摘要
目的探讨头部CT血肿形态不规则对行开颅血肿清除术的自发性脑出血(ICH)患者术后再出血及预后的影响。方法回顾性连续纳入2019年1月至2024年6月于贵州医科大学附属贵阳市第二人民医院神经外科行开颅血肿清除术的ICH患者。收集患者的基线及临床资料,包括年龄、性别、吸烟史、饮酒史、高血压病、糖尿病、抗凝剂应用史、入院收缩压、入院舒张压、入院美国国立卫生研究院卒中量表(NIHSS)评分、入院格拉斯哥昏迷量表(GCS)评分、发病至首次头部CT时间、入院中性粒细胞与淋巴细胞比值(NLR)、入院血小板与淋巴细胞比值(PLR)。通过ICH患者入院头部CT评估患者血肿形态(规则、不规则)、血肿位置(基底节、脑叶、多部位)、血肿体积、血肿周围水肿体积、中线是否偏移、是否破入脑室。术后2 d经CT评估血肿体积。术后再出血定义为术后2周内CT血肿体积较前次增加12.5 ml以上或血肿完全清除后随访头部CT局灶区域再次出现高密度影。术后6个月对患者进行电话随访,评估患者改良Rankin量表(mRS)评分。应用滑动二分法根据患者的基础情况及病情严重程度定义预后,预后评分=10×入院GCS评分-年龄-0.64×入院血肿体积,预后评分>27.672分为可能预后良好,预后评分≤27.672分为可能预后不良,对于可能预后良好的患者,mRS评分0~2分为预后良好,3~6分为预后不良;对于可能预后不良的患者,mRS评分0~3分为预后良好,4~6分为预后不良。将血肿形态规则和不规则患者基线与临床资料比较中P<0.05的因素纳入倾向性评分匹配(PSM)调整混杂因素,采用最邻近匹配法进行1∶1匹配,卡钳值设为0.25。将PSM后术后再出血与非术后再出血患者、预后良好与预后不良患者组间比较差异有统计学意义的变量纳入多因素Logistic回归分析,分别分析ICH患者行开颅血肿清除术后再出血及预后不良的影响因素,并通过受试者工作特征(ROC)曲线分析血肿形态不规则对ICH患者术后再出血及预后不良的预测价值。结果(1)共纳入440例ICH患者,男342例,女98例,年龄20~84岁,平均(56±12)岁。PSM前血肿形态规则组和血肿形态不规则组患者基线及临床资料中年龄、入院GCS评分、NIHSS评分、NLR、血肿破入脑室患者比例、血肿体积、中线偏移患者比例、血肿周围水肿体积、血肿位于多部位患者比例及术后2 d血肿体积差异均有统计学意义(均P<0.05)。将上述因素进行PSM后共298例ICH患者被纳入统计学分析,其中男228例,女70例,年龄20~84岁,平均(57±12)岁。PSM后血肿形态不规则组和血肿形态规则组患者基线及临床资料比较差异均无统计学意义(均P>0.05)。(2)PSM后术后再出血患者28例,非术后再出血患者270例,两组间有抗凝剂应用史的患者比例、入院PLR、入院NLR、入院CT血肿形态不规则患者比例及术后2 d血肿体积差异均有统计学意义(均P<0.05),余基线及临床资料组间差异均无统计学意义(均P>0.05)。以术后再出血为因变量,将组间比较中P<0.05的因素作为自变量行多因素Logistic回归分析,结果显示,入院CT血肿形态不规则(OR=2.821,95%CI:1.142~6.968,P=0.025)及术后2 d血肿体积大(OR=1.062,95%CI:1.026~1.099,P<0.01)是ICH患者行开颅血肿清除术后再出血的独立危险因素。ROC曲线分析显示,入院CT血肿形态不规则预测ICH患者行开颅血肿清除术后再出血的曲线下面积(AUC)为0.62,敏感度和特异度分别为71.4%、52.2%。(3)PSM后预后不良患者174例,预后良好患者124例,两组间年龄、入院GCS评分、入院NIHSS评分、入院CT血肿形态不规则、血肿位于基底节和脑叶患者比例及术后2 d血肿体积差异均有统计学意义(均P<0.05),余基线及临床资料差异均无统计学意义(均P>0.05)。以预后不良为因变量,将组间比较中P<0.05的因素作为自变量,进行多因素Logistic回归分析,结果显示,高龄(OR=1.039,95%CI:1.015~1.064,P=0.002)、高入院NIHSS评分(OR=1.068,95%CI:1.025~1.113,P=0.002)、入院CT血肿形态不规则(OR=2.675,95%CI:1.582~4.524,P<0.01)、术后2 d血肿体积大(OR=1.033,95%CI:1.002~1.064,P=0.038)是ICH行开颅血肿清除术患者预后不良的独立危险因素,血肿位于脑叶(OR=0.192,95%CI:0.073~0.504,P<0.01)是预后不良的保护因素。ROC曲线分析结果显示,入院CT血肿形态不规则预测ICH患者行开颅血肿清除术后预后不良的AUC为0.61,敏感度和特异度分别为59.2%、62.9%。结论入院头部CT血肿形态不规则是行开颅血肿清除术的ICH患者术后再出血及预后不良的独立危险因素。
Objective To explore the impact of irregular shape of head CT hematomas on postoperative re-bleeding and prognosis of patients with spontaneous intracerebral hemorrhage(ICH)who undergo craniotomy for hematoma evacuation.Methods We retrospectively enrolled consecutive patients with ICH who underwent craniotomy for hematoma evacuation in the Department of Neurosurgery of the Second People′s Hospital of Guiyang Affiliated to Guizhou Medical University from January 2019 to June 2024.Baseline and clinical data were collected form the patients,including age,gender,smoking history,drinking history,hypertension,diabetes,history of anticoagulant use,admission systolic and diastolic blood pressure,admission National Institutes of Health stroke scale(NIHSS)score,Glasgow coma scale(GCS)score,time from onset to the first head CT,neutrophil-to-lymphocyte ratio(NLR),and platelet-to-lymphocyte ratio(PLR).Admission head CT scans were used to assess hematoma shape(regular or irregular),hematoma location(basal