血管造影阴性蛛网膜下腔出血：出血模式与临床结果的关系。
Angiogram-negative subarachnoid hemorrhage: relationship between bleeding pattern and clinical outcome.
机构信息
Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, BWH-CA-133, Boston, MA 02115, USA.
出版信息
Neurocrit Care. 2012 Jun;16(3):389-98. doi: 10.1007/s12028-012-9680-6.
BACKGROUND
Angiogram-negative subarachnoid hemorrhage (anSAH) accounts for 15% of spontaneous SAH. Recent studies suggest the outcome and diagnostic yield in anSAH differ based on initial bleeding pattern. We present a single-center experience in managing patients with SAH and negative initial digital-subtracted angiogram (DSA).
METHODS
Records of all patients with anSAH were reviewed. Bleeding pattern was determined from computed tomography (CT) and was categorized as perimesencephalic (PMN), diffuse, cortical, or xanthochromia (blood not detectable by CT). Diagnostic yield, in-hospital complications, and outcome parameters were analyzed.
RESULTS
Of 352 patients admitted with spontaneous SAH from 2003 to 2008, 68 (19.3%) had negative initial DSA. Mean age was 59.5 ± 14, and 33 were female. By CT, 27 (39.7%) patients exhibited PMN SAH, 33 (48.5%) diffuse SAH, 6 (8.8%) cortical SAH, and 2 (2.9%) xanthochromia only. Sixty-one patients had good Hunt and Hess (H/H) grades (I-III) and seven had poor grades (IV-V). Additional diagnostic studies included repeat angiogram (54), brain and C-spine magnetic resonance imaging (20), and repeat CTA (15). A structural bleeding cause was determined in six (8.8%) patients, 4 of which had diffuse SAH and 2 cortical SAH. Among these, two aneurysms (2.9%) were detected and surgically clipped, and both had diffuse SAH. Twenty-nine patients (42.6%) experienced medical complications, with infection (18), cardiovascular problems (12), and vasospasm (10) being the most frequent events. Additional surgeries included 13 ventriculoperitoneal shunts, 4 tracheostomies, and 9 gastric tube placements. Favorable outcome (mRS = 0-2) was recorded in 49 (72.1%) patients and unfavorable (3-6) in 19 (17.49%), with 1 (1.2%) in-hospital death. Multivariable logistic regression revealed older age and diffuse bleeding pattern were significant predictors of unfavorable outcome.
CONCLUSIONS
The overall incidence of true aneurysms in patients with angiogram-negative SAH is low (2.9%). Initial bleeding pattern strongly correlates with diagnostic yield and clinical outcome. Diffuse bleeding pattern is associated with significantly higher diagnostic yield, more in-hospital complications, and worse clinical outcome. Patients with initial imaging characteristics other than diffuse pattern SAH developed few disease related complications, with the majority of in-hospital adverse events treatment related.
背景
血管造影阴性蛛网膜下腔出血（anSAH）占自发性 SAH 的 15%。最近的研究表明，anSAH 的初始出血模式不同，其结果和诊断效果也不同。我们报告了一家单中心管理 SAH 患者和初始数字减影血管造影（DSA）阴性的经验。
方法
回顾了所有 anSAH 患者的记录。根据 CT 确定出血模式，并按中脑周围（PMN）、弥漫性、皮质或黄染（CT 无法检测到的血液）进行分类。分析诊断效果、住院并发症和结果参数。
结果
2003 年至 2008 年期间，352 例自发性 SAH 患者中，68 例（19.3%）初始 DSA 为阴性。平均年龄为 59.5±14 岁，33 例为女性。根据 CT，27 例（39.7%）患者表现为 PMN SAH，33 例（48.5%）为弥漫性 SAH，6 例（8.8%）为皮质性 SAH，2 例（2.9%）为黄染。61 例患者具有良好的 Hunt 和 Hess（H/H）分级（I-III），7 例为较差分级（IV-V）。其他诊断性研究包括重复血管造影（54 例）、脑和 C 颈磁共振成像（20 例）和重复 CTA（15 例）。6 例（8.8%）患者确定了结构性出血原因，其中 4 例为弥漫性 SAH，2 例为皮质性 SAH。其中，2 例（2.9%）动脉瘤被发现并接受手术夹闭，均为弥漫性 SAH。29 例（42.6%）患者发生了医疗并发症，感染（18 例）、心血管问题（12 例）和血管痉挛（10 例）是最常见的事件。其他手术包括 13 例脑室-腹腔分流术、4 例气管切开术和 9 例胃管放置术。49 例（72.1%）患者的预后良好（mRS=0-2），19 例（17.49%）预后不良（3-6），1 例（1.2%）住院死亡。多变量逻辑回归显示，年龄较大和弥漫性出血模式是预后不良的显著预测因素。
结论
血管造影阴性 SAH 患者中真正动脉瘤的总体发生率较低（2.9%）。初始出血模式与诊断效果和临床结果密切相关。弥漫性出血模式与更高的诊断效果、更多的住院并发症和更差的临床结果显著相关。初始影像学特征除弥漫性模式 SAH 外的患者发生疾病相关并发症较少，大多数住院不良事件与治疗相关。
Zotero 插件