Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage
Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage
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DOI：
10.3171/2019.6.jns19704
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发表时间：
2020-11-01
影响因子：
4.1
通讯作者：
Matsuo, Takayuki
中科院分区：
文献类型：
--
作者：
Horie, Nobutaka;Sato, Shuntaro;Matsuo, Takayuki
目的动脉瘤再出血是动脉瘤性蛛网膜下腔出血（SAH）患者死亡和发病的主要原因。认识到再出血的预测因素可能有助于确定哪些患者将从急性治疗中受益。本研究旨在探讨动脉瘤再出血的预测因素及其对术前、术中和术后临床结果的影响。方法回顾性分析2000年以来4933例动脉瘤性SAH患者的再出血发生率、人口学资料和临床资料。作者进行了多重逻辑回归分析，以确定影响SAH后再出血和预后的危险因素。结果术前再出血发生率为7.2%。患者年龄（p = 0.01）、多发动脉瘤（p < 0.01）、动脉瘤大小（p < 0.0001）、心脏病（p = 0.03）与术前再出血显著相关。相反，11.2%的患者发生术中再出血。动脉瘤位置（前交通动脉[ACoA]）、家族史（p = 0.02）、术前再出血（p < 0.01）、夹持/卷取（p < 0.0001）与术中再出血有显著相关性。交互作用分析显示，夹持术中再出血对ACoA有显著影响（OR 4.00; 95% CI 1.82-8.80; p < 0.001）。术后再出血发生率为2.4%。卷取/夹取（p < 0.0001）和术中再出血（p < 0.01）与术后再出血显著相关。所有时间段的再出血对SAH后的临床结果有显著影响。结论：SAH术后动脉瘤再出血在术前、术中、术后均有其特殊的特点，这些特点影响着SAH的临床预后。ACoA有较高的术中再出血风险，尽管需要完成动脉瘤完全闭塞，但就预防术中再出血的技术而言，血管内盘绕可能是一个很好的选择。
OBJECTIVE Aneurysm rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding might help to identify patients who will benefit from acute management. This study was performed to investigate the predictors of aneurysm rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods.METHODS The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. The authors performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and outcome after SAH.RESULTS Preoperative rebleeding occurred in 7.2% of patients. Patient age (p = 0.01), multiple aneurysms (p < 0.01), aneurysm size (p < 0.0001), and heart disease (p = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery [ACoA]), family history (p = 0.02), preoperative rebleeding (p < 0.01), and clipping/coiling (p < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR 4.00; 95% CI 1.82-8.80; p < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (p < 0.0001) and intraoperative rebleeding (p < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH.CONCLUSIONS Aneurysm rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.