低级别动脉瘤性蛛网膜下腔出血预后不良的影响因素分析

Influencing factors for unfavorable outcome of low-grade aneurysmal subarachnoid hemorrhage

目的探讨低级别动脉瘤性蛛网膜下腔出血(aSAH)预后不良的影响因素。方法回顾性收集南华大学附属第二医院神经外科自2017年4月至2021年3月收治的273例世界神经外科联盟(WNFS)分级Ⅰ、Ⅱ级aSAH患者的临床资料, 根据患者术后3个月的改良Rankin量表(mRS)评分将其分为预后良好组(mRS评分0~2分)与预后不良组(mRS评分3~6分), 采用统计学方法分析2组患者间临床及影像学资料的差异以及明确患者预后不良的独立影响因素, 并绘制受试者工作特征(ROC)曲线评估不同独立影响因素对患者预后不良的预测价值。结果 273例低级别aSAH患者中预后不良组45例, 预后良好组228例。单因素分析显示2组患者在年龄、Fisher分级分布、并发分流依赖性脑积水比例、并发迟发性脑缺血比例、并发颅内出血比例、WNFS分级等方面差异均有统计学意义(P<0.05)。多因素Logistic回归分析显示并发分流依赖性脑积水(OR=5.075, 95%CI:1.705~15.102, P=0.004)、年龄(OR=1.090, 95%CI:1.036~1.147, P=0.004)、并发迟发性脑缺血(OR=8.282, 95%CI:3.447~19.896, P=0.000)、并发颅内出血(OR=8.603, 95%CI:2.332~31.745, P=0.001)是患者预后不良的独立影响因素。ROC曲线分析显示年龄的最佳临界值是65岁, 并发迟发性脑缺血、年龄预测患者预后不良的曲线下面积分别为0.733(95%CI:0.653~0.813, P=0.000)、0.709(95%CI:0.622~0.796, P=0.000)。结论年龄大于65岁及伴有术后分流依赖性脑积水、迟发性脑缺血、颅内出血的低级别aSAH患者预后不良的可能性更高, 年龄及并发迟发性脑缺血对其有一定的诊断价值。

Objective To investigate the influencing factors for unfavorable outcome of low-grade aneurysmal subarachnoid hemorrhage(aSAH).Methods A retrospective study was performed.The clinical data of 273 patients with aSAH of World Federation of Neurosurgery(WNFS)grading I and II,admitted to our hospital from April 2017 to March 2021,were collected.According to modified Rankin scale(mRS)scores 3 months after treatment,these patients were divided into favorable outcome group(mRS scores of 0-2)and unfavorable outcome group(mRS scores of 3-6).Statistical methods were used to analyze the clinical and imaging data differences between the two groups and identify the independent influencing factors for unfavorable outcome.Receiver operating characteristic(ROC)curves were drawn to evaluate the predictive values of different independent factors in unfavorable outcome.Results Among the 273 patients with low-grade aSAH,45 patients had unfavorable outcome and 228 patients had favorable outcome.Univariate analysis showed that there was significant difference between the 2 groups in age,Fisher grading distribution,proportions of patients complicated with shunt dependent hydrocephalus,with delayed cerebral ischemia,or with intracranial hemorrhage,and WNFS grading(P<0.05).Multivariate Logistic regression analysis showed that concurrent shunt dependent hydrocephalus(OR=5.075,95%CI:1.705-15.102,P=0.004),age(OR=1.090,95%CI:1.036-1.147,P=0.004),delayed cerebral ischemia(OR=8.282,95%CI:3.447-19.896,P=0.000),and postoperative intracranial hemorrhage(OR=8.603,2.332-31.745,0.001)were independent influencing factors for unfavorable outcome.ROC curve analysis showed that the optimal diagnostic threshold of age was 65 years,and the areas under ROC curve for delayed cerebral ischemia and age in predicting unfavorable outcome were 0.733(95%CI:0.653-0.813,P=0.000)and 0.709(95%CI:0.622-0.796,P=0.000).Conclusion Low-grade aSAH patients with age≥65,postoperative shunt dependent hydrocephalus,delayed cerebral ischemia,and intracranial hemorrhage are more likely to have unfavorable outcome;age and complicated delayed cerebral ischemia have certain diagnostic value in low-grade aSAH patients.