血肿异质性对血肿扩大的影响及预测评分系统的建立
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摘要
目的探讨血肿异质性对幕上原发性脑出血血肿扩大的影响及依此建立血肿扩大的预测评分系统。方法回顾性连续纳入2015年6月至2017年12月湖南省吉首大学第一附属医院首诊治疗的原发性脑出血患者208例,利用3D软件进行血肿成像,计算血肿体积和表面积,根据血肿有无扩大分为血肿扩大组(44例)和血肿未扩大组(164例),利用血肿CT值的标准差(CTSD)及血肿形态的不规则比值(IR)反映血肿的异质性,分析血肿异质性与血肿扩大的关系,并依此建立预测血肿扩大的评分模型。应用SPSS 20. 0软件分析处理数据,采用单因素分析及多因素Logistic回归分析影响血肿扩大的危险因素,采用受试者工作特征(ROC)曲线评估评分系统对血肿扩大的预测价值。结果原发性脑出血血肿扩大的发生率为21. 2%(44/208)。单因素分析结果显示,血肿扩大组体积增加量[(15±11) ml]、血肿CTSD(12. 9±2. 2)、IR(2. 7±0. 5)均高于血肿未扩大组[分别为(4±6) ml、9. 1±1. 6、1. 5±0. 3;均P <0. 01],规律服用药物、首诊高血糖、首诊收缩压、发病时间、入院意识、出血原因、GCS评分两组差异均有统计学意义(均P <0. 05)。多因素Logistic回归分析结果显示:入院时GCS评分≥10分(OR=4. 141,95%CI:1. 526~11. 237,P=0. 005)、CTSD≥10. 85(OR=3. 593,95%CI:1. 354~9. 540,P=0. 010)及IR≥2. 0(OR=93. 487,95%CI:27. 656~316. 012,P <0. 01)是血肿扩大的独立危险因素,并依此建立CIG(CTSD、IR及GCS)预测评分系统,ROC曲线分析显示,当CIG评分≥9. 5分时,其预测血肿扩大的敏感度为86. 9%,特异度为95. 1%。结论通过个性化的成像处理,首次通过血肿的密度不均质性及形态的不规则度量化了血肿异质性,并依此建立血肿扩大的预测评分模型,为临床对血肿扩大的判断提供新的思路。
Objective To investigate the influence of hematoma heterogeneity for the enlargement of primary supratentorial intracerebral hemorrhage and established predictive scoring model of hematoma enlargement. Methods From June 2015 to December 2017,a total of 208 patients with primary cerebral hemorrhage treated first at the First Affiliated Hospital of Jishou University were analyzed retrospectively. 3 D software was used to conduct hematoma imaging and calculate hematoma volume and surface area. The patients were divided into enlarged hematoma group( n = 44) and non-enlarged hematoma group( n = 164)according to whether the hematomas were enlarged or not. The standard deviation of CT value( CTSD) of hematoma and irregular ratio( IR) of hematoma morphology were used to reflect the heterogeneity of hematoma. Univariate analysis and Multivariate Logistic regression analysis were used to analyze the Influencing factors of hematoma enlargement with SPSS 22. 0 software,and the predictive value of predictive scoring model to hematoma enlargement was evaluated with receiver operating characteristic( ROC) curve.Results The incidence of hematoma enlargement in primary cerebral hemorrhage was 21. 2%( 44/208).Compared with the non-enlarged hematoma group,the increased volume of hematoma in the enlarged hematoma group increased significantly( 15 ± 11 ml vs. 4 ± 6 ml,t = 45. 568,P < 0. 01). The CTSD of hematoma was higher( 12. 9 ±2. 2 vs. 9. 1 ±1. 6,P <0. 01). The IR of hematoma morphology was larger in the enlarged hematoma group( 2. 7 ± 0. 5 vs. 1. 5 ± 0. 3,P < 0. 01). There were significant differences in taking medicine regularly,first diagnosed hyperglycemia,first diagnosed systolic blood pressure,the time of onset,admission awareness,causes of bleeding and the Glasgow coma scale score between the enlarged hematoma group and the non-enlarged hematoma group( all P < 0. 05). When IR was ≥2. 0 and CTSD was ≥10. 85,the heterogeneity of hematomas increased. Multivariate analysis showed that GCS ≥ 10 score at admission( OR,4. 141,95% CI 1. 526-11. 237,P = 0. 005),CTSD ≥10. 85( OR,3. 593,95% CI 1. 354-9. 540,P = 0. 010),and IR ≥2. 0( OR,93. 487,95% CI 27. 656-316. 012,P < 0. 01) were the independent risk factors for hematoma enlargement,and based on this,a predictive scoring model of CIG( CTSD,IR,and GCS) was established. ROC curve analysis showed that the sensitivity and specificity of CIG score model predicting the hematoma enlargement were86. 9 % and 95. 1 %,respectively when the predictive score was ≥9. 5 score. Conclusion The heterogeneity of hematoma was first quantified by the density heterogeneity and morphological irregularity of hematoma through individualized imaging processing,and a scoring model of hematoma enlargement was established based on this,which provided a new idea for clinical identification of hematoma enlargement.
