Zhongguo cuzhong zazhi (May 2023)
高血压性脑出血患者钻孔引流手术后继发性脑梗死的危险因素分析 Risk Factors of Secondary Cerebral Infarction after Trepanation and Drainage in Patients with Hypertensive Intracerebral Hemorrhage
Abstract
目的 探索高血压性脑出血（hypertensive cerebral hemorrhage，HICH）患者钻孔引流手术后继发性脑梗死的危险因素。 方法 连续纳入2017年1月—2020年1月在南京同仁医院神经外科行钻孔引流术治疗的HICH患者的临床资料，进行回顾性分析。根据术后1～7 d头颅CT检查是否存在继发性脑梗死，分为继发性脑梗死组和无继发性脑梗死组。通过单因素分析和多因素logistic回归分析筛选出HICH患者继发性脑梗死的独立危险因素，并构建继发性脑梗死的风险预测模型。采用ROC曲线、校准曲线、临床决策曲线评价模型的区分度、准确度和有效性。 结果 本研究共纳入210例HICH患者，其中24例术后继发性脑梗死，发生率为11.43%。单因素分析显示，继发性脑梗死组高血压病史时间（年）、收缩压、舒张压、糖尿病比例、血肿量、脑水肿分布范围、脑组织移位距离、hs-CRP和尿酸（uric acid，UA）水平均高于无继发性脑梗死组，服用扩血管药物比例患者低于无继发性脑梗死组，上述差异均有统计学意义。多因素分析显示，高血压病史时间长（OR 1.642，95%CI 1.175～1.892，P<0.001）、高收缩压（OR 1.349，95%CI 1.048～2.071，P=0.013）、高舒张压（OR 1.299，95%CI 1.091～1.715，P=0.016）、合并糖尿病病史（OR 2.074，9%CI 1.192～2.891，P=0.027）、血肿量大（OR 1.457，95%CI 1.183～1.894，P=0.001）、脑水肿分布范围大（OR 1.516，95%CI 1.029～2.183，P=0.005）和脑组织移位距离大（OR 1.439，95%CI 1.167～2.446，P=0.008）是HICH患者钻孔引流手术后继发性脑梗死的独立危险因素，服用扩血管药物（OR 0.774，95%CI 0.415～0.975，P=0.011）则是其保护因素。将上述因素用于构建评估患者继发性脑梗死发生风险的列线图模型。模型评价结果显示，一致性指数（C-index）为0.852（95%CI 0.773～0.920），区分度较好，准确度较高，具有较强的实用性。 结论 入院时高血压病史时间长、高收缩压、高舒张压、合并糖尿病病史、血肿量大、脑水肿分布范围大及脑组织移位距离大的HICH患者钻孔引流手术后继发性脑梗死的风险增高，术后服用扩血管药物可降低发病风险。 Abstract: Objective To investigate the risk factors of secondary cerebral infarction after trepanation and drainage in patients with hypertensive cerebral hemorrhage (HICH). Methods Clinical data of HICH patients who underwent trepanation and drainage in the Neurosurgery Department of Nanjing Tongren Hospital from January 2017 to January 2020 were included for retrospective analysis. According to the results of head CT examination 1-7 d after surgery, they were divided into two groups: secondary cerebral infarction group (24 cases) and non-secondary cerebral infarction group (186 cases). The independent risk factors for secondary cerebral infarction in HICH patients were screened by univariate analysis and multivariate logistic regression analysis, and the risk prediction model of secondary cerebral infarction was constructed. The differentiation, accuracy and validity of the model were evaluated by receiver operating characteristic (ROC) curve, calibration curve and clinical decision curve. Results A total of 210 HICH patients were included in this study, including 24 patients with postoperative secondary cerebral infarction, with an incidence of 11.43%. Univariate analysis showed that hypertension history, systolic blood pressure, diastolic blood pressure, proportion of diabetic patients, hematoma quantity, distribution range of cerebral edema, brain tissue displacement, hs-CRP and uric acid (UA) levels in patients with secondary cerebral infarction group were higher than those without secondary cerebral infarction group, and the proportion of patients taking vasodilators was lower than that without secondary cerebral infarction group. The difference was statistically significant. Multivariate analysis showed that long history of hypertension (OR 1.642, 95%CI 1.175-1.892, P<0.001), high systolic blood pressure (OR 1.349, 95%CI 1.048-2.071, P=0.013), high diastolic blood pressure (OR 1.299, 95%CI 1.091-1.715, P=0.016), history of diabetes (OR 2.074, 95%CI 1.192-2.891, P=0.027), large volume of hematoma (OR 1.457, 95%CI 1.183-1.894, P=0.001), large distribution range of cerebral edema (OR 1.516, 95%CI 1.029-2.183, P=0.005) and high level of brain tissue displacement (OR 1.439, 95%CI 1.167-2.446, P=0.008) were independent risk factors for secondary cerebral infarction after drilling and drainage surgery in HICH patients after trepanation and drainage surgery, while vasodilators was the protective factor (OR 0.774, 95%CI 0.415-0.975, P=0.011). The above factors were used to construct a alignment diagram model to assess the risk of secondary cerebral infarction. The evaluation results of the model show that Consistency Index (C-Index) is 0.852 (95%CI 0.773-0.920), with good differentiation and high calibration, which has strong practicability. Conclusions HICH patients with long history of hypertension, high systolic blood pressure, high diastolic blood pressure, history of diabetes, large volume of hematoma, large distribution range of cerebral edema and high level of brain tissue displacement are at an increased risk of secondary cerebral infarction after trepanation and drainage surgery, and vasodilators can reduce the risk.
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