【作者】 冯金福；

【导师】 段传志；

【作者基本信息】 南方医科大学 ， 神经外科学， 2009， 硕士

【摘要】 研究背景:蛛网膜下腔出血(subarachnoid hemorrhage,SAH)是指各种原因引起的脑血管突然破裂,血液流至蛛网膜下腔的统称,占急性脑血管意外的15%左右,具有很高的死亡率和致残率。蛛网膜下腔出血患者转归不良主要有3个重要原因为:1、SAH的直接结果:包括急性缺血性神经功能缺损(acuteischemic neurological deficit,AIND)、血肿和脑水肿;2、再出血:发生率很高,SAH后2周内约为20%;3、迟发性脑血管痉挛(delayed cerebral vasospasm,DCVS):可造成脑缺血或脑损害,蛛网膜下腔出血患者,约70%并发DCVS;36%患者于此基础上继发延迟性缺血性神经功能障碍(delayed ischemicneurological deficit,DIND),是蛛网膜下腔出血后死亡或残疾的最主要原因。在动脉瘤手术或血管内治疗技术和疗效提高的情况下,再出血问题已得到较好解决,对DCVS预防和处理的研究显得越来越重要。因此研究SAH迟发性CVS(DCVS)发生的相关临床因素,对防治DIND并发症的发生,降低SAH患者残疾、死亡率有重要意义。目的:探讨蛛网膜下腔出血(SAH)患者迟发性脑血管痉挛(DCVS)的临床影响因素,从而为临床上预防蛛网膜下腔出血患者发生迟发性脑血管痉挛提供参考。材料和方法:回顾性队列分析南方医科大学珠江医院自2005年1月至2008年12月收治的74例动脉瘤性SAH患者的临床资料,判定DCVS,统计患者的年龄、吸烟史、出血次数、Hunt-Hess分级、Fisher分级、白细胞计数峰值等因素的分布,应用SPSS13.0统计软件分析各因素与DCVS的关系,对初步筛选预期变量采用χ~2检验,对可能引起DCVS的预期变量采用非条件多因素Logistic回归分析,以确定影响DCVS的危险因素,以P≤0.05为差异有统计学意义。结果:本组74例患者中有37例发生DCVS,总发生率50%。其中,≤60岁患者DCVS发生率为56.9%(33/58),出血二次以上患者发生率为81.8%(9/11),吸烟组患者发生率为76.9%(10/13),Hunt-Hess分级Ⅲ级以上患者发生率为68.1%(32/47),Fisher分级Ⅲ以上患者发生率为83.8%(31/37),白细胞计数峰值＞15×10~9/L患者发生率为75.0%(12/16),以上各因素组迟发性脑血管痉挛(DCVS)发生率与相应对照组比较均有统计学差异(P＜0.05)。而高血压、高血糖及性别因素与DCVS的发生无统计学差异(P＞0.05)。根据以上各危险因素分析结果,对有统计意义的6个因素分别赋值进行非条件Logistic回归分析,发现年龄、出血次数、Fisher分级、Hunt-Hess分级均进入最终模型,为DCVS发生的独立危险因素。其中,年龄因素的偏回归系数为—2.702,提示年龄与DCVS的发生呈负相关,年龄越小DCVS发生率越高。整个回归模型对组内病例的判对率为85.1%。结论:低年龄、出血2次以上及Hunt-Hess分级或Fisher分级Ⅲ级以上患者更易发生迟发性脑血管痉挛,临床上对此类患者应加强监测、及早发现和处理迟发性脑血管痉挛,改善患者预后。更多还原

【Abstract】 Background:Subarachnoid hemorrhage(SAH)is due to the blood leaking into the subarachnoid space because of the sudden rupture of cerebral vessels,which accouts up to 15%in cerebral vascular diseses,and causes high morbidities and disabilities. poor prognosis mainly result from 3 factors:1.AIND,hemorrhage,brain oedema.2.reoccurence of hemmorrhage.3.DCVS.About 70%patients had the complication of DCVS which eventually results in brain ischemia or brain damage,and 36%of these patients suffered from DIND,which is the main reason of deaths or disabilities of the patients after SAH.With the improvement of aneurysm clipping technique and effect of treatment,the problem of rebleeding has been resolved,but the prevention of DCVS still needs more research,so,it is very important to study the clinical factors causing DCVS and decrease the occurence of DIND so as to decrease the rate of disabilities and death in patients with SAH.Objective:To explore the risk factors of delayed cerebral vasospasm following aneurysmal subarachnoid hemorrhage.Methods:The clinical data of 74 patients from Jan 2005 to Dec 2008 with SAH were selected and analysed retrospectively.Six factors including age,history of smoking, number of bleeding,Hunt-Hess grading,Fisher grading and the peak value of white cell count were recorded,The severity of cerebral vasospasm was determined by DSA. The risk factors related to delayed cerebral vasospasm were analysed.All data were dealt with SPSS13.0 software to find the relation between factors and DCVS and select variants using Chi-square.A P value less than 0.05 was considered statistically significant.Results:37 of 74 patients in this group were diagnosed DCVS,56.9%in patients less than 60 years old,81.8%in patients with history of bleeding more than twice,76.9% in patients with history of somking,68.1%and 83.8%in patients ranked in Hunt-Hess grading or Fisher grading respectively,75%in patients with white cell over 15×10~9/L,So,age,number of bleeding,history of smoking,Hunt-Hess grade, Fisher grade and peak concurrency of white blood cell count are significantly related to the occurrences of delayed cerebral vasospasm.Among above factors,age,number of bleeding,Hunt -Hess grading,Fisher grading are the independent factors of delayed cerebral vasospasm.Hypertensio,sex and hyperglucemia has no significant correlation with DCVS.Age has the negtive correlation with DCVS,the younger the patient is,the higher probability of DCVS occour.The whole model correct judgement is 85.1%.Conclusions:The patients of lower age,hemorrhage more than twice,Hunt-Hess grading or Fisher grading overⅢare more susceptible to delayed cerebral vasospasm,such patients should be closely monitored and delt with in time in case of delayed cerebral vasospasm.更多还原