慢性硬膜下血肿钻孔引流术后复发的危险因素分析

Analysis of risk factors for recurrence of chronic subdural hematoma after drilling drainage

目的探讨慢性硬膜下血肿(CSDH)患者钻孔引流术后血肿复发的危险因素及其预测作用。方法回顾性分析2018年1月至2022年5月石河子大学第一附属医院神经外科收治的129例行钻孔引流术的CSDH患者的临床资料。随访3个月, 根据血肿是否复发将患者分为复发组与未复发组。比较两组患者的一般资料、与凝血功能相关的药物史和术前实验室检查指标、术前临床症状、手术前后血肿的影像学相关资料的差异, 对差异有统计学意义的指标(P<0.05)行多因素logistic回归分析。绘制受试者工作特征曲线(ROC)并计算曲线下面积(AUC), 评价相关危险因素对CSDH钻孔引流术后复发的预测作用。结果 129例患者中, 术后7~90 d共有24例(18.6%)血肿复发。单因素分析显示, 与未复发组(104例)比较, 复发组(24例)中女性、有吸烟史、发病时头晕、双侧血肿、血肿腔内有分隔患者的占比高, 有外伤史的占比低, 术前检查部分凝血酶原时间缩短、凝血酶时间延长、纤维蛋白降解产物含量高, 术后血肿引流量少、颅内积气量多, 上述指标差异均有统计学意义(均P<0.05)。多因素logistic回归分析显示, 性别(OR=24.19, 95%CI:1.98~295.01)、外伤史(OR=0.08, 95%CI:0.01~0.65)、吸烟史(OR=70.19, 95%CI:6.00~820.78), 术前纤维蛋白降解产物(OR=1.10, 95%CI:1.03~1.17)、部分凝血酶原时间(OR=0.43, 95%CI:0.22~0.86)、凝血酶时间(OR=5.13, 95%CI:2.05~12.85), 以及术后颅内积气量(OR=1.04, 95%CI:1.01~1.07)是CSDH钻孔引流术后复发的重要影响因素(均P<0.05)。由上述指标绘制的ROC的AUC为0.96(95%CI: 0.93~0.99), 最佳临界值为0.11, 预测CSDH钻孔引流术后复发的灵敏度为91.71%, 特异度为88.60%。结论性别、外伤史、吸烟史、术前纤维蛋白降解产物、术前部分凝血酶原时间、术前凝血酶时间及术后颅内积气量是CSDH钻孔术后复发的预测因素, 预测价值较高。

Objective To explore the risk factors and their predictive roles in postoperative recurrence of chronic subdural hemorrhage(CSDH).Methods A retrospective study was conducted on the clinical data of 129 patients with CSDH who underwent routine drilling drainage surgery at the Department of Neurosurgery,First Affiliated Hospital of Shihezi University from January 2018 to May 2022.During the follow-up period of 3 months,patients were divided into recurrent and non-recurrent groups based on the recurrence of hematoma.Comparison of general patient data,medication history and preoperative laboratory examination indicators related to the function of blood clotting,pre-operative clinical symptoms,imaging data related to pre-surgical hematoma,multivariate logistic regression analysis was performed for indicators with statistically significant differences.Receiver operating characteristic curves(ROC)was drawn to evaluate the predictive effect of associated risk factors on recurrence after drilling drainage for CSDH.Results Among 129 patients,a total of 24(18.6%)hematomas recurred at 7-90 d after surgery.Univariate analysis showed that compared with the non-recurrence group(104 cases),the recurrence group(24 cases)had higher proportions of female and patients with history of smoking,dizziness at the onset,bilateral hematomas and segregation in the hematoma lumen and lower proportions of patients with history of trauma.In addition,recurrence group had shortened preoperative examination of some prothrombinogen time,prolonged prothrombin time,and high content of fibrin degradation products,little postoperative drainage of the hematoma,and high intracranial volume of pneumoperitoneum with significant differences in the above indexes(all P<0.05).Multivariate logistic regression analysis showed that gender(OR=24.19,95%CI:1.98-295.01),history of trauma(OR=0.08,95%CI:0.01-0.65),history of smoking(OR=70.19,95%CI:6.00-820.78),preoperative fibrin degradation products(OR=1.10,95%CI:1.03-1.17),partial thromboplastin time(OR=0.43,95%CI:0.22-0.86),prothrombin time(OR=5.13,95%CI:2.05-12.85),and postoperative intracranial air volume(OR=1.04,95%CI:1.01-1.07)were independent influencing factor for recurrence after CSDH drilling and drainage surgery(all P<0.05).The area under the curve of the ROC curve plotted from the above metrics was 0.96(95%CI:0.93-0.99)with an optimal cutoff value of 0.11.The sensitivity for predicting recurrence after CSDH drilling and drainage was 91.71%with the specificity of 88.60%.Conclusion Sex,history of trauma,history of smoking,fibrin degradation products,partial thromboplastin time,prothrombin time and postoperative intracranial air volume are predictors of recurrence after CSDH drilling with high predictive value.