中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
2期
133-137
,共5页
刘洋%孙圣凯%陈旭义%程世翔%秦至臻%刘秀%陈孝储%宁莉莉%王志宏
劉洋%孫聖凱%陳旭義%程世翔%秦至臻%劉秀%陳孝儲%寧莉莉%王誌宏
류양%손골개%진욱의%정세상%진지진%류수%진효저%저리리%왕지굉
蛛网膜下腔出血%动脉瘤%脑积水%Hunt-Hess分级
蛛網膜下腔齣血%動脈瘤%腦積水%Hunt-Hess分級
주망막하강출혈%동맥류%뇌적수%Hunt-Hess분급
Subarachnoid hemorrhage%Aneurysm%Hydrocephalus%Hunt-Hess grade
目的：分析比较Hunt-Hess Ⅲ～Ⅳ级动脉瘤性蛛网膜下腔出血（aSAH）患者血管介入栓塞与开颅夹闭手术后并发急性脑积水的差异及预后。方法回顾性分析武警后勤学院附属医院和武警总医院2011年1月至2014年7月接受血管介入栓塞（介入栓塞组，403例）或开颅夹闭手术（开颅夹闭组，364例）的Hunt-Hess Ⅲ～Ⅳ级aSAH患者的临床资料，筛选出术后出现急性脑积水的病例，运用统计学方法对可能造成两组术后脑积水形成差异的因素进行量化与赋值，通过出院时格拉斯哥预后评分（GOS）判断脑积水患者短期预后情况，比较两种手术的优缺点。结果介入栓塞组403例患者中术后出现脑积水56例（13.90%），开颅夹闭组364例患者中术后出现脑积水33例（9.07%），两组脑积水发生率差异有统计学意义（χ2＝4.350， P＝0.037）。767例aSAH患者中，行血肿清除者脑积水发生率显著低于未行血肿清除者〔3.07%（11/358）比19.07%（78/409），χ2＝47.635，P＝0.000〕；行脑室引流者脑积水发生率显著低于未行脑室引流者〔2.77%（19/685）比85.37%（70/82），χ2＝487.032，P＝0.000〕。在介入栓塞组403例患者中，行血肿清除者脑积水发生率略低于未行血肿清除者〔8.06%（5/62）比14.96%（51/341），χ2＝2.082，P＝0.168〕；行脑室引流者脑积水发生率显著低于未行脑室引流者〔2.59%（9/347）比83.93%（47/56），χ2＝266.599，P＝0.000〕。在开颅夹闭组364例患者中，行血肿清除者脑积水发生率显著低于未行血肿清除者〔2.03%（6/296）比39.71%（27/68），χ2＝95.226，P＝0.000〕；行脑室引流者脑积水发生率显著低于未行脑室引流者〔2.96%（10/338）比88.46%（23/26），χ2＝203.852，P＝0.000〕。介入栓塞组与开颅夹闭组之间行血肿清除者脑积水发生率差异有统计学意义〔8.06%（5/62）比2.03%（6/296），χ2＝4.411，P＝0.027〕；而行脑室引流者脑积水发生率差异无统计学意义〔2.59%（9/347）比2.96%（10/338），χ2＝0.085，P＝0.819〕。56例行介入栓塞术后出现脑积水的患者，出院时预后良好（GOS评分4～5分）23例（41.07%），预后不良（GOS评分1～3分）33例（58.93%）；33例行开颅夹闭手术后出现脑积水的患者，出院时预后良好（GOS评分4～5分）21例（63.64%），预后不良（GOS评分1～3分）12例（36.36%），两组预后差异有统计学意义（χ2＝4.230，P＝0.039）。结论血肿清除是造成Hunt-HessⅢ～Ⅳ级患者血管介入栓塞和开颅夹闭手术后脑积水差异形成的主要因素之一；侧脑室引流可能不是造成Hunt-HessⅢ～Ⅳ级患者血管介入栓塞和开颅夹闭手术术后脑积水差异形成的因素；患者开颅夹闭手术短期预后优于血管介入栓塞治疗。
目的：分析比較Hunt-Hess Ⅲ～Ⅳ級動脈瘤性蛛網膜下腔齣血（aSAH）患者血管介入栓塞與開顱夾閉手術後併髮急性腦積水的差異及預後。方法迴顧性分析武警後勤學院附屬醫院和武警總醫院2011年1月至2014年7月接受血管介入栓塞（介入栓塞組，403例）或開顱夾閉手術（開顱夾閉組，364例）的Hunt-Hess Ⅲ～Ⅳ級aSAH患者的臨床資料，篩選齣術後齣現急性腦積水的病例，運用統計學方法對可能造成兩組術後腦積水形成差異的因素進行量化與賦值，通過齣院時格拉斯哥預後評分（GOS）判斷腦積水患者短期預後情況，比較兩種手術的優缺點。結果介入栓塞組403例患者中術後齣現腦積水56例（13.90%），開顱夾閉組364例患者中術後齣現腦積水33例（9.07%），兩組腦積水髮生率差異有統計學意義（χ2＝4.350， P＝0.037）。767例aSAH患者中，行血腫清除者腦積水髮生率顯著低于未行血腫清除者〔3.07%（11/358）比19.07%（78/409），χ2＝47.635，P＝0.000〕；行腦室引流者腦積水髮生率顯著低于未行腦室引流者〔2.77%（19/685）比85.37%（70/82），χ2＝487.032，P＝0.000〕。在介入栓塞組403例患者中，行血腫清除者腦積水髮生率略低于未行血腫清除者〔8.06%（5/62）比14.96%（51/341），χ2＝2.082，P＝0.168〕；行腦室引流者腦積水髮生率顯著低于未行腦室引流者〔2.59%（9/347）比83.93%（47/56），χ2＝266.599，P＝0.000〕。在開顱夾閉組364例患者中，行血腫清除者腦積水髮生率顯著低于未行血腫清除者〔2.03%（6/296）比39.71%（27/68），χ2＝95.226，P＝0.000〕；行腦室引流者腦積水髮生率顯著低于未行腦室引流者〔2.96%（10/338）比88.46%（23/26），χ2＝203.852，P＝0.000〕。介入栓塞組與開顱夾閉組之間行血腫清除者腦積水髮生率差異有統計學意義〔8.06%（5/62）比2.03%（6/296），χ2＝4.411，P＝0.027〕；而行腦室引流者腦積水髮生率差異無統計學意義〔2.59%（9/347）比2.96%（10/338），χ2＝0.085，P＝0.819〕。56例行介入栓塞術後齣現腦積水的患者，齣院時預後良好（GOS評分4～5分）23例（41.07%），預後不良（GOS評分1～3分）33例（58.93%）；33例行開顱夾閉手術後齣現腦積水的患者，齣院時預後良好（GOS評分4～5分）21例（63.64%），預後不良（GOS評分1～3分）12例（36.36%），兩組預後差異有統計學意義（χ2＝4.230，P＝0.039）。結論血腫清除是造成Hunt-HessⅢ～Ⅳ級患者血管介入栓塞和開顱夾閉手術後腦積水差異形成的主要因素之一；側腦室引流可能不是造成Hunt-HessⅢ～Ⅳ級患者血管介入栓塞和開顱夾閉手術術後腦積水差異形成的因素；患者開顱夾閉手術短期預後優于血管介入栓塞治療。
