Gruber A, Reinprecht A, Illievich U M, Fitzgerald R, Dietrich W, Czech T, Richling B
Department of Neurosurgery, University of Vienna, Austria.
Crit Care Med. 1999 Mar;27(3):505-14. doi: 10.1097/00003246-199903000-00026.
To analyze the influence of extracerebral organ system dysfunction after aneurysmal subarachnoid hemorrhage (SAH) on mortality and neurologic outcome.
Observational study with retrospective data extraction.
Neurosurgical intensive care unit (NICU) at a primary level university hospital, supervised and staffed by both members of the Clinic of Neurosurgery and the Clinic of Anesthesiology and General Intensive Care.
Two hundred forty-two patients treated for intracranial aneurysm rupture within 7 days of the most recent SAH.
Routine neurosurgical interventions for obliteration of the ruptured aneurysm (microsurgery, Guglielmi Detachable Coils embolization) and for treatment of posthemorrhagic hydrocephalus (ventriculostomy, cerebrospinal fluid shunt implantation).
Respiratory, renal, hepatic, cardiovascular, and hematologic organ system functions were evaluated both individually and in aggregate by using a modified version of the Multiple Organ Dysfunction (mMOD) score. Of 1,452 organ system functions assessed in 242 patients during their NICU stay, 714 organ system functions were intact (cerebral: 0, extracerebral: 714), 556 organ systems had mild-to-moderate dysfunctions (mMOD scoremax 1-2 for the affected organ system; cerebral: 153, extracerebral: 403), and 182 organ systems failed (mMOD scoremax 3 for the affected organ system; cerebral: 89, extracerebral: 93). Severity of extracerebral organ system dysfunctions correlated with the degree of neurologic impairment (Hunt and Hess [H&H] score) in a graded fashion. Similarly, the chance to develop systemic inflammatory response syndrome (SIRS) during the NICU stay increased with increasing admission H&H grade. The incidence of SIRS and septic shock was 29% and 10.3%, respectively. The mortality rate was 40.2% in patients with SIRS and 80% for patients suffering septic shock. Seventy-seven percent of extracerebral organ system failures (OSFs) occurred in conjunction with SIRS: 51% of respiratory OSFs, 97% of renal OSFs, 100% of hepatic OSFs, 96% of cardiovascular OSFs, and 73% of hematopoietic OSFs. Both CNS dysfunction and extracerebral organ system dysfunctions were significantly related to neurologic outcome. The probability of unfavorable neurologic outcome significantly increased with both decreasing cerebral perfusion pressure (CPP) and increasing severity of extracerebral organ dysfunction.
Aneurysmal SAH and its neurologic sequelae accounted for the principal morbidity and mortality in the current series. Development of extracerebral organ system dysfunction was associated with a higher probability of unfavorable neurologic outcome. Systemic inflammation (SIRS) and secondary organ dysfunction were the principal non-neurologic causes of death.
分析动脉瘤性蛛网膜下腔出血（SAH）后脑外器官系统功能障碍对死亡率和神经功能转归的影响。
回顾性数据提取的观察性研究。
一所初级大学医院的神经外科重症监护病房（NICU），由神经外科诊所和麻醉与综合重症监护诊所的人员进行监督和配备。
242例在最近一次SAH后7天内接受颅内动脉瘤破裂治疗的患者。
用于闭塞破裂动脉瘤的常规神经外科干预措施（显微手术、 Guglielmi可脱卸弹簧圈栓塞）以及用于治疗出血后脑积水的措施（脑室造瘘术、脑脊液分流植入术）。
采用改良的多器官功能障碍（mMOD）评分对呼吸、肾脏、肝脏、心血管和血液学器官系统功能进行单独和综合评估。在242例患者入住NICU期间评估的1452项器官系统功能中，714项器官系统功能完好（脑内：0项，脑外：714项），556项器官系统有轻度至中度功能障碍（受影响器官系统的mMOD评分最大值为1 - 2；脑内：153项，脑外：403项），182项器官系统功能衰竭（受影响器官系统的mMOD评分最大值为3；脑内：89项，脑外：93项）。脑外器官系统功能障碍的严重程度与神经功能损害程度（Hunt和Hess [H&H]评分）呈分级相关。同样，入住NICU期间发生全身炎症反应综合征（SIRS）的几率随入院时H&H分级的增加而增加。SIRS和感染性休克的发生率分别为29%和10.3%。SIRS患者的死亡率为40.2%，感染性休克患者的死亡率为80%。77%的脑外器官系统功能衰竭（OSF）与SIRS同时发生：呼吸OSF的51%、肾脏OSF的97%、肝脏OSF的100%、心血管OSF的96%以及造血OSF的73%。中枢神经系统功能障碍和脑外器官系统功能障碍均与神经功能转归显著相关。随着脑灌注压（CPP）降低和脑外器官功能障碍严重程度增加，不良神经功能转归的概率显著增加。
动脉瘤性SAH及其神经后遗症是本系列研究中主要的发病和死亡原因。脑外器官系统功能障碍的发生与不良神经功能转归的可能性较高相关。全身炎症（SIRS）和继发性器官功能障碍是主要的非神经源性死亡原因。
