Operative complications and differences in outcome after clipping and coiling of ruptured intracranial aneurysms
Operative complications and differences in outcome after clipping and coiling of ruptured intracranial aneurysms
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DOI：
10.3171/2014.11.jns141607
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发表时间：
2015-09-01
影响因子：
4.1
通讯作者：
Macdonald, R. Loch
中科院分区：
文献类型：
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作者：
Ayling, Oliver G. S.;Ibrahim, George M.;Macdonald, R. Loch
目的动脉瘤性蛛网膜下腔出血（aSAH）与大量的发病率和死亡率相关，与神经外科切除动脉瘤相比，血管内盘绕术的预后更好。作者评估了围手术期并发症和神经功能下降对两种动脉瘤固定手术后患者预后的影响。方法对克唑生坦治疗蛛网膜下腔出血后神经缺血和梗死的围手术期并发症（consciousness -1）进行事后分析。术前和术后每天对神经外科夹持和血管内盘绕患者的格拉斯哥昏迷评分（GCS）进行分析。在两个队列中都发现了术后GCS评分下降相关的并发症。由于患者没有随机分配到动脉瘤固定手术，因此进行倾向评分匹配以平衡两个队列之间的选定协变量。使用多变量逻辑回归，作者评估围手术期GCS评分下降是否与扩展格拉斯哥预后量表（eGOS）的长期预后相关。结果在所有入组受试者以及倾向匹配队列中，接受夹持术的患者术后GCS评分的下降幅度明显大于接受夹持术的患者（p = 0.0024）。多因素分析显示，术中高血压（p = 0.011）和术中诱导低血压（p = 0.0044）与夹持术患者GCS评分下降有关。围手术期血栓栓塞与盘绕患者术后GCS下降相关（p = 0.03）。在多因素logistic回归中，术后神经功能恶化与3个月时较差的ego评分密切相关（OR 0.86, 95% CI 0.78-0.95, p = 0.0032）。结论：与血管内盘绕术相比，aSAH后的神经外科夹持术与更大的围手术期GCS评分下降相关，而后者又与较差的长期预后相关。这些发现为卷绕术后改善预后的假设机制提供了新的见解，强调了在比较夹持和卷绕术的结果时围手术期因素的潜在重要性，以及减轻aSAH后手术策略发病率的必要性。
OBJECT Aneurysmal subarachnoid hemorrhage (aSAH) is associated with substantial morbidity and mortality, with better outcomes reported following endovascular coiling compared with neurosurgical clipping of the aneurysm. The authors evaluated the contribution of perioperative complications and neurological decline to patient outcomes after both aneurysm-securing procedures.METHODS A post hoc analysis of perioperative complications from the Clazosentan to Overcome Neurological iSChemia and Infarction Occurring after Subarachnoid hemorrhage (CONSCIOUS-1) study was performed. Glasgow Coma Scale (GCS) scores for patients who underwent neurosurgical clipping and endovascular coiling were analyzed preoperatively and each day following the procedure. Complications associated with a decline in postoperative GCS scores were identified for both cohorts. Because patients were not randomized to the aneurysm-securing procedures, propensity-score matching was performed to balance selected covariates between the 2 cohorts. Using a multivariate logistic regression, the authors evaluated whether a perioperative decline in GCS scores was associated with long-term outcomes on the extended Glasgow Outcome Scale (eGOS).RESULTS Among all enrolled subjects, as well as the propensity-matched cohort, patients who underwent clipping had a significantly greater decline in their GCS scores postoperatively than patients who underwent coiling (p = 0.0024). Multivariate analysis revealed that intraoperative hypertension (p = 0.011) and intraoperative induction of hypotension (p = 0.0044) were associated with a decline in GCS scores for patients undergoing clipping. Perioperative thromboembolism was associated with postoperative GCS decline for patients undergoing coiling (p = 0.03). On multivariate logistic regression, postoperative neurological deterioration was strongly associated with a poor eGOS score at 3 months (OR 0.86, 95% CI 0.78-0.95, p = 0.0032).CONCLUSIONS Neurosurgical clipping following aSAH is associated with a greater perioperative decline in GCS scores than endovascular coiling, which is in turn associated with poorer long-term outcomes. These findings provide novel insight into putative mechanisms of improved outcomes following coiling, highlighting the potential importance of perioperative factors when comparing outcomes between clipping and coiling and the need to mitigate the morbidity of surgical strategies following aSAH.