목적：분석비교Hunt-Hess Ⅲ～Ⅳ급동맥류성주망막하강출혈（aSAH）환자혈관개입전새여개로협폐수술후병발급성뇌적수적차이급예후。방법회고성분석무경후근학원부속의원화무경총의원2011년1월지2014년7월접수혈관개입전새（개입전새조，403례）혹개로협폐수술（개로협폐조，364례）적Hunt-Hess Ⅲ～Ⅳ급aSAH환자적림상자료，사선출술후출현급성뇌적수적병례，운용통계학방법대가능조성량조술후뇌적수형성차이적인소진행양화여부치，통과출원시격랍사가예후평분（GOS）판단뇌적수환자단기예후정황，비교량충수술적우결점。결과개입전새조403례환자중술후출현뇌적수56례（13.90%），개로협폐조364례환자중술후출현뇌적수33례（9.07%），량조뇌적수발생솔차이유통계학의의（χ2＝4.350， P＝0.037）。767례aSAH환자중，행혈종청제자뇌적수발생솔현저저우미행혈종청제자〔3.07%（11/358）비19.07%（78/409），χ2＝47.635，P＝0.000〕；행뇌실인류자뇌적수발생솔현저저우미행뇌실인류자〔2.77%（19/685）비85.37%（70/82），χ2＝487.032，P＝0.000〕。재개입전새조403례환자중，행혈종청제자뇌적수발생솔략저우미행혈종청제자〔8.06%（5/62）비14.96%（51/341），χ2＝2.082，P＝0.168〕；행뇌실인류자뇌적수발생솔현저저우미행뇌실인류자〔2.59%（9/347）비83.93%（47/56），χ2＝266.599，P＝0.000〕。재개로협폐조364례환자중，행혈종청제자뇌적수발생솔현저저우미행혈종청제자〔2.03%（6/296）비39.71%（27/68），χ2＝95.226，P＝0.000〕；행뇌실인류자뇌적수발생솔현저저우미행뇌실인류자〔2.96%（10/338）비88.46%（23/26），χ2＝203.852，P＝0.000〕。개입전새조여개로협폐조지간행혈종청제자뇌적수발생솔차이유통계학의의〔8.06%（5/62）비2.03%（6/296），χ2＝4.411，P＝0.027〕；이행뇌실인류자뇌적수발생솔차이무통계학의의〔2.59%（9/347）비2.96%（10/338），χ2＝0.085，P＝0.819〕。56례행개입전새술후출현뇌적수적환자，출원시예후량호（GOS평분4～5분）23례（41.07%），예후불량（GOS평분1～3분）33례（58.93%）；33례행개로협폐수술후출현뇌적수적환자，출원시예후량호（GOS평분4～5분）21례（63.64%），예후불량（GOS평분1～3분）12례（36.36%），량조예후차이유통계학의의（χ2＝4.230，P＝0.039）。결론혈종청제시조성Hunt-HessⅢ～Ⅳ급환자혈관개입전새화개로협폐수술후뇌적수차이형성적주요인소지일；측뇌실인류가능불시조성Hunt-HessⅢ～Ⅳ급환자혈관개입전새화개로협폐수술술후뇌적수차이형성적인소；환자개로협폐수술단기예후우우혈관개입전새치료。
ObjectiveTo analyze and compare the difference and prognosis between vascular embolization and craniotomy occlusion in patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) with Hunt-Hess levelⅢ-Ⅳ, and acute postoperative hydrocephalus.Methods A retrospective study was conducted on 767 patients who had undergone vascular embolization (vascular embolization group,n = 403) or craniotomy occlusion operation (craniotomy occlusion operation group,n = 364), and the patients with postoperative acute hydrocephalus were screened. The clinical data of patients of both groups was analyzed. By judging short-term prognosis in patients with hydrocephalus with Glasgow outcome scale (GOS) score estimated at discharge, the advantages and disadvantages of two surgical procedures were compared.Results The number of cases with postoperative hydrocephalus in vascular embolization group was 56 (13.90%), while that in craniotomy occlusion group was 33 (9.07%). The difference between the two groups of incidence of hydrocephalus was statistically significant (χ2= 4.350,P = 0.037 ). In 767 patients with aSAH, the incidence of hydrocephalus among the patients