Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Center of Excellence of Neurovascular Intervention and Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
World Neurosurg. 2024 Sep;189:e1066-e1076. doi: 10.1016/j.wneu.2024.07.083. Epub 2024 Jul 14.
The prior trials investigating triple-H therapy for preventing delayed cerebral ischemia (DCI) enrolled patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent early aneurysm therapy within 3 days. However, surgical clipping might be performed during 4-7 days that high incidence cerebral vasospasm is likely. We examined effects of hypervolemia-augmented blood pressure (HV-ABP) protocol on DCI prevention when clipping was delayed.
The study enrolled aSAH patients hospitalized during 2013-2019 who underwent clipping 4-7 days after rupture in a university hospital in Thailand. DCI and secondary outcomes were compared among patients who achieved the HV-ABP protocol (3-5 L/day fluid intake and 140-180 mmHg systolic blood pressure maintained for 72 hours postoperatively) and those who did not. The intervention-outcome associations were estimated using logistic regression for the whole group and a patient subgroup with similar propensity scores (PS) for protocol achievement.
One hundred seventy-seven aSAH patients were clipped 4-7 days after rupture; 97 patients (54.8%) achieved the HV-ABP protocol, while 80 patients (45.2%) did not. One hundred twenty-two patients with one-to-one PS matching reduced the originally unequal patient characteristics. The observed DCI was lower in patients with protocol-achieved (8.3%) than in their nonachieved counterparts (22.5%). This resulted in an association with the HV-ABP intervention with adjusted odds ratios of 0.201 (95% confidence interval, 0.066-0.613) in the whole sample and 0.228 (0.065-0.794) in the PS-matched subsample. No statistically significant differences in the secondary outcomes were found.
Achieving the targets recommended in the HV-ABP protocol was associated with reducing the DCI incidence in patients with aSAH who underwent delayed clipping.
先前研究三重 H 治疗以预防迟发性脑缺血（DCI）的试验纳入了在发病后 3 天内行早期动脉瘤治疗的蛛网膜下腔出血（aSAH）患者。然而，夹闭手术可能在 4-7 天内进行，此时很可能发生高发生率的脑血管痉挛。我们研究了在延迟夹闭时，高血容量增强血压（HV-ABP）方案对预防 DCI 的效果。
该研究纳入了 2013 年至 2019 年期间在泰国一所大学医院住院的 aSAH 患者，这些患者在破裂后 4-7 天行夹闭术。比较了达到 HV-ABP 方案（术后 72 小时内每天摄入 3-5 升液体，收缩压维持在 140-180mmHg）和未达到该方案的患者的 DCI 和次要结局。使用逻辑回归对全组和具有相似倾向评分（PS）以实现方案的患者亚组进行干预-结局关联估计。
177 例 aSAH 患者在破裂后 4-7 天行夹闭术；97 例（54.8%）达到 HV-ABP 方案，80 例（45.2%）未达到该方案。122 例具有一对一 PS 匹配的患者减少了原本不均衡的患者特征。达到方案的患者中观察到的 DCI 发生率（8.3%）低于未达到方案的患者（22.5%）。这导致调整后的比值比为 0.201（95%置信区间，0.066-0.613），在全样本和 PS 匹配亚组中分别为 0.228（0.065-0.794）。在次要结局方面未发现统计学上的显著差异。
在接受延迟夹闭的 aSAH 患者中达到 HV-ABP 方案推荐的目标与降低 DCI 发生率相关。
