Halim Alexander X, Johnston S Claiborne, Singh Vineeta, McCulloch Charles E, Bennett John P, Achrol Achal S, Sidney Stephen, Young William L
Department of Anesthesia, University of California San Francisco, San Francisco, Calif 94110, USA.
Stroke. 2004 Jul;35(7):1697-702. doi: 10.1161/01.STR.0000130988.44824.29. Epub 2004 May 27.
Accurate estimates for risk and rates of intracranial hemorrhage (ICH) in the natural course of patients harboring brain arteriovenous malformation (BAVM) are needed to provide a quantitative basis for planning clinical trials to evaluate interventional strategies and to help guide practice management.
We identified patients with BAVM at the Kaiser Permanente Northern California health maintenance organization and documented their clinical course. The influences of age at diagnosis, gender, race-ethnicity, ICH at presentation, venous draining pattern, and BAVM size on ICH subsequent to presentation were studied using the multivariate Cox proportional hazards model and Kaplan-Meier curves.
We identified 790 patients with BAVM (51% female; 63% white; mean age+/-SD at diagnosis: 38+/-19 years) between 1961 and 2001. Patients who presented with ICH experienced a higher rate of subsequent ICH than those who presented without ICH under multivariate analysis (hazard ratio, 3.6; 95% CI, 1.1 to 11.9; P<0.032). The effect was similar across race-ethnicity and gender. This difference in ICH rates was greatest in the first year (7% versus 3% per year) and converged over time. The effect of subsequent ICH on functional status was similar to that of the initial ICH.
Presentation with ICH was the most important predictor of future ICH, confirming previous studies. Future ICH had similar impact on functional outcome as incident ICH. Intervention to prevent ICH would be of potentially greater benefit to patients presenting with ICH, although the advantage decreases over time.
为评估介入策略的临床试验规划提供定量依据并指导实践管理，需要准确估计脑动静脉畸形（BAVM）患者自然病程中颅内出血（ICH）的风险和发生率。
我们在北加利福尼亚凯撒永久医疗保健组织中识别出患有BAVM的患者，并记录其临床病程。使用多变量Cox比例风险模型和Kaplan-Meier曲线研究诊断时年龄、性别、种族、就诊时ICH、静脉引流模式和BAVM大小对就诊后ICH的影响。
我们在1961年至2001年间识别出790例BAVM患者（51%为女性；63%为白人；诊断时平均年龄±标准差：38±19岁）。多变量分析显示，就诊时发生ICH的患者随后发生ICH的发生率高于未发生ICH的患者（风险比，3.6；95%置信区间，1.1至11.9；P<0.032）。种族和性别之间的影响相似。ICH发生率的差异在第一年最大（每年7%对3%），并随时间趋于一致。后续ICH对功能状态的影响与初始ICH相似。
就诊时发生ICH是未来ICH的最重要预测因素，证实了先前的研究。未来ICH对功能结局的影响与首次发生的ICH相似。预防ICH的干预措施可能对就诊时发生ICH的患者更有益，尽管随着时间推移这种优势会降低。
