自发性蛛网膜下腔出血患者术后血尿酸水平与短期预后的关系

Relationship between postoperative blood uric acid level and short-term prognosis of patients with spontaneous subarachnoid hemorrhage

目的观察自发性蛛网膜下腔出血(SAH)患者术后血尿酸水平变化及与短期预后的关系。方法2021年2月—2023年4月周口市中心医院诊治自发性SAH患者100例,均于入院5 d内行手术治疗,术后第1、3、5、7、14天检测血尿酸水平,根据术后3个月格拉斯哥预后评分(GOS)分为预后不良组(GOS评分≤3分)28例和预后良好组(GOS评分>3分)72例,比较预后不良组与预后良好组合并症、Hunt-Hess分级、Fisher分级、术后14 d内并发症、术后血尿酸水平等临床资料;采用多因素logistic回归分析自发性SAH患者术后3个月预后不良的影响因素;绘制ROC曲线,评估术后血尿酸预测自发性SAH患者术后3个月预后不良的效能。结果预后不良组合并脑室出血(32.14%)、合并颅内出血(25.00%)、Hunt-Hess分级Ⅳ~Ⅴ级(42.86%)、Fisher分级Ⅲ~Ⅳ级(64.29%)及术后迟发性脑缺血(25.00%)、院内再出血(35.71%)比率均高于预后良好组(4.17%、4.17%、8.33%、13.89%、6.94%、12.50%)(χ^(2)=14.942、9.722、16.280、25.398、6.224、7.059,P均<0.05)。预后不良组术后第1、3、5、7、14天血尿酸水平[(485.89±120.43)、(569.43±145.83)、(479.83±115.69)、(402.94±106.41)、(342.85±92.83)μmol/L]均高于预后良好组[(425.84±109.14)、(372.09±98.26)、(328.69±94.31)、(281.37±86.22)、(240.59±81.32)μmol/L](t=2.400、7.815、6.742、6.919、5.424,P均<0.05)。合并脑室出血(OR=3.483,95%CI:1.231~9.852,P<0.001)、合并颅内出血(OR=3.497,95%CI:1.075~11.374,P<0.001)、Hunt-Hess分级(OR=4.997,95%CI:1.362~18.337,P<0.001)、Fisher分级(OR=4.433,95%CI:1.275~15.413,P<0.001)、术后迟发性脑缺血(OR=10.080,95%CI:3.251~31.255,P<0.001)、术后院内再出血(OR=8.654,95%CI:2.111~35.478,P<0.001)、术后第1天血尿酸(OR=1.506,95%CI:1.013~2.056,P<0.001)、术后第3天血尿酸(OR=1.489,95%CI:1.020~2.174,P<0.001)、术后第5天血尿酸(OR=1.501,95%CI:1.022~2.204,P<0.001)、术后第7天血尿酸(OR=1.509,95%CI:1.024~2.225,P<0.001)、术后第14天血尿酸(OR=1.553,95%CI:1.031~2.338,P<0.001)是自发性SAH患者术后3个月预后不良的影响因素。术后第1、3、5、7、14天血尿酸分别以478.47、549.01、459.41、380.58、273.02μmol/L为最佳截断值,预测自发性SAH患者术后3个月预后不良的AUC分别为0.748(95%CI:0.651~0.830,P<0.001)、0.758(95%CI:0.662~0.838,P<0.001)、0.781(95%CI:0.687~0.858,P<0.001)、0.802(95%CI:0.710~0.875,P<0.001)、0.831(95%CI:0.743~0.899,P<0.001),灵敏度分别为71.43%、75.00%、67.86%、75.00%、89.29%,特异度分别为79.17%、75.00%、80.56%、83.33%、75.28%;术后第14天血尿酸预测自发性SAH患者术后3个月预后不良的AUC均大于术后第1、3、5、7天血尿酸(Z=4.535,P<0.001;Z=4.656,P<0.001;Z=5.240,P<0.001;Z=5.504,P<0.001)。结论合并脑室出血和颅内出血、术后发生迟发性脑缺血和院内再出血、Hunt-Hess分级和Fisher分级高及术后血尿酸水平升高的自发性SAH患者术后短期预后不良的风险增大;术后第14天血尿酸预测自发性SAH患者术后短期预后不良有较高价值。

