症状性血管痉挛与动脉瘤性蛛网膜下腔出血后的预后：手术修复与血管内弹簧圈栓塞的比较

Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion.

作者信息

Rabinstein Alejandro A, Pichelmann Mark A, Friedman Jonathan A, Piepgras David G, Nichols Douglas A, McIver Jon I, Toussaint L Gerard, McClelland Robyn L, Fulgham Jimmy R, Meyer Fredric B, Atkinson John L D, Wijdicks Eelco F

机构信息

Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.

出版信息

J Neurosurg. 2003 Feb;98(2):319-25. doi: 10.3171/jns.2003.98.2.0319.

DOI:10.3171/jns.2003.98.2.0319

PMID:12593618

Abstract

OBJECT

The authors studied patients with aneurysmal subarachnoid hemorrhage (SAH) to determine whether the incidence of symptomatic vasospasm or overall clinical outcomes differed between patients treated with craniotomy and clip application and those treated by endovascular coil occlusion.

METHODS

The authors reviewed 415 consecutive patients with aneurysmal SAH who had been treated with either craniotomy and clip application or endovascular coil occlusion at a single institution between 1990 and 2000. Three hundred thirty-nine patients underwent surgical clip application procedures, whereas 76 patients underwent endovascular coil occlusion. Symptomatic vasospasm occurred in 39% of patients treated with clip application, 30% of patients treated with endovascular coil occlusion, and 37% of patients overall. Compared with patients treated with clip application, patients treated with endovascular coil occlusion were more likely to suffer acute hydrocephalus (50 compared with 34%, p = 0.008) and were more likely to harbor aneurysms in the posterior circulation (53 compared with 20%, p < 0.001). Logistic regression models controlling for patient age, admission World Federation of Neurosurgical Societies (WFNS) grade, acute hydrocephalus, aneurysm location, and day of treatment revealed that, among patients with an admission WFNS grade of I to III, endovascular coil occlusion carried a lower risk of symptomatic vasospasm (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14-0.8) and death or permanent neurological deficit due to vasospasm (OR 0.28, 95% CI 0.08-1) compared with craniotomy and clip application. Similar models revealed no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less at the longest follow-up review (median 6 months) between treatment groups (OR 0.58, 95% CI 0.28-1.21).

CONCLUSIONS

Patients with better clinical grades (WFNS Grades I-III) at hospital admission were less likely to suffer symptomatic vasospasm when treated by endovascular coil occlusion, compared with craniotomy and clip application. Nevertheless, there was no significant difference in overall outcome at the longest follow-up examination between the two treatment groups.

摘要

目的

作者对动脉瘤性蛛网膜下腔出血（SAH）患者进行研究，以确定开颅夹闭术治疗的患者与血管内弹簧圈栓塞术治疗的患者在症状性血管痉挛的发生率或总体临床结局方面是否存在差异。

方法

作者回顾了1990年至2000年间在单一机构接受开颅夹闭术或血管内弹簧圈栓塞术治疗的415例连续性动脉瘤性SAH患者。339例患者接受了手术夹闭术，而76例患者接受了血管内弹簧圈栓塞术。症状性血管痉挛发生在39%接受夹闭术治疗的患者、30%接受血管内弹簧圈栓塞术治疗的患者以及37%的总体患者中。与接受夹闭术治疗的患者相比，接受血管内弹簧圈栓塞术治疗的患者更易发生急性脑积水（50% 对比34%，p = 0.008），且更易在后循环中存在动脉瘤（53% 对比20%，p < 0.001）。控制患者年龄、入院时世界神经外科医师协会（WFNS）分级、急性脑积水、动脉瘤位置和治疗日期的逻辑回归模型显示，在入院WFNS分级为I至III级的患者中，与开颅夹闭术相比，血管内弹簧圈栓塞术发生症状性血管痉挛的风险较低（比值比[OR] 0.34，95%置信区间[CI] 0.14 - 0.8），因血管痉挛导致死亡或永久性神经功能缺损的风险也较低（OR 0.28，95% CI 0.08 - 1）。类似模型显示，在最长随访复查（中位时间6个月）时，治疗组之间格拉斯哥预后量表评分为3分及以下的可能性无差异（OR 0.58，95% CI 0.28 - 1.21）。