重症动脉瘤性蛛网膜下腔出血患者预后改善的影响因素分析

Analysis of influencing factors for the neurological improvement following severe aneurysmal subarachnoid hemorrhage

目的探讨重症动脉瘤性蛛网膜下腔出血(SaSAH)患者的预后及影响预后改善的危险因素.方法回顾性分析2016年1月至2020年12月苏州大学附属第二医院神经外科重症监护病房收治的SaSAH患者的临床资料.评估出院及术后6个月时的改良Rankin量表评分(mRS),并比较其差异.采用单因素分析和多因素logistic回归分析探讨影响SaSAH患者出院后预后改善(术后6个月的mRS较出院时降低≥1分)的危险因素.纳入独立危险因素构建联合预测模型,绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC),以评估联合预测模型对SaSAH患者出院后6个月预后改善的预测价值.结果研究共纳入154例患者.术后6个月,53.2%(82/154)的SaSAH患者预后良好(mRS≤3分),51.9%(80/154)预后有改善;出院时的mRS高于术后6个月的mRS[分别为(3.75±0.97)分和(3.13±1.57)分,配对t=7.86,P<0.001].经多因素logistic回归分析发现,年龄>65岁(OR=15.74,95%CI:5.46~45.39,P<0.001)、术前为高级别动脉瘤(OR=5.96,95%CI:1.93~18.39,P=0.002)、术前存在脑疝(OR=15.26,95%CI:2.72~85.46,P=0.002)以及术后发生脑梗死(OR=2.90,95%CI:1.13~7.45,P=0.027)是影响SaSAH患者术后6个月预后改善的独立危险因素.ROC曲线分析结果显示,联合预测模型预测SaSAH患者预后改善的AUC值为0.86(95%CI:0.80~0.92,P<0.001).结论年龄>65岁、高级别动脉瘤、术前存在脑疝以及术后发生脑梗死不利于SaSAH患者术后6个月的预后改善.联合预测模型能够有效预测SaSAH患者的预后改善情况.

Objective To explore the functional recovery of patients with severe aneurysmal subarachnoid hemorrhage(SaSAH)and influencing factors for neurological improvement following SaSAH.Methods A retrospective analysis was performed on the clinical data of patients who received neurosurgical intensive care unit treatment post operation in the Department of Neurosurgery of the Second Affiliated Hospital of Soochow University from January 2016 to December 2020.Modified Rankin Scale(mRS)scores were assessed at discharge and 6 months after discharge and the results were compared.Good functional status was defined as a mRS score of 0-3.Neurological improvement was defined as a reduction in the mRS score by at least one grade.Univariate contingency statistics and multivariate logistic analysis were performed to determine the influencing factors for neurological improvement following SaSAH.Then,independent risk factors were used as variables to construct a joint prediction model.The receiver operator characteristic(ROC)curve was drawn and the area under the curve(AUC)was calculated to evaluate the predictive value of independent risk factors and joint prediction model.Results A total of 154 patients were enrolled into this study.Six months after discharge,53.2%(82/154)of patients achieved good neurological recovery.Neurological improvement was reported in 51.9%(80/154)of the patients,and there was a statistical difference between the mRS score at discharge(3.75±0.97)and at 6 months post operation(3.13±1.57)(paired t=7.86,P<0.001).Multivariate logistic analysis revealed that age>65 years(OR=15.74,95%CI:5.46-45.39,P<0.001),high-grade aneurysms(OR=5.96,95%CI:1.93-18.39,P=0.002),preoperative cerebral hernia(OR=15.26,95%CI:2.72-85.46,P=0.002)and postoperative cerebral infarction(OR=2.90,95%CI:1.13-7.45,P=0.027)were independent risk factors for neurological improvement.ROC curve showed that joint prediction model(with independent risk factors as variables)had excellent discrimination with an AUC value of 0.86(95%CI:0.80-0.92,P<0.001).Conclusions Age>65 years,high-grade aneurysm,preoperative cerebral hernia and postoperative cerebral infarction could be unfavorable factors of neurological improvement.The joint prediction model constructed with independent risk factors can be used to effectively predict the improvement of neurological function of SaSAH patients.