ganglia,lobar,multifocal),hematoma volume,perihematomal edema volume,the presence of midline shift,and intraventricular extension.Volume of the hematoma was assessed 2 days after surgery.Postoperative re-bleeding is defined as an increase in the volume of the hematoma by 12.5 ml compared to the previous postoperative CT scan within 2 weeks after surgery,or the reappearance of high-density areas in the focal area of the head CT scan during follow-up after complete hematoma clearance.Conduct patients follow-ups via telephone at 6 months postoperatively to assess their modified Rankin scale(mRS)scores.The sliding dichotomy method was applied to define prognosis based on the patients′baseline characteristics and disease severity.The prognostic score was calculated using formula:10×admission GCS score-age-0.64×admission hematoma volume.A prognostic score>27.672 was considered potentially favorable,while a score≤27.672 was considered potentially unfavorable.For patients with a potentially favorable prognosis,an mRS score of 0-2 was defined as a good outcome,and a score of 3-6 as a poor outcome.For those with a potentially unfavorable prognosis,an mRS score of 0-3 was defined as a good outcome,and a score of 4-6 as a poor outcome.In the comparison of baseline and clinical data between patients with regular and irregular hematoma shapes,factors with P<0.05 were included in propensity score matching(PSM)to adjust for confounding variables.A 1∶1 matching was performed using the nearest neighbor method with a caliper value set to 0.25.Variables with statistically significant differences between groups after PSM matching were included in the multivariate Logistic regression analysis to identify influencing factors for postoperative re-bleeding and poor prognosis in ICH patients undergoing craniotomy hematoma evacuation.The predictive value of irregular hematoma shape for postoperative rebleeding and poor prognosis in ICH patients was analyzed using receiver operating characteristic(ROC)curve analysis.Results(1)A total of 440 ICH patients were enrolled,including 342 males and 98 females,aged from 20 to 84 years with a mean age of(56±12)years.Statistically significant differences were observed in baseline and clinical data between patients with regular and irregular hematoma shapes before PSM,including age,admission GCS score,NIHSS score,NLR,proportion of patients with hematoma rupture into ventricles,preoperative hematoma volume,proportion of patients with midline shift,preoperative volume of hematoma surrounding edema,proportion of patients with hematoma located in multiple sites,and postoperative 2-day hematoma volume(all P<0.05).After propensity score matching of these factors,298 ICH patients were included in the statistical analysis,comprising 228 males and 70 females,with an age range of 20 to 84 years and a mean age of(57±12)years.Following PSM,no statistically significant differences were observed in the baseline and clinical characteristics between patients with irregular and regular hematoma shapes(all P>0.05).