创伤性颅内出血后脑血管痉挛的影响因素分析
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摘要
目的 探讨创伤性颅内出血后脑血管痉挛发生的危险因素。方法 连续性纳入195例经头颅CT确诊创伤后颅内出血患者,并通过脑血管数字减影血管造影(Digital Subtraction Angiography,DSA)检查将患者分为出现脑血管痉挛的观察组(67例)和无脑血管痉挛的对照组(128例),比较2组患者的入院时格拉斯哥评分,通过受试者工作特征曲线(receiver operating characteristic,ROC)确定格拉斯哥昏迷评估对脑血管痉挛的诊断阈值,并通过多因素logistics回归分析评估其独立预测价值。结果 观察组昏迷时间高于对照组[(3.1±1.1)h vs (2.6±0.9)h]、而入院时的格拉斯哥昏迷评分低于对照组[(7.9±2.3)分vs (11.8±3.3分)](P均<0.05)。观察组中蛛网膜下腔出血患者比例高于对照组(61.2%vs 40.6%),并且Fisher分级II级和III级患者的比例(分别为53.7%,28.4%)高于对照组(分别为33.6%,10.2%),迟发性脑出血(delayed cerebral ischemia,DCI)发生率高于对照组(34.3%vs 13.3%)(P均<0.05)。ROC曲线证实格拉斯哥昏迷评分低于9分是脑血管痉挛的诊断阈值,特异度87.2%,灵敏度73.4%。多因素logistics回归分析显示格拉斯哥评分<9分(OR=2.344,95%CI=1.892～4.323,P<0.001)和蛛网膜下腔出血(OR=1.234,95%CI=1.104～1.574,P=0.020)是影响颅脑创伤后脑血管痉挛发生的独立危险因素。结论 颅脑创伤后颅内出血患者的低格拉斯哥昏迷评分能够有效预测脑血管痉挛的发生。
Objective To evaluate risk factors of cerebral vasospasm after traumatic intracranial hemorrhage. Methods 195 patients with post-traumatic intracranial hemorrhage confirmed by cranial CT were enrolled, and the patients were divided into observation group(67 cases) with cerebral vasospasm confirmed by digital subtraction angiography(DSA), and control group(128 cases) without cerebral vasospasm. The Glasgow scores at admission were compared between the two groups. The receiver operating characteristic curve(ROC) was used to determine the diagnostic threshold for cerebral vasospasm in the Glasgow score assessment, and the independent predictive value was validated by multivariate logistic regression analysis. Results The coma time of the observation group was higher than that of the control group(3.1±1.1 h vs 2.6±0.9 h), and the Glasgow coma score at admission was lower than that of the control group(7.9±2.3 scores vs 11.8±3.3 scores)(P<0.05). The proportion of patients with subarachnoid hemorrhage in the observation group was higher than that of the control group(61.2% vs 40.6%), and the proportions of patients with grade II and III of Fisher grade(53.7%, 28.4% respectively) were higher than those of the control group(33.6%, 10.2% respectively), and the incidence of delayed cerebral ischemia(DCI) was higher than that of the control group(34.3% vs 13.3%)(all P<0.05). The ROC curve confirmed that the Glasgow coma score below 9 was the diagnostic threshold for cerebral vasospasm, with the specificity of 87.2% and the sensitivity of 73.4%. Multivariate logistic regression analysis confirmed that Glasgow score <9(OR=2.344, 95% CI=1.892～4.323, P<0.001) and subarachnoid hemorrhage(OR=1.234, 95%CI=1.104～1.574, P=0.020) were independent risk factors for the development of cerebral vasospasm after traumatic brain injury. Conclusion The low Glasgow coma score in patients with intracranial hemorrhage after traumatic brain injury could effectively predict cerebral vasospasm.
Objective To evaluate risk factors of cerebral vasospasm after traumatic intracranial hemorrhage. Methods 195 patients with post-traumatic intracranial hemorrhage confirmed by cranial CT were enrolled, and the patients were divided into observation group(67 cases) with cerebral vasospasm confirmed by digital subtraction angiography(DSA), and control group(128 cases) without cerebral vasospasm. The Glasgow scores at admission were compared between the two groups. The receiver operating characteristic curve(ROC) was used to determine the diagnostic threshold for cerebral vasospasm in the Glasgow score assessment, and the independent predictive value was validated by multivariate logistic regression analysis. Results The coma time of the observation group was higher than that of the control group(3.1±1.1 h vs 2.6±0.9 h), and the Glasgow coma score at admission was lower than that of the control group(7.9±2.3 scores vs 11.8±3.3 scores)(P<0.05). The proportion of patients with subarachnoid hemorrhage in the observation group was higher than that of the control group(61.2% vs 40.6%), and the proportions of patients with grade II and III of Fisher grade(53.7%, 28.4% respectively) were higher than those of the control group(33.6%, 10.2% respectively), and the incidence of delayed cerebral ischemia(DCI) was higher than that of the control group(34.3% vs 13.3%)(all P<0.05). The ROC curve confirmed that the Glasgow coma score below 9 was the diagnostic threshold for cerebral vasospasm, with the specificity of 87.2% and the sensitivity of 73.4%. Multivariate logistic regression analysis confirmed that Glasgow score <9(OR=2.344, 95% CI=1.892～4.323, P<0.001) and subarachnoid hemorrhage(OR=1.234, 95%CI=1.104～1.574, P=0.020) were independent risk factors for the development of cerebral vasospasm after traumatic brain injury. Conclusion The low Glasgow coma score in patients with intracranial hemorrhage after traumatic brain injury could effectively predict cerebral vasospasm.
