Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland.
Department of Neurosurgery, University Hospital Geneva, Geneva, Switzerland.
World Neurosurg. 2014 Nov;82(5):e599-605. doi: 10.1016/j.wneu.2014.05.011. Epub 2014 May 15.
Prior studies have shown that the incidence of neuropsychological deficits (NPDs) after aneurysmal subarachnoid hemorrhage (aSAH) is high despite excellent outcome according to neurologic grading scales. Delayed cerebral ischemia (DCI) occurs in 30% of patients after aSAH and significantly contributes to the mortality and morbidity of aSAH. We tested the hypothesis that DCI is associated with neuropsychological outcome.
Files of patients treated between January 2009 and August 2012 at 2 neurovascular centers were reviewed. Neuropsychological outcome was assessed in a face-to-face-interview of 2-2.5 hours' duration and graded as no (regular), minimal, moderate, or severe deficit according to normative population data by an experienced, independent neuropsychologist. The test battery was applied with consideration of the patients' individual premorbid level of workload and social activities and accounted for the following cognitive domains: memory, attention, executive function, visual and spatial perception, language and calculation, and behavior.
Of 226 patients treated at 2 centers, 187 were discharged alive. Full neuropsychological outcome assessment was available in 92 patients. DCI developed in 28 (30.4%) patients; 24 of these patients (85.7%) showed moderate to severe NPD. From a univariate perspective, patients with DCI were 6.38 times as likely to experience moderate to severe NPD after aSAH as patients without DCI (odds ratio [OR]; 95% confidence interval [CI], 1.98-20.50; P = 0.002), which remained statistically significant after correction for admission World Federation of Neurological Surgeons Grading System and Fisher scores, patient age, hydrocephalus, and further potential confounders (OR, 4.9; 95% CI, 1.26-19.58; P = 0.022). Of all factors analyzed, DCI was the strongest predictor of NPD in the multivariate analysis, followed by chronic hydrocephalus (OR, 4.85; 95% CI, 1.26-18.63; P = 0.022) and patient age ≥ 50 years (OR, 4.06; 95% CI, 1.39-11.92; P = 0.001).
Patients with evidence of DCI during their hospital course have a 5-fold increased risk of experiencing moderate to severe NPD compared with patients who do not develop DCI after aSAH. Secondary events occurring during acute hospitalization (DCI, hydrocephalus) may be more important to the overall neuropsychological outcome than hemorrhage (Fisher) and clinical severity (World Federation of Neurological Surgeons Grading System) scores at admission.
先前的研究表明，尽管根据神经学分级量表显示预后良好，但动脉瘤性蛛网膜下腔出血（aSAH）后神经认知缺损（NPD）的发生率仍然很高。aSAH 后 30%的患者会发生迟发性脑缺血（DCI），这显著增加了 aSAH 的死亡率和发病率。我们检验了这样一个假设，即 DCI 与神经认知结局有关。
回顾了 2009 年 1 月至 2012 年 8 月在 2 个神经血管中心治疗的患者的档案。由一名经验丰富的独立神经心理学家进行面对面访谈，持续 2-2.5 小时，根据常模人群数据，将神经认知结局评定为无（正常）、轻度、中度或重度缺损。应用测试组合时，考虑到患者个体的工作负荷和社会活动的前期水平，并考虑到以下认知领域：记忆、注意力、执行功能、视觉和空间感知、语言和计算以及行为。
在 2 个中心治疗的 226 例患者中，187 例患者存活出院。在 92 例患者中进行了完整的神经认知结局评估。28 例（30.4%）患者发生 DCI；其中 24 例（85.7%）患者出现中重度 NPD。从单变量角度来看，与无 DCI 的患者相比，发生 DCI 的患者发生中重度 NPD 的可能性高 6.38 倍（比值比[OR]；95%置信区间[CI]，1.98-20.50；P=0.002），在调整入院时的世界神经外科学会分级系统和 Fisher 评分、患者年龄、脑积水和其他潜在混杂因素后，这一结果仍具有统计学意义（OR，4.9；95%CI，1.26-19.58；P=0.022）。在多变量分析中，DCI 是 NPD 的最强预测因素，其次是慢性脑积水（OR，4.85；95%CI，1.26-18.63；P=0.022）和患者年龄≥50 岁（OR，4.06；95%CI，1.39-11.92；P=0.001）。
与未发生 aSAH 后 DCI 的患者相比，在住院期间出现 DCI 的患者发生中重度 NPD 的风险增加 5 倍。急性住院期间发生的继发性事件（DCI、脑积水）可能比入院时的出血（Fisher）和临床严重程度（世界神经外科学会分级系统）评分对整体神经认知结局更重要。
