Department of Neurology, University of Heidelberg, Heidelberg, Germany.
J Stroke Cerebrovasc Dis. 2011 Jul-Aug;20(4):287-94. doi: 10.1016/j.jstrokecerebrovasdis.2009.12.008. Epub 2010 May 8.
The value of neurosurgical interventions after spontaneous intracerebral hemorrhage (SICH) is uncertain. We evaluated clinical outcomes in patients diagnosed with SICH within 3 hours of symptom onset who underwent hematoma evacuation or external ventricular drainage (EVD) of the hematoma in the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST). FAST was a randomized, multicenter, double-blind, placebo-controlled trial conducted between May 2005 and February 2007 at 122 sites in 22 countries. Neurosurgical procedures (hematoma evacuation and external ventricular drainage) performed at any point after hospital admission were prospectively recorded. Clinical outcomes evaluated were post-SICH disability, as assessed by the modified Rankin Scale; neurologic impairment, as assessed by the National Institutes of Health Stroke Scale; and mortality at 90 days after SICH onset. The impact of neurosurgical procedures on clinical outcomes was evaluated using multivariate logistic regression analysis, controlling for relevant baseline characteristics. Fifty-five of 821 patients underwent neurosurgery. Patients who underwent hematoma evacuation or EVD were on average younger, had greater baseline neurologic impairment, and lower levels of consciousness compared with patients who did not undergo neurosurgery. After adjusting for these differences and other relevant baseline characteristics, we found that neurosurgery was generally associated with unfavorable outcomes at day 90. Among the patients who underwent hematoma evacuation, those with lobar ICH had less ICH expansion than those with deep gray matter ICH, and the smaller expansion was associated with lower mortality. ICH volume was substantially decreased in patients who underwent hematoma evacuation between 24 and 72 hours after hospital admission, and this was associated with better clinical outcome. In conclusion, a small number of patients who underwent neurosurgery in FAST exhibited no overall clinical benefit from neurosurgical intervention, although outcomes varied by type of surgery, time of surgery, and hematoma location. Our findings support the need for further research into the value of neurosurgery in patients with SICH.
自发性脑出血（ICH）后神经外科干预的价值尚不确定。我们评估了在症状发作后 3 小时内接受血肿清除术或血肿外引流术（EVD）的 FAST 试验（Factor Seven for Acute Hemorrhagic Stroke Trial）中诊断为 ICH 的患者的临床结局。FAST 是一项在 2005 年 5 月至 2007 年 2 月期间在 22 个国家的 122 个地点进行的随机、多中心、双盲、安慰剂对照试验。入院后任何时间进行的神经外科手术（血肿清除术和外引流术）均前瞻性记录。评估的临床结局是 ICH 后残疾，采用改良 Rankin 量表评估；神经功能损伤，采用 NIH 卒中量表评估；ICH 发病后 90 天的死亡率。采用多变量逻辑回归分析评估神经外科手术对临床结局的影响，控制相关基线特征。821 例患者中有 55 例接受了神经外科手术。与未接受神经外科手术的患者相比，接受血肿清除术或 EVD 的患者平均年龄较小，基线神经功能损伤更严重，意识水平更低。在调整这些差异和其他相关基线特征后，我们发现神经外科手术通常与 90 天的不良结局相关。在接受血肿清除术的患者中，脑叶 ICH 患者的 ICH 扩展量小于深部灰质 ICH 患者，而较小的扩展与较低的死亡率相关。在入院后 24 至 72 小时内接受血肿清除术的患者中，ICH 体积显著减少，并且与更好的临床结局相关。总之，在 FAST 中接受神经外科手术的少数患者并未从神经外科干预中获得总体临床获益，尽管手术类型、手术时间和血肿部位不同，结果也有所不同。我们的研究结果支持进一步研究神经外科手术在自发性脑出血患者中的价值。