after the hematoma removal operation was significantly lower than that of patients without hematoma removal [3.07% (11/358) vs. 19.07% (78/409),χ2 = 47.635,P = 0.000]. The incidence of hydrocephalus among the patients after ventricular drainage was significantly lower than that of patients without the drainage [2.77% (19/685) vs. 85.37% (70/82),χ2 = 487.032,P = 0.000]. In 403 cases of vascular embolization group, the incidence of hydrocephalus in the patients after the hematoma removal operation was lower than that of patients without it [8.06% (5/62) vs. 14.96% (51/341),χ2 = 2.082,P = 0.168]. The incidence of hydrocephalus in the patients after the ventricular drainage was lower than that of patients without drainage [2.59% (9/347) vs. 83.93% (47/56),χ2 = 266.599,P = 0.000]. In 364 cases of craniotomy occlusion operation group, the incidence of hydrocephalus in the patients after hematoma removal operation was significantly lower than that of patients did not receive [2.03% (6/296) vs. 39.71% (27/68),χ2 = 95.226,P = 0.000]. The incidence of hydrocephalus among the patients after the ventricular drainage was significantly lower than that of patients without drainage [2.96% (10/338) vs. 88.46% (23/26),χ2 = 203.852,P = 0.000]. The difference in incidence of hydrocephalus between the patients who had hematoma removal surgery between vascular embolization group and craniotomy occlusion operation group was statistically significant [8.06% (5/62) vs. 2.03% (6/296),χ2 = 4.411,P = 0.027], while no statistically difference was present in ventricular drainage patients [2.59% (9/347) vs. 2.96% (10/338),χ2 = 0.085,P = 0.819]. There were 23 patients (41.07%) with good outcome (GOS score 4-5), while 33 (58.93%) with poor outcome (GOS score 1-3) in 56 patients undergone vascular embolization operation. Good result (GOS score 4-5) was shown in 21 (63.64%) and 12 (36.36%) with poor outcome (GOS score 1-3) among 33 patients with hydrocephalus after craniotomy occlusion operation, and the difference was statistically significant (χ2 = 4.230,P = 0.039).Conclusions Hematoma is one of the main factor contributing to the differences in the incidence of postoperative hydrocephalus of Hunt-Hess gradeⅢ-Ⅳ patients either receiving vascular embolization or craniotomy occlusion operation. Lateral ventricle drainage may not be the factor that contributes to the difference in incidence of hydrocephalus formation between the vascular embolization and craniotomy occlusion operation groups in Hunt-Hess levelⅢ-Ⅳ patients. The short term prognosis in the craniotomy occlusion operation group is superior to that of endovascular intervention embolization group.