Objective To investigate the influence of hematoma heterogeneity for the enlargement of primary supratentorial intracerebral hemorrhage and established predictive scoring model of hematoma enlargement. Methods From June 2015 to December 2017,a total of 208 patients with primary cerebral hemorrhage treated first at the First Affiliated Hospital of Jishou University were analyzed retrospectively. 3 D software was used to conduct hematoma imaging and calculate hematoma volume and surface area. The patients were divided into enlarged hematoma group( n = 44) and non-enlarged hematoma group( n = 164)according to whether the hematomas were enlarged or not. The standard deviation of CT value( CTSD) of hematoma and irregular ratio( IR) of hematoma morphology were used to reflect the heterogeneity of hematoma. Univariate analysis and Multivariate Logistic regression analysis were used to analyze the Influencing factors of hematoma enlargement with SPSS 22. 0 software,and the predictive value of predictive scoring model to hematoma enlargement was evaluated with receiver operating characteristic( ROC) curve.Results The incidence of hematoma enlargement in primary cerebral hemorrhage was 21. 2%( 44/208).Compared with the non-enlarged hematoma group,the increased volume of hematoma in the enlarged hematoma group increased significantly( 15 ± 11 ml vs. 4 ± 6 ml,t = 45. 568,P < 0. 01). The CTSD of hematoma was higher( 12. 9 ±2. 2 vs. 9. 1 ±1. 6,P <0. 01). The IR of hematoma morphology was larger in the enlarged hematoma group( 2. 7 ± 0. 5 vs. 1. 5 ± 0. 3,P < 0. 01). There were significant differences in taking medicine regularly,first diagnosed hyperglycemia,first diagnosed systolic blood pressure,the time of onset,admission awareness,causes of bleeding and the Glasgow coma scale score between the enlarged hematoma group and the non-enlarged hematoma group( all P < 0. 05). When IR was ≥2. 0 and CTSD was ≥10. 85,the heterogeneity of hematomas increased. Multivariate analysis showed that GCS ≥ 10 score at admission( OR,4. 141,95% CI 1. 526-11. 237,P = 0. 005),CTSD ≥10. 85( OR,3. 593,95% CI 1. 354-9. 540,P = 0. 010),and IR ≥2. 0( OR,93. 487,95% CI 27. 656-316. 012,P < 0. 01) were the independent risk factors for hematoma enlargement,and based on this,a predictive scoring model of CIG( CTSD,IR,and GCS) was established. ROC curve analysis showed that the sensitivity and specificity of CIG score model predicting the hematoma enlargement were86. 9 % and 95. 1 %,respectively when the predictive score was ≥9. 5 score. Conclusion The heterogeneity of hematoma was first quantified by the density heterogeneity and morphological irregularity of hematoma through individualized imaging processing,and a scoring model of hematoma enlargement was established based on this,which provided a new idea for clinical identification of hematoma enlargement.
引文
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[21]Zheng W,Zhang C,Hou D,et al.Comparison on different strategies for treatments of hypertensive hemorrhage in the basal ganglia region with a volume of 25 to 35 ml[J].Acta Cir Bras,2012,27(10):727-731.
[22]Barras CD,Tress BM,Christensen S,et al.Density and shape as CT predictors of intracerebral hemorrhage growth[J].Stroke,2009,40(4):1325-1331.
[23]Fujii Y,Takeuchi S,Sasaki O,et al.Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage[J].Stroke,1998,29(6):1160-1166.
[24]李卓星,褚晓凡,窦汝香,等.量化评价血肿形态对脑出血血肿扩大危险因素分析[J].中风与神经疾病杂志,2011,28(2):151-155.
[25]Wagemans BA,Klinkenberg S,Postma AA.Teaching neuroimages:swirl sign and spot sign in intraparenchymal hematoma[J].Neurology,2016,87(18):e225-e226.
[26]Webb AJ,Ullman NL,Morgan TC,et al.Accuracy of the ABC/2 score for intracerebral hemorrhage:systematic review and analysis of MISTIE,CLEAR-IVH,and CLEARⅢ[J].Stroke,2015,46(9):2470-2476.
[2]Delgado Almandoz JE,Yoo AJ,Stone MJ,et al.The spot sign score in primary intracerebral hemorrhage identifies patients at highest risk of in-hospital mortality and poor outcome among survivors[J].Stroke,2010,41(1):54-60.