引文
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[9] 项德坤,闫永龙,张东霞,等.MRI对蛛网膜下腔出血后脑血管痉挛脑血流动力学的评估应用价值[J].中国地方病防治杂志,2016,31(7):804.
[10] Kramer DR,Winer JL,Pease BA,et al.Cerebral vasospasm in traumatic brain injury[J].Neurol Res Int,2013,2013(6):415813.
[11] Wong B,Ong BB,Milne N.The source of haemorrhage in traumatic basal subarachnoid haemorrhage[J].Journal of Forensic and Legal Medicine,2015,29(1):18-23.
[12] Salottolo K,Levy AS,Slone DS,et al.The effect of age on Glasgow coma scale score in patients with traumatic brain injury[J].JAMA Surgery,2014,149(7):727-734.
[13] 郜风清.颅脑创伤后脑血管痉挛发生的影响因素[J].中国实用神经疾病杂志,2015,18(1):42-43.
[14] Naranjo D,Arkuszewski M,Rudzinski W,et al.Brain ischemia in patients with intracranial hemorrhage:pathophysiological reasoning for aggressive diagnostic management[J].The Neuroradiology Journal,2013,26(6):610-628.
[15] 王玉妹,唐思魏,石广志.蛛网膜下腔出血后迟发性脑血管痉挛的发病机制和治疗进展[J].中国卒中杂志,2016,11(6):494-500.
[2] 许乐宜,邱峰,书国伟,等.经颅多普勒超声在颅脑外伤病人早期脑血管痉挛诊断中的应用分析[J].中西医结合心脑血管病杂志,2017,15(17):2183-2184.
[3] 陆敏,张静.急性脑损伤患者熵指数与格拉斯哥昏迷评分的相关性研究[J].中华危重病急救医学,2018,30(1):47-50.
[4] 中华医学会神经外科学分会.脑血管痉挛防治神经外科专家共识[J].中国临床神经外科杂志,2009,3(5):248-252.
[5] Perrein A,Petry L,Reis A,et al.Cerebral vasospasm after traumatic brain injury:an update[J].Minerva Anestesiologica,2015,81(11):1219-1228.
[6] Al-Mufti F,Amuluru K,Changa A,et al.Traumatic brain injury and intracranial hemorrhage-induced cerebral vasospasm:a systematic review[J].Neurosurgical Focus,2017,43(5):E14.
[7] O'brien NF.Maa T,yeates KO.the epidemiology of vasospasm in children with moderate-to-severe traumatic brain injury[J].Critical Care Medicine,2015,43(3):674-685.
[8] Papanikolaou J,Spathoulas K,Makris D,et al.Hemodynamic challenges in traumatic subarachnoid hemorrhage complicated by cerebral vasospasm[J].American Journal of Emergency Medicine,2016,34(5):904-906.
[9] 项德坤,闫永龙,张东霞,等.MRI对蛛网膜下腔出血后脑血管痉挛脑血流动力学的评估应用价值[J].中国地方病防治杂志,2016,31(7):804.
[10] Kramer DR,Winer JL,Pease BA,et al.Cerebral vasospasm in traumatic brain injury[J].Neurol Res Int,2013,2013(6):415813.
[11] Wong B,Ong BB,Milne N.The source of haemorrhage in traumatic basal subarachnoid haemorrhage[J].Journal of Forensic and Legal Medicine,2015,29(1):18-23.
[12] Salottolo K,Levy AS,Slone DS,et al.The effect of age on Glasgow coma scale score in patients with traumatic brain injury[J].JAMA Surgery,2014,149(7):727-734.
[13] 郜风清.颅脑创伤后脑血管痉挛发生的影响因素[J].中国实用神经疾病杂志,2015,18(1):42-43.
[14] Naranjo D,Arkuszewski M,Rudzinski W,et al.Brain ischemia in patients with intracranial hemorrhage:pathophysiological reasoning for aggressive diagnostic management[J].The Neuroradiology Journal,2013,26(6):610-628.
[15] 王玉妹,唐思魏,石广志.蛛网膜下腔出血后迟发性脑血管痉挛的发病机制和治疗进展[J].中国卒中杂志,2016,11(6):494-500.