Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage
Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage
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DOI：
10.1227/01.neu.0000137628.51839.d5
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发表时间：
2004-10-01
期刊：
影响因子：
4.8
通讯作者：
Ogilvy, CS
中科院分区：
文献类型：
--
作者：
Hoh, BL;Topcuoglu, MA;Ogilvy, CS
目的：尽管最近的几项研究表明，与夹闭术相比，接受蛛网膜下腔弹簧圈栓塞术的患者蛛网膜下腔出血后血管痉挛的发生率较低，但其他研究的结果相互矛盾。我们回顾了我们8年的经验，并评估了夹闭术、开颅术或弹簧圈栓塞术是否影响患者的预后或血管痉挛的风险。我们纳入了2000年11月至2003年2月前瞻性确定的515例蛛网膜下腔出血患者（243例患者）和回顾性分析1995年11月至2000年10月（272例患者），采用国际疾病分类第9次修订版，蛛网膜下腔出血代码。我们将患者分类如下：夹闭术（413例患者）、弹簧圈栓塞术（79例患者）和开颅术（436例患者，包括所有413例接受夹闭术的患者加上23例因各种原因接受弹簧圈栓塞术和开颅术的患者）。我们研究了四个结局指标：总血管痉挛、症状性血管痉挛、不良结局（改良兰金评分3-6分）和住院死亡率。为了评估总血管痉挛和症状性血管痉挛的风险，我们进行了多变量回归分析，调整了年龄、Fisher分级、Hunt和Hess分级、动脉瘤位置（前循环与后循环）和动脉瘤治疗方式。为了评估不良预后和住院死亡率的风险，我们调整了所有上述变量以及总血管痉挛和症状性血管痉挛。开颅组完全性脑血管痉挛占64%，症状性脑血管痉挛占28%。在多变量分析中，年龄= 50岁（P < 0.0001），Fisher分级3级（P = 0.0072），Hunt和Hess分级IV或V级（P <0.00001），症状性血管痉挛（P < 0.0001）和弹簧圈栓塞术（P = 0.0314 vs夹闭术，P = 0.045 vs开颅术）。院内死亡率的预测因素是年龄！50年（P = 0.0030）、Hunt和Hess分级IV或V级（P = 0.0001）、症状性血管痉挛（P < 0.00001）和弹簧圈栓塞术（P = 0.008 vs夹闭术，P = 0.0013 vs开颅术）。当接受夹闭术或开颅术的患者与接受弹簧圈栓塞术的患者相比时，总血管痉挛或症状性血管痉挛无显著差异。在Hunt和Hess分级为I至III级（“良好”）的患者中，夹闭术和开颅术与更好的结局和更低的住院死亡率相关，但总血管痉挛或症状性血管痉挛与弹簧圈栓塞术无差异。Hunt和Hess IV级或V级患者（“差等级”），治疗组之间的任何结果测量没有差异。在一项单中心、回顾性、非随机研究中，与弹簧圈栓塞术相比，夹闭术和/或开颅术在良好等级患者中的结局明显更好，出院时死亡率更低，但对良好或不良等级患者的总血管痉挛或症状性血管痉挛没有影响。
OBJECTIVE: Although several recent studies have suggested that the incidence of vasospasm after aneurysmal subarachnoid hemorrhage is lower in patients undergoing aneurysmal coiling as compared with clipping, other studies have had conflicting results. We reviewed our experience over 8 years and assessed whether clipping, craniotomy, or coiling affects patient outcomes or the risk for vasospasm.METHODS: We included 515 patients with aneurysmal subarachnoid hemorrhage, identified prospectively from November 2000 to February 2003 (243 patients) and retrospectively from November 1995 to October 2000 (272 patients), by using International Classification of Diseases, 9th Revision, codes for subarachnoid hemorrhage. We classified patients as follows: clipping (413 patients), coiling (79 patients), and craniotomy (436 patients, including all 413 patients who underwent clipping plus 23 who underwent coiling as well as craniotomy for various reasons). We studied four outcome measures: total vasospasm, symptomatic vasospasm, poor outcome (modified Rankin score 3-6), and in-hospital mortality. To assess the risk of total vasospasm and symptomatic vasospasm, we performed multivariate regression analyses adjusting for age, Fisher grade, Hunt and Hess grade, aneurysm location (anterior versus posterior circulation), and aneurysm treatment modality. To assess the risk for poor outcome and in-hospital mortality, we adjusted for all the above variables as well as for total and symptomatic vasospasm.RESULTS: In the clipping group there was 63% total vasospasm and 28% symptomatic vasospasm; in the coiling group there was 54% total vasospasm and 33% symptomatic vasospasm; and in the craniotomy group there was 64% total vasospasm and 28% symptomatic vasospasm. In the multivariate analysis, age = 50 years (P < 0.0001), Fisher Grade 3 (P = 0.0072), Hunt and Hess Grade IV or V (P < 0.00001), symptomatic vasospasm (P < 0.0001), and coiling (P = 0.0314 versus clipping and P = 0.045 versus craniotomy). Predictors of in-hospital mortality were age ! 50 years (P = 0.0030), Hunt and Hess Grade IV or V (P = 0.0001), symptomatic vasospasm (P < 0.00001), and coiling (P = 0.008 versus clipping and P = 0.0013 versus craniotomy). There was no significant difference in total vasospasm or symptomatic vasospasm when patients who underwent clipping or craniotomy were compared with patients who underwent coiling. In patients with Hunt and Hess Grade I to III ("good grade"), clipping and craniotomy were associated with better outcome and less in-hospital mortality, but there was no difference in total vasospasm or symptomatic vasospasm versus coiling. In patients with Hunt and Hess Grade IV or V ("poor grade"), there was no difference in any outcome measure among the treatment groups.CONCLUSION: In a single-center, retrospective, nonrandomized study, performance of clipping and/or craniotomy had significantly better outcome and lower mortality at discharge than coiling in good-grade patients but had no effect on total vasospasm or symptomatic vasospasm in good- or poor-grade patients.