Rosengart Axel J, Schultheiss Kim E, Tolentino Jocelyn, Macdonald R Loch
Neurocritical Care and Acute Stroke Program, Department of Neurology, University of Chicago Medical Center, Chicago, IL, USA.
Stroke. 2007 Aug;38(8):2315-21. doi: 10.1161/STROKEAHA.107.484360. Epub 2007 Jun 14.
The purpose of this study was to describe prognostic factors for outcome in a large series of patients undergoing neurosurgical clipping of aneurysms after subarachnoid hemorrhage (SAH).
Data were analyzed from 3567 patients with aneurysmal SAH enrolled in 4 randomized clinical trials between 1991 and 1997. The primary outcome measure was the Glasgow outcome scale 3 months after SAH. Multivariable logistic regression with backwards selection and Cox proportional hazards regression models were derived to define independent predictors of unfavorable outcome.
In multivariable analysis, unfavorable outcome was associated with increasing age, worsening neurological grade, ruptured posterior circulation aneurysm, larger aneurysm size, more SAH on admission computed tomography, intracerebral hematoma or intraventricular hemorrhage, elevated systolic blood pressure on admission, and previous diagnosis of hypertension, myocardial infarction, liver disease, or SAH. Variables present during hospitalization associated with poor outcome were temperature >38 degrees C 8 days after SAH, use of anticonvulsants, symptomatic vasospasm, and cerebral infarction. Use of prophylactic or therapeutic hypervolemia or prophylactic-induced hypertension were associated with a lower risk of unfavorable outcome. Time from admission to surgery was significant in some models. Factors that contributed most to variation in outcome, in descending order of importance, were cerebral infarction, neurological grade, age, temperature on day 8, intraventricular hemorrhage, vasospasm, SAH, intracerebral hematoma, and history of hypertension.
Although most prognostic factors for outcome after SAH are present on admission and are not modifiable, a substantial contribution to outcome is made by factors developing after admission and which may be more easily influenced by treatment.
本研究旨在描述大量蛛网膜下腔出血（SAH）后接受动脉瘤神经外科夹闭术患者的预后因素。
分析了1991年至1997年间纳入4项随机临床试验的3567例动脉瘤性SAH患者的数据。主要结局指标是SAH后3个月的格拉斯哥预后评分。采用向后选择的多变量逻辑回归和Cox比例风险回归模型来确定不良结局的独立预测因素。
在多变量分析中，不良结局与年龄增加、神经功能分级恶化、后循环动脉瘤破裂、动脉瘤尺寸较大、入院计算机断层扫描显示SAH较多、脑内血肿或脑室内出血、入院时收缩压升高以及既往有高血压、心肌梗死、肝病或SAH诊断有关。住院期间出现的与不良结局相关的变量包括SAH后8天体温>38摄氏度、使用抗惊厥药、症状性血管痉挛和脑梗死。使用预防性或治疗性高血容量或预防性诱导高血压与不良结局风险较低相关。在某些模型中，从入院到手术的时间具有显著性。对结局差异贡献最大的因素，按重要性降序排列，依次为脑梗死、神经功能分级、年龄、第8天体温、脑室内出血、血管痉挛、SAH、脑内血肿和高血压病史。
虽然SAH后大多数预后因素在入院时就已存在且无法改变，但入院后出现的因素对结局有很大影响，且可能更容易受到治疗的影响。
