微创穿刺引流对高血压自发基底神经节区脑出血预后的影响——前瞻性非随机对照研究  

Can minimal invasive puncture and drainage for hypertension spontaneous basal ganglia intracerebral hemorrhage improve patient outcome: A prospective non-randomized comparative study

作　　者：王国强[1] 李世强 张微微[1] 阮文伟 秦家振[3] 李莹[1] 尹维民[1] 李运军[3] 任政军 朱吉强 丁云艳 彭俊琦 李培建[3] 黄勇华[1] 

机构地区：[1]北京军区总医院神经内科,北京100700 [2]香河县中医医院,河北香河065400 [3]北京军区总医院神经外科,北京100700

出　　处：《解放军医学杂志》2014年第7期531-541,共11页Medical Journal of Chinese People's Liberation Army

基　　金：国家自然科学基金(81070948)~~

摘　　要：目的研究与开颅去骨瓣（DC）清除血肿相比,微创穿刺引流（MIPD）是否更有利于改善高血压自发基底神经节区脑出血患者的预后。方法选择2009年2月-2012年2月符合条件的高血压自发脑出血（ICH）患者（基底节区≥30ml,发病24h内）,非随机分配接受MIPD（A组）或DC（B组）治疗。采用格拉斯哥结局量表（GOS）评估发病30d和1年时的结局（GOS≥4为功能独立）。结果共198例患者接受治疗（A组84例,B组114例）,其中9例失访（A组2例,B组7例,以其末次观察数据作为最终结果作意向性分析）。198例患者平均年龄57.1（31-95）岁,男144例,女54例,基线GCS8.1±3.4分,NIHSS 20.8±5.3分,平均出血量（HV）56.7（30-144）ml,134例（67.7%）出血破入脑室。除A组年龄大于B组（59.4±14.5岁vs 55.3±11.1岁,P=0.025）外,两组其他基线数据及术后并发症发生率无显著差异。累计30d及1年总死亡率分别为32.3%和43.4%,且A组与B组无显著差异（27.4%vs 36.0%,P=0.203;36.1%vs 48.2%,P=0.112）,但年龄≤60岁、NIHSS〈15或HV≤60ml的患者,A组30d及1年死亡率均显著低于B组（P〈0.05）。累计1年良好结局率26.8%,A组显著高于B组（39.3%vs 17.5%,P=0.001）。无脑室出血的患者1年死亡率A组显著低于B组（P=0.01）,重度脑室出血患者30d和1年死亡率B组显著低于A组（P=0.025,P=0.036）,但1年良好结局无组间差异。Logistic回归分析显示,不同治疗方式、年龄、GCS、HV、脑室出血和肺部感染均为1年良好结局的重要影响因素。结论对高血压自发深部ICH,与常规DC手术相比,MIPD的1年良好结局率显著提高,选择性病例（年龄≤60岁、NIHSS〈15分或HV≤60ml）的死亡率显著降低。对HV〉60ml、深昏迷、重度神经功能损伤或严重脑室出血患者,两种治疗方法的结局无显著差异。Objective The treatment of hypertensive spontaneous intracranial hemorrhage （ICH） is still controversial. The purpose of the present study was to investigate whether minimally invasive puncture and drainage （MIPD） could provide improved patient outcome compared with decompressive craniectomy （DC）. Methods Eligible, consecutive patients with ICH （≥ 30 ml, in basal ganglia, within 24 hours of ictus） were non-randomly assigned to receive MIPD （group A） or to undergo DC （group B） hematoma evacuation. The primary outcome was death at 30 days after onset. Functional independence was assessed at 1 year using the Glasgow Outcome Scale （GOS, scores range from 1 to 5, score 1 indicating death, t〉4 indicating functional independence, with lower scores indicating greater disability）. Results A total of 198 patients met the per protocol analysis （84 cases in group A and 114 cases in group B）, including 9 cases lost during follow-up （2 cases in group A and 7 cases in group B）. For these 9 patients, theirlast observed data were used as their final results for intention-to-treat analysis. The mean age of all patients was 57.1 years （range of 31-95 years）, and 144 patients were male. The initial Glasgow Coma Scale （GCS） score was 8.1 ± 3.4, and the National Institutes of Health Stroke Scale （NIHSS） score was 20.8 ±5.3. The mean hematoma volume （HV） was 56.7 ± 23.0 ml （range of 30-144 ml）, and there was extended intraventricular hemorrhage （IVH） in 134 patients （67.7%）. There were no significant intergroup differences in the above baseline data, except group A had a higher mean age （59.4 ± 14.5 years） than the mean age of group B （55.3 ± 11.1 years, P=0.025）. The total cumulative mortalities at 30 days and 1 year were 32.3% and 43.4%, respectively, and there were no significant differences between groups A and B （30 days： 27.4% vs 36.0%, P=0.203; 1 year： 36.1% vs 48.2%, P=0.112, respectively）. However, the mortality for patients ≤ 60 years,

关 键 词：脑出血 脑室出血 微创穿刺 开颅去骨瓣 重组组织型纤溶酶原激活剂 尿激酶 

分 类 号：R743.34[医药卫生—神经病学与精神病学]