a single-center experience

目的评估接受微创手术联合重组组织型纤溶酶原激活剂(rt-PA)或尿激酶治疗自发性幕上脑出血的疗效。方法回顾性分析华中科技大学同济医学院附属同济医院神经内科电子病例数据库中2011年10月至2013年11月接受微创手术联合rt-PA(rt-PA组)或尿激酶(尿激酶组)治疗的自发性幕上脑出血患者。评估其临床资料、影像学资料、住院期间并发症和发病3个月的预后。采用t检验比较2组治疗结束后残余血肿体积、占位效应和血肿清除率的差异,采用χ^(2)检验比较住院期间并发症、病死率及90 d预后的差异。结果共纳入患者136例,其中rt-PA组80例,尿激酶组56例。2组患者的基线特征比较,差异均无统计学意义(P均>0.05),再出血风险为6.6%(9/136)。与尿激酶组相比,微创手术治疗结束时rt-PA组患者血肿清除率更高(83.7%±20.0%vs 69.5%±26%,t=3.597,P=0.001)、残余血肿体积更小[(9.2±7.4)ml vs(13.8±8.3)ml;t=3.393,P=0.001]、占位效应缓解更明显[(5.3±3.6)mm vs(3.2±3.1)mm;t=3.541,P=0.001];rt-PA组3个月病死率明显低于尿激酶组(2.5%vs 12.5%,χ^(2)=5.291,P=0.032),且有改善3个月预后的趋势(32.5%vs 21.4%,χ^(2)=2.001,P=0.157)。2组患者住院期间并发症发生情况比较,差异均无统计学意义(P均>0.05)。结论微创手术联合rt-PA或尿激酶能够安全有效的清除颅内血肿。与尿激酶相比,rt-PA清除血肿的效果可能更好,并有助于降低患者病死率。

Objective To investigate the efficacy and safety of recombinant tissue-type plasminogen activator(rt-PA,Alteplase)and urokinase after minimally invasive surgery(MIS)for spontaneous supratentorial intracerebral hemorrhage(ICH).Methods Patients with spontaneous supratentorial ICH≥20 ml,who were treated with MIS plus rt-PA(rt-PA group)or urokinase(urokinase group)in Department of Neurology,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,were retrospectively included from our prospective database between October 2011 and November 2013.The clinical features,imaging data,as well as adverse events and functional outcome at 3 months were analyzed.The residual hematoma volume,mass effect and clot removal rate at the end of treatment in the two groups were analyzed by Student's t test.The outcome at 3 months,complications and mortality during hospitalization were assessed by the χ^(2) test.Results Atotal of 136 patients were included,that was 80 in rt-PA group and 56 in urokinase group.The baseline characteristics between the two groups were similar.Compared with the urokinase group,patients in the rt-PA group had a higher hematoma clearance rate(83.7%±20.0%vs 69.5%±26.0%,t=3.597,P=0.001),smaller residual hematoma volume[(9.2±7.4)ml vs(13.8±8.3)ml,t=3.393,P=0.001],and more reduced mass at the end ofMIS treatment[(5.3±3.6)mm vs(3.2±3.1)mm,t=3.541,P=0.001].The mortality at 3 months in the rt-PA group was significantly lower than that in urokinase group(2.5%vs 12.5%,χ^(2)=5.291,P=0.032),and there was a tendency of the improvement of 3-month functional outcome(32.5%vs 21.4%,χ^(2)=2.001,P=0.157).There was no difference between the two groups in infectious complications and adverse events.The recurrence of bleeding after MIS was 6.6%(9/136).Conclusion MIS combined with rt-PA or urokinase can safely remove the hematoma in patients with supratentorial ICH.Intra-clot rt-PAtreatment after MIS has a likely slight superiority over urokinase for hematoma removal,whichmay further help to reduce themortality.