动脉瘤性蛛网膜下腔出血患者脑脊液D-二聚体水平与迟发性脑缺血的关系

Relationship between cerebrospinal fluid D-dimer level and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)患者脑脊液D-二聚体水平与迟发性脑缺血(DCI)的关系。方法以2018年5月至2020年12月经南阳市第一人民医院收治的68例aSAH患者为研究对象进行前瞻性研究,所有患者均接受动脉瘤夹闭术或血管内动脉瘤栓塞术,分别于术后即刻、术后24 h、术后48 h、术后72 h取静脉血和脑脊液进行D-二聚体(D-D)水平检测,根据住院期间是否发生DCI分为DCI组和NDCI组,对比两组患者各时间点血液D-D和脑脊液D-D水平变化特点,采用二元Logistic逐步回归分析影响DCI发生的因素,并建立DCI预测模型,通过绘制受试者操作特征(ROC)曲线图观察其临床预测价值。结果单因素分析显示,DCI组术后各时间点血液D-D、脑脊液D-D水平均高于NDCI组。以DCI发生为阳性时间进行Logistic回归分析显示:①术后即刻-24 h、术后即刻-72 h血液D-D水平平均差是影响术后DCI发生的独立危险因素(P<0.05)。ROC曲线分析显示,该预测模型对预测DCI发生有效(AUC=0.913,95%CI:0.847~0.979,P<0.001),敏感性和特异性分别为100.00%、69.50%。②术后48 h脑脊液D-D水平是影响DCI发生的危险因素(P<0.05)。ROC曲线分析显示,该预测模型对预测DCI发生有效(AUC=0.990,95%CI:0.974~1.000,P<0.001),敏感性和特异性分别为100.00%、91.50%。以96 h内DCI发生为阳性事件进行Logistic回归分析显示,各时间点血液D-D水平改变均不是该事件发生的影响因素(P>0.05);仅术后即刻-72 h脑脊液D-D平均水平差是影响术后96 h DCI发生的独立危险因素(P<0.001)。ROC曲线分析显示,该预测模型预测术后96 h DCI发生有效(AUC=0.901,95%CI:0.804~0.998,P<0.001),敏感性和特异性最高,分别为78.60%、88.90%。结论脑脊液D-D和血液D-D水平变化均可有效预测SAH患者术后DCI的发生,然而通过监测术后脑脊液D-D水平改变有助于预测患者术后96 h内DCI的发生,相比血液D-D监测临床价值更高。

【Objective】To investigate the relationship between cerebrospinal fluid D-dimer(D-D)level and delayed cerebral ischemia(DCI)in patients with aneurysmal subarachnoid hemorrhage(aSAH).【Methods】A prospective study was conducted on 68 patients with aSAH treated in our hospital from May 2018 to December 2020.All patients underwent aneurysm clipping or endovascular aneurysm embolization.Venous blood and cerebrospinal fluid levels were detected immediately after operation,24 hours,48 hours and 72 hours after operation,respectively.According to the occurrence of DCI during hospitalization,they were divided into DCI group and NDCI group.Comparing the changes of blood and cerebrospinal fluid levels of DCI in the two groups at different time points,binary Logistic stepwise regression was used to analyze the factors affecting the occurrence of DCI,and a DCI prediction model was established.The clinical predictive value was observed by drawing ROC curve.【Results】The univariate analysis showed that the levels of D-D in blood and cerebrospinal fluid in DCI group were higher than those in NDCI group at each time point after operation.Logistic regression analysis showed that:(1)the average difference of blood DCI D-D level from immediate to 24 h and from immediate to 72 h after operation was an independent risk factor affecting the occurrence of postoperative DCI(P<0.05).ROC curve analysis showed that the prediction model was effective in predicting the occurrence of DCI(AUC=0.913,95%CI:0.847-0.979,P<0.001),and the sensitivity and specificity were 100.00%and 69.50%,respectively.(2)48 hours after operation,the level of D-D in cerebrospinal fluid was a risk factor for the occurrence of DCI(P<0.05).ROC curve analysis showed that the predictive model was effective in predicting the occurrence of DCI(AUC=0.990,95%CI:0.974-1.000,P<0.001),and the sensitivity and specificity were 100.00%and 91.50%,respectively.Logistic regression analysis with the occurrence of DCI within 96 hours as a positive event showed that the change of blood D-D level at each time point was not a factor affecting the occurrence of this event,but only the average difference of D-D level in cerebrospinal fluid from immediately to 72 h after operation was an independent risk factor affecting the occurrence of postoperative 96 hDCI(P<0.001).ROC curve analysis showed t hat the prediction model was effective in predicting the occurrence of postoperative 96 hDCI(AUC=0.901,95%CI:0.804-0.998,P<0.001),with the highest sensitivity and specificity,which were 78.60%and 88.90%,respectively.【Conclusion】The changes of D-D levels in cerebrospinal fluid and blood can effectively predict the occurrence of DCI in patients with SAH after operation.however,monitoring the changes of D-D levels in cerebrospinal fluid is helpful to predict the occurrence of DCI within 96 hours after operation,which is of higher clinical value than that of blood D-D monitoring.