Deliberate employment of postoperative hypotension for brain arteriovenous malformation surgery and the incidence of delayed postoperative hemorrhage: a prospective cohort study
Deliberate employment of postoperative hypotension for brain arteriovenous malformation surgery and the incidence of delayed postoperative hemorrhage: a prospective cohort study
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DOI：
10.3171/2016.9.jns161333
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发表时间：
2017-11-01
影响因子：
4.1
通讯作者：
Heller, Gillian Z.
中科院分区：
文献类型：
--
作者：
Morgan, Michael Kerin;Wiedmann, Markus Karl Hermann;Heller, Gillian Z.
目的：本研究旨在探讨术后故意降压对所有Spetzler-Ponce Class (SPC) C脑动静脉畸形（bAVMs）和SPC B脑动静脉畸形>= 3.5 cm直径（SPC B 3.5+）的术后迟发性出血（DPH）的影响。方法1997年6月，对所有SPC C和SPC B 3.5+ bam患者引入了术后刻意降压方案。目的是在bAVMs切除后至少7天内达到最大平均动脉血压（BP） 50 mm Hg。作者比较了2个时期（采用BP方案之前和引入BP方案之后）和4种bAVM类别（SPC a、SPC B 3.5-（即SPC B < 3.5 cm最大直径）、SPC B 3.5+和SPC C）发生DPH（定义为脑出血进入切除床，导致新的神经功能缺损或住院期间因显微手术切除而再次手术）的患者。被排除在血压方案之外的患者在重症监护病房进行管理，以避免中度高血压发作。对所有接受手术治疗的bAVM合并病例进行分析，以确定与DPH风险相关的特征。这些识别的特征，然后通过多重逻辑回归分析在SPC b3.5 +和SPC C病例中进行检验。结果在641例经显微手术治疗的bavm队列中，鉴定出32例DPH患者。其中66% （95% CI 48-80）有永久性的新神经功能缺损，改良Rankin量表评分为2-6。其中包括13%的死亡率（95% CI 4.4-29）。采用BP方案治疗162例SPC B 3.5+或SPC c患者。对于SPC B 3.5+患者，引入BP方案后DPH没有显著降低（p = 0.77）。对于SPC C，引入BP方案后，DPH从29% （95% CI 13%-53%）显著降低（p = 0.035）至8.2% （95% CI 3.2%-18%）。多元logistic回归分析发现，BP方案的缺失（p = 0.011，优势比为7.5,95% CI为1.6-36）对于SPC C型bAVMs患者DPH的发展仍然具有重要意义。结论：采用在切除后立即降低血压的方案治疗SPC C bAVMs患者似乎可以降低DPH的风险。对于SPC A和SPC B 3.5- bavm，除了避免术后高血压外，不太可能需要做更多的事情。对于SPC b3.5 +的bavm，需要更多的患者来测试BP方案是否没有益处。
OBJECTIVE The aim of this study was to examine the impact of deliberate employment of postoperative hypotension on delayed postoperative hemorrhage (DPH) for all Spetzler-Ponce Class (SPC) C brain arteriovenous malformations (bAVMs) and SPC B bAVMs >= 3.5 cm in diameter (SPC B 3.5+).METHODS A protocol of deliberate employment of postoperative hypotension was introduced in June 1997 for all SPC C and SPC B 3.5+ bAVMs. The aim was to achieve a maximum mean arterial blood pressure (BP) 50 mm Hg) for a minimum of 7 days after resection of bAVMs (BP protocol). The authors compared patients who experienced DPH (defined as brain hemorrhage into the resection bed that resulted in a new neurological deficit or that resulted in reoperation during the hospitalization for microsurgical bAVM resection) between 2 periods (prior to adopting the BP protocol and after introduction of the BP protocol) and 4 bAVM categories (SPC A, SPC B 3.5-[ that is, SPC B < 3.5 cm maximum diameter], SPC B 3.5+, and SPC C). Patients excluded from treatment by the BP protocol were managed in the intensive care unit to avoid moderate hypertensive episodes. The pooled cases of all bAVM treated by surgery were analyzed to identify characteristics associated with the risk of DPH. These identified characteristics were then examined by multiple logistic regression analysis in both SPC B 3.5+ and SPC C cases.RESULTS From a cohort of 641 bAVMs treated by microsurgery, 32 patients with DPH were identified. Of those, 66% (95% CI 48-80) had a permanent new neurological deficit with a modified Rankin Scale score of 2-6. This included a mortality rate of 13% (95% CI 4.4-29). The BP protocol was used to treat 162 patients with either SPC B 3.5+ or SPC C. For SPC B 3.5+, there was no significant reduction in DPH with the introduction of the BP protocol (p = 0.77). For SPC C, there was a significant (p = 0.035) reduction of DPH from 29% (95% CI 13%-53%) to 8.2% (95% CI 3.2%-18%) associated with the introduction of the BP protocol. Multiple logistic regression analysis found that the absence of the BP protocol (p = 0.011, odds ratio 7.5, 95% CI 1.6-36) remained significant for the development of DPH in patients with SPC C bAVMs.CONCLUSIONS Treating patients with SPC C bAVMs with a protocol that lowers BP immediately after resection seems to reduce the risk of DPH. For SPC A and SPC B 3.5-bAVMs, there is unlikely to be a need to do more than avoid postoperative hypertension. For SPC B 3.5+ bAVMs, a larger number of patients would be required to test the absence of benefit of the BP protocol.