James Robert F, Khattar Nicolas K, Aljuboori Zaid S, Page Paul S, Shao Elaine Y, Carter Lacey M, Meyer Kimberly S, Daniels Michael W, Craycroft John, Gaughen John R, Chaudry M Imran, Rai Shesh N, Everhart D Erik, Simard J Marc
1Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky.
2Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina.
J Neurosurg. 2018 May 11;130(5):1460-1467. doi: 10.3171/2017.11.JNS17894. Print 2019 May 1.
Cognitive dysfunction occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH) survivors. Low-dose intravenous heparin (LDIVH) infusion using the Maryland protocol was recently shown to reduce clinical vasospasm and vasospasm-related infarction. In this study, the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive changes in aSAH patients treated with the Maryland LDIVH protocol compared with controls.
A retrospective analysis of all patients treated for aSAH between July 2009 and April 2014 was conducted. Beginning in 2012, aSAH patients were treated with LDIVH in the postprocedural period. The MoCA was administered to all aSAH survivors prospectively during routine follow-up visits, at least 3 months after aSAH, by trained staff blinded to treatment status. Mean MoCA scores were compared between groups, and regression analyses were performed for relevant factors.
No significant differences in baseline characteristics were observed between groups. The mean MoCA score for the LDIVH group (n = 25) was 26.4 compared with 22.7 in controls (n = 22) (p = 0.013). Serious cognitive impairment (MoCA ≤ 20) was observed in 32% of controls compared with 0% in the LDIVH group (p = 0.008). Linear regression analysis demonstrated that only LDIVH was associated with a positive influence on MoCA scores (β = 3.68, p =0.019), whereas anterior communicating artery aneurysms and fevers were negatively associated with MoCA scores. Multivariable linear regression analysis resulted in all 3 factors maintaining significance. There were no treatment complications.
This preliminary study suggests that the Maryland LDIVH protocol may improve cognitive outcomes in aSAH patients. A randomized controlled trial is needed to determine the safety and potential benefit of unfractionated heparin in aSAH patients.
高达70%的动脉瘤性蛛网膜下腔出血（aSAH）幸存者会出现认知功能障碍。最近有研究表明，采用马里兰方案进行低剂量静脉肝素（LDIVH）输注可减少临床血管痉挛及与血管痉挛相关的梗死。在本研究中，使用蒙特利尔认知评估量表（MoCA）来评估采用马里兰LDIVH方案治疗的aSAH患者与对照组相比的认知变化。
对2009年7月至2014年4月期间所有接受aSAH治疗的患者进行回顾性分析。从2012年开始，aSAH患者在术后接受LDIVH治疗。由对治疗状态不知情的经过培训的工作人员在常规随访期间对所有aSAH幸存者进行MoCA评估，随访时间至少在aSAH后3个月。比较两组的平均MoCA评分，并对相关因素进行回归分析。
两组之间在基线特征方面未观察到显著差异。LDIVH组（n = 25）的平均MoCA评分为26.4，而对照组（n = 22）为22.7（p = 0.013）。32%的对照组患者出现严重认知障碍（MoCA≤20），而LDIVH组这一比例为0%（p = 0.008）。线性回归分析表明，只有LDIVH对MoCA评分有积极影响（β = 3.68，p = 0.019），而前交通动脉瘤和发热与MoCA评分呈负相关。多变量线性回归分析显示所有这3个因素均保持显著意义。未出现治疗并发症。
这项初步研究表明，马里兰LDIVH方案可能改善aSAH患者的认知结局。需要进行一项随机对照试验来确定普通肝素在aSAH患者中的安全性和潜在益处。