[3]Morotti A,Jessel MJ,Brouwers HB,et al.CT angiography spot sign,hematoma expansion,and outcome in primary pontine intracerebral hemorrhage[J].Neurocrit Care,2016,25(1):79-85.
[4]Orito K,Hirohata M,Nakamura Y,et al.Leakage sign for primary intracerebral hemorrhage:a novel predictor of hematoma growth[J].Stroke,2016,47(4):958-963.
[5]Li Q,Zhang G,Huang YJ,et al.Blend sign on computed tomography:novel and reliable predictor for early hematoma growth in patients with intracerebral hemorrhage[J].Stroke,2015,46(8):2119-2123.
[6]Li Q,Zhang G,Xiong X,et al.Black hole sign:novel imaging marker that predicts hematoma growth in patients with intracerebral hemorrhage[J].Stroke,2016,47(7):1777-1781.
[7]Li Q,Liu QJ,Yang WS,et al.Island sign:an imaging predictor for early hematoma expansion and poor outcome in patients with intracerebral hemorrhage[J].Stroke,2018,48(11):3019-3025.
[8]Boulouis G,Dumas A,Betensky RA,et al.Anatomic pattern of intracerebral hemorrhage expansion:relation to CT angiography spot sign and hematoma center[J].Stroke,2014,45(4):1154-1156.
[9]文婉玲,于瀛,黄清海,译.自发性脑出血诊疗指南---美国心脏协会/美国卒中协会的健康职业者指南[J].中国脑血管病杂志,2015,12(9):490-504.
[10]Brott T,Broderick J,Kothari R,et al.Early hemorrhage growth in patients with intracerebral hemorrhage[J].Stroke,1997,28(1):1-5.
[11]中国老年学和老年医学学会心脑血管病专业委员会.老年高血压的诊断与治疗中国专家共识(2017版)[J].中华内科杂志,2017,56(11):885-893.
[12]贾伟平.中国2型糖尿病防治指南(2017年版)[J].中华医学会糖尿病学分会,2017,10(1):4-67.
[13]诸骏仁,高润霖,赵水平,等.中国成人血脂异常防治指南(2016年修订版)[J].中国循环杂志,2016,16(10):15-35.
[14]卢洪流.中英对照GCS评分[J].中华神经医学杂志,2005,4(5):497.
[15]孙国臣,陈晓雷,侯远征,等.基于简易虚拟现实和增强现实定位的内镜辅助下清除幕上自发性脑内血肿[J].中华神经外科杂志,2017,33(1):15-18.
[16]Ning X,Sun J,Jiang R,et al.Increased stroke burdens among the low-income young and middle aged in rural China[J].Stroke,2017,48(1):77-83.
[17]Brouwers HB,Falcone GJ,Mcnamara KA,et al.CTA spot sign predicts hematoma expansion in patients with delayed presentation after intracerebral hemorrhage[J].Neurocrit Care,2012,17(3):421-428.
[18]Park SY,Kong MH,Kim JH,et al.Role of‘pot sign’on CT angiography to predict hematoma expansion in spontaneous intracerebral hemorrhage[J].J Korean Neurosurg Soc,2010,48(5):399-405.
[19]Brouwers HB,Chang Y,Falcone GJ,et al.Predicting hem atom a expansion after prim ary intracerebral hem orrhage[J].JAMA Neurol,2014,71(2):158-164.
[20]Ji R,Shen H,Pan Y,et al.Novel risk score to predict pneumonia after acute ischemic stroke[J].Stroke,2013,44(5):1303-1309.
[21]Zheng W,Zhang C,Hou D,et al.Comparison on different strategies for treatments of hypertensive hemorrhage in the basal ganglia region with a volume of 25 to 35 ml[J].Acta Cir Bras,2012,27(10):727-731.
[22]Barras CD,Tress BM,Christensen S,et al.Density and shape as CT predictors of intracerebral hemorrhage growth[J].Stroke,2009,40(4):1325-1331.
[23]Fujii Y,Takeuchi S,Sasaki O,et al.Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage[J].Stroke,1998,29(6):1160-1166.
[24]李卓星,褚晓凡,窦汝香,等.量化评价血肿形态对脑出血血肿扩大危险因素分析[J].中风与神经疾病杂志,2011,28(2):151-155.
[25]Wagemans BA,Klinkenberg S,Postma AA.Teaching neuroimages:swirl sign and spot sign in intraparenchymal hematoma[J].Neurology,2016,87(18):e225-e226.
[26]Webb AJ,Ullman NL,Morgan TC,et al.Accuracy of the ABC/2 score for intracerebral hemorrhage:systematic review and analysis of MISTIE,CLEAR-IVH,and CLEARⅢ[J].Stroke,2015,46(9):2470-2476.