Objective To observe the changes in blood uric acid level after operation in patients with spontaneous subarachnoid hemorrhage(SAH)and its relationship with the short-term prognosis.Methods Totally 100 patients with spontaneous SAH were diagnosed and treated in Zhoukou Central Hospital from February 2021 to April 2023.All patients underwent operation within 5 days after admission.The blood uric acid level was detected on postoperative day 1,3,5,7 and 14.According to the Glasgow Outcome Scale(GOS)score 3 months after operation,100 patients were divided into 28 patients with GOS score≤3(poor prognosis group)and 72 patients with GOS>3(good prognosis group).The clinical data including comorbidities,Hunt-Hess grade,Fisher grade,complications within 14 days after operation,and postoperative blood uric acid level were compared between two groups.Multivariate logistic regression analysis was done to evaluate the influencing factors of poor prognosis 3 months after operation in spontaneous SAH patients.The ROC curve was plotted to evaluate the efficiency of postoperative blood uric acid on predicting poor prognosis 3 months after operation in spontaneous SAH patients.Results The proportions of intraventricular hemorrhage,intracranial hemorrhage,Hunt-Hess gradeⅣ-Ⅴ,Fisher gradeⅢ-Ⅳ,postoperative delayed cerebral ischemia,and in-hospital rebleeding were higher in poor prognosis group(32.14%,25.00%,42.86%,64.29%,25.00%,35.71%)than those in good prognosis group(4.17%,4.17%,8.33%,13.89%,6.94%,12.50%)(χ^(2)=14.942,9.722,16.280,25.398,6.224,7.059;all P values<0.05).The blood uric acid levels were higher in poor prognosis group on postoperative day 1,3,5,7 and 14[(485.89±120.43),(569.43±145.83),(479.83±115.69),(402.94±106.41),(342.85±92.83)μmol/L]than those in good prognosis group[(425.84±109.14),(372.09±98.26),(328.69±94.31),(281.37±86.22),(240.59±81.32)μmol/L](t=2.400,7.815,6.742,6.919,5.424;all P values<0.05).Intraventricular hemorrhage(OR=3.483,95%CI:1.231-9.852,P<0.001),intracranial hemorrhage(OR=3.497,95%CI:1.075-11.374,P<0.001),Hunt-Hess grade(OR=4.997,95%CI:1.362-18.337,P<0.001),Fisher grade(OR=4.433,95%CI:1.275-15.413,P<0.001),postoperative delayed cerebral ischemia(OR=10.080,95%CI:3.251-31.255,P<0.001),in-hospital rebleeding(OR=8.654,95%CI:2.111-35.478,P<0.001),blood uric acid level on postoperative day 1(OR=1.506,95%CI:1.013-2.056,P<0.001),blood uric acid level on postoperative day 3(OR=1.489,95%CI:1.020-2.174,P<0.001),blood uric acid level on postoperative day 5(OR=1.501,95%CI:1.022-2.204,P<0.001),blood uric acid level on postoperative day 7(OR=1.509,95%CI:1.024-2.225,P<0.001),and blood uric acid level on postoperative day 14(OR=1.553,95%CI:1.031-2.338,P<0.001)were the influencing factors of poor prognosis 3 months after operation in spontaneous SAH patients.When the optimal cut-off values of blood uric acid levels on postoperative day 1,3,5,7 and 14 were 478.47,549.01,459.41,380.58 and 273.02μmol/L,the AUCs for predicting poor prognosis 3 months after operation were 0.748(95%CI:0.651-0.830,P<0.001),0.758(95%CI:0.662-0.838,P<0.001),0.781(95%CI:0.687-0.858,P<0.001),0.802(95%CI:0.710-0.875,P<0.001),and 0.831(95%CI:0.743-0.899,P<0.001),with the sensitivities of 71.43%,75.00%,67.86%,75.00%and 89.29%,and the specificities of 79.17%,75.00%,80.56%,83.33%and 75.28%,respectively.The AUC of blood uric acid on postoperative day 14 was higher than that of blood uric acid on postoperative day 1,3,5 and 7 for predicting poor prognosis 3 months after operation(Z=4.535,P<0.001;Z=4.656,P<0.001;Z=5.240,P<0.001;Z=5.504,P<0.001).Conclusions The spontaneous SAH patients have an increased risk of poor short-term prognosis after operation when they are complicated with intraventricular hemorrhage,intracranial hemorrhage,postoperative delayed cerebral ischemia,postoperative in-hospital rebleeding,high Hunt-Hess and Fisher grades,and elevated postoperative blood uric acid level.The blood uric acid level on postoperative day 14 has a high value to the prediction of poor short-term prognosis.