Weigel Ralf, Hohenstein Axel, Schlickum Linda, Weiss Christel, Schilling Lothar
Department of Neurosurgery, Division of Neurosurgical Research, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
Neurosurgery. 2007 Oct;61(4):788-92; discussion 792-3. doi: 10.1227/01.NEU.0000298907.56012.E8.
Chronic subdural hematoma (CSH) is characterized by pathological vascularization of the parietal membrane. Plasma leakage from immature vessels may be involved in hematoma enlargement and recurrence. We tested the hypothesis that the antiangiogenic side-effect of angiotensin converting enzyme (ACE)-inhibitor treatment for the control of arterial hypertension reduces the risk of recurrence in CSH.
We analyzed the data of 438 patients with CSH treated by a standard surgical procedure for hematoma evacuation in our department between 1995 and 2003. Patients with coagulopathies, malignancies, and independent neurological disorders were excluded from this study. Patient records were screened for age, sex, pre- and postoperative Markwalder score, arterial hypertension, medication with ACE-inhibitors, and recurrence of CSH. The rate of ACE-inhibitor treatment in our CSH patients was compared with an age-matched control group treated for herniated lumbar disc at the same time. The concentration of vascular endothelial growth factor was analyzed in hematoma samples and corresponding venous blood in 40 consecutive patients.
A total of 310 patients were included in this study. The demographic data of Group A (with ACE-inhibition) and Group B (without ACE-inhibition) were comparable. In Group A, 5% (four out of 81) of the patients experienced recurrence as opposed to 18% (42 out of 229) in Group B (P = 0.00345). A negative correlation was found between the yearly rates of medication with ACE-inhibitors and recurrence (r = -0.8488; P = 0.0044). The rate of ACE-inhibitor treatment was lower in the CSH patients (25%) than in the control group (40%). The VEGF content was significantly lower in the hematoma in patients with ACE-inhibition (mean, 8891 pg/ml; range, 4300-18,300 pg/ml) than in patients without (mean, 22,565 pg/ml; range, 4200-89,650 pg/ml; P = 0.0116).
Our data suggest that ACE-inhibitor treatment for the control of arterial hypertension lowers the risk of recurrence in patients undergoing operation for CSH and possibly even the development of CSH. This effect might be the result of an antiangiogenic mechanism of ACE-inhibitors.
慢性硬膜下血肿（CSH）的特征是顶叶膜出现病理性血管化。未成熟血管的血浆渗漏可能与血肿扩大和复发有关。我们检验了这样一个假设，即血管紧张素转换酶（ACE）抑制剂治疗动脉高血压的抗血管生成副作用可降低CSH复发风险。
我们分析了1995年至2003年间在我科接受标准血肿清除手术治疗的438例CSH患者的数据。本研究排除了患有凝血障碍、恶性肿瘤和独立神经系统疾病的患者。筛查患者记录，了解其年龄、性别、术前和术后Markwalder评分、动脉高血压、ACE抑制剂用药情况以及CSH复发情况。将我们的CSH患者中ACE抑制剂治疗率与同时接受腰椎间盘突出症治疗的年龄匹配对照组进行比较。对40例连续患者的血肿样本和相应静脉血中的血管内皮生长因子浓度进行了分析。
本研究共纳入310例患者。A组（接受ACE抑制治疗）和B组（未接受ACE抑制治疗）的人口统计学数据具有可比性。A组中5%（81例中有4例）的患者出现复发，而B组为18%（229例中有42例）（P = 0.00345）。发现ACE抑制剂的年用药率与复发之间呈负相关（r = -0.8488；P = 0.0044）。CSH患者中ACE抑制剂治疗率（25%）低于对照组（40%）。接受ACE抑制治疗的患者血肿中的VEGF含量（平均8891 pg/ml；范围4300 - 18300 pg/ml）显著低于未接受治疗的患者（平均22565 pg/ml；范围4200 - 89650 pg/ml；P = 0.0116）。
我们的数据表明，ACE抑制剂治疗动脉高血压可降低接受CSH手术患者的复发风险，甚至可能降低CSH的发生风险。这种效应可能是ACE抑制剂抗血管生成机制的结果。