(2)After propensity score matching,28 patients experienced postoperative re-bleeding while 270 did not.Significant differences were observed between the two groups in the following factors:proportion of patients with a history of anticoagulant use,admission PLR,NLR,irregular hematoma shape,and hematoma volume at 2 days after operation(all P<0.05).No statistically significant differences were found in the remaining baseline and clinical characteristics(all P>0.05).Using postoperative re-bleeding as the dependent variable and incorporating factors with P<0.05 from the univariate analysis as independent variables,multivariate Logistic regression analysis identified irregular hematoma shape(OR,2.821,95%CI 1.142-6.968,P=0.025)and larger hematoma volume at 2 days post-operation(OR,1.062,95%CI 1.026-1.099,P<0.01)as independent risk factors for re-bleeding following intracranial hematoma evacuation in ICH patients.ROC curve analysis demonstrated that irregular hematoma shape predicted postoperative re-bleeding with an area under the curve(AUC)of 0.62,showing a sensitivity of 71.4%and a specificity of 52.2%.(3)After propensity score matching,174 patients had poor prognosis while 124 had good prognosis.Significant intergroup differences were observed in age,admission GCS score,NIHSS score,irregular hematoma shape,proportion of patients with hematomas located in the basal ganglia and cerebral lobes,and hematoma volume at 2 days post-operation(all P<0.05).No statistically significant differences were found in the remaining baseline and clinical characteristics(all P>0.05).Using poor prognosis as the dependent variable and incorporating factors with P<0.05 from univariate analysis as independent variables,multivariate Logistic regression analysis revealed that advanced age(OR,1.039,95%CI 1.015-1.064,P=0.002),high admission NIHSS score(OR,1.068,95%CI 1.025-1.113,P=0.002),irregular hematoma shape(OR,2.675,95%CI 1.582-4.524,P<0.01),and larger hematoma volume at 2 days post-operation(OR,1.033,95%CI 1.002-1.064,P=0.038)were independent risk factors for poor prognosis.Conversely,lobar hematoma location(OR,0.192,95%CI 0.073-0.504,P<0.01)was identified as a protective factor.ROC curve analysis showed that irregular hematoma shape predicted poor prognosis after intracranial hematoma evacuation with an AUC of 0.61,demonstrating a sensitivity of 59.2%and specificity of 62.9%.Conclusion Irregular hematoma shape on head CT is an independent risk factor for both postoperative re-bleeding and poor prognosis in ICH patients undergoing craniotomy for hematoma evacuation.
作者
付媛媛
罗莉
杨金花
王丽琨
何莲
伍国锋
任思颖
林世奇
Fu Yuanyuan;Luo Li;Yang Jinhua;Wang Likun;He Lian;Wu Guofeng;Ren Siying;Lin Shiqi(Emergency Department,the Affiliated Hospital of Guizhou Medical University,Guiyang 550004,China)
出处
《中国脑血管病杂志》
北大核心
2025年第9期601-611,共11页
Chinese Journal of Cerebrovascular Diseases
基金
国家自然科学基金(82260244)
贵州医科大学校级重点实验室建设项目([2024]fy007)
贵州医科大学附属医院学科领军人才(gyfyxkyc-2023-05)。
关键词
脑出血
预后
形态不规则
颅内血肿清除术
术后再出血
Intracerebral hemorrhage
Prognosis
Irregular shape
Evacuation of intracranial hematoma
Postoperative re-bleeding
作者简介
通信作者:王丽琨,Email:769070308@qq.com。
