动脉瘤性蛛网膜下腔出血脑灌注压与迟发性脑梗死相关性研究

发布时间：2018-08-28 10:23

【摘要】：背景:迟发性脑梗死(DCI)是影响动脉瘤性蛛网膜下腔出血(a SAH)预后的重要因素,治疗效果多不理想,预防其发生具有很大意义。动脉瘤破裂后,由于脑血管自动调节功能受损、脑血管痉挛等原因,脑血流量(CBF)的维持更加依赖于脑灌注压(CPP)的改变(CBF=CPP/CVR),如果灌注不足可能导致脑缺血缺氧,甚至引起不可逆性脑梗死。目前美国及欧洲动脉瘤性蛛网膜下腔出血处理指南均未提出合适的预防迟发性脑梗死的脑灌注压阈值范围,而且国内外少有相关研究。目的:探索脑灌注压与迟发性脑梗死的相关性,初步获得能够降低迟发性脑梗死发生的脑灌注压范围,并验证迟发性脑梗死的发生除了与脑灌注压阈值有关外,是否还与灌注压过低持续的时间有关。方法:前瞻性收集2014年2月至2014年12月就诊我科并行脑灌注压监测的动脉瘤性蛛网膜下腔出血患者的灌注压数值及临床资料。将50mm Hg~80mm Hg范围内的脑灌注压以5mm Hg为间隔划分出7个特定阈值(50mm Hg、55mm Hg...75mm Hg、80mm Hg),统计每个病人低于各阈值的时间比例,并通过绘制ROC曲线及二元logistic回归分析其与迟发性脑梗死之间的相关性。结果:共有44例病人符合纳入排除标准并进行脑灌注压监测,其中11例发生迟发性脑梗死。通过绘制ROC曲线获得脑灌注压低于50mm Hg、55mm Hg、60mm Hg、65mm Hg、70mm Hg高危发生迟发性脑梗死的时间比分别为超过0.25%(AUC=0.769)、2.9%(AUC=0.748)、10.1%(AUC=0.720)、15.4%(AUC=0.715)、23.7%(AUC=0.708),logistic回归分析中均与迟发性脑梗死相关。灌注压低于75mm Hg和80mm Hg高危发生迟发性脑梗死的时间比分别为48.8%(AUC=0.674)、54.3%(AUC=0.623),logistic回归分析中与迟发性脑梗死未见相关(P=0.08,P=0.339)。结论:动脉瘤性蛛网膜下腔出血后迟发性脑梗死的发生除了与低于阈值的脑灌注压相关外,还与其持续的时间有关。脑灌注压阈值与患者对迟发性脑梗死的耐受时间呈正相关,即脑灌注压阈值越低,患者可以耐受的在低于该阈值以下脑灌注压的持续时间也会缩短。为了减少迟发性脑梗死的发生,应避免低脑灌注压及其所持续的时程。维持脑灌注压在75mm Hg以上可能有助于减少迟发性脑梗死的发生,但尚需进行前瞻性的队列研究进一步验证。在多模态监测下获取“个体化”的脑灌注压可能更有意义。
[Abstract]:Background: delayed cerebral infarction (DCI) is an important factor affecting the prognosis of aneurysm subarachnoid hemorrhage (a SAH). After aneurysm rupture, the maintenance of cerebral blood flow (CBF) depends more on the change of cerebral perfusion pressure (CBF=CPP/CVR) due to the damage of cerebral autoregulation function and cerebral vasospasm. If insufficient perfusion may lead to cerebral ischemia and hypoxia, the maintenance of cerebral blood flow (CBF) is more dependent on the changes of cerebral perfusion pressure (CBF=CPP/CVR). It even causes irreversible cerebral infarction. At present, the guidelines for the treatment of aneurysm subarachnoid hemorrhage in the United States and Europe have not proposed a suitable range of cerebral perfusion pressure thresholds for the prevention of delayed cerebral infarction, and there are few related studies at home and abroad. Objective: to explore the correlation between cerebral perfusion pressure and delayed cerebral infarction, to obtain the range of cerebral perfusion pressure that can reduce the occurrence of delayed cerebral infarction, and to verify that the occurrence of delayed cerebral infarction is related to the threshold of cerebral perfusion pressure. Whether or not it is related to the duration of low perfusion pressure. Methods: the perfusion pressure and clinical data of patients with aneurysm subarachnoid hemorrhage treated in our department from February 2014 to December 2014 were prospectively collected. The cerebral perfusion pressure in the range of 50mm Hg~80mm Hg was divided into seven specific thresholds by 5mm Hg interval (50mm Hg,55mm Hg.75mm Hg,80mm Hg), counted the time ratio of each patient below each threshold. The correlation between the ROC curve and delayed cerebral infarction was analyzed by ROC curve and binary logistic regression analysis. Results: a total of 44 patients met the exclusion criteria and monitored cerebral perfusion pressure, of which 11 had delayed cerebral infarction. The time ratio of cerebral perfusion depression to high risk of delayed cerebral infarction in 50mm Hg,55mm Hg,60mm Hg,65mm Hg,70mm Hg was obtained by drawing ROC curve. The ratio of delayed cerebral infarction was more than 0.25% (AUC=0.769) 2.9% (AUC=0.748) 10.1% (AUC=0.720) 15.4% (AUC=0.715) 23.7% (AUC=0.708) logistic regression analysis. The time ratio of hypoperfusion depression to high risk of delayed cerebral infarction in 75mm Hg and 80mm Hg was 48.8% (AUC=0.674) 54.3% (AUC=0.623) and not correlated with delayed cerebral infarction (P0. 08% P0. 339). Conclusion: the occurrence of delayed cerebral infarction after aneurysm subarachnoid hemorrhage is related not only to the cerebral perfusion pressure below the threshold value, but also to its duration. The cerebral perfusion pressure threshold was positively correlated with the patient's tolerance time to delayed cerebral infarction, that is, the lower the cerebral perfusion pressure threshold, the shorter the duration of cerebral perfusion pressure that patients could tolerate below the threshold. In order to reduce the occurrence of delayed cerebral infarction, low cerebral perfusion pressure and its duration should be avoided. Maintaining cerebral perfusion pressure above 75mm Hg may help to reduce the incidence of delayed cerebral infarction, but a prospective cohort study is needed to further verify it. It may be more meaningful to obtain individualized cerebral perfusion pressure under multi-modal monitoring.
【学位授予单位】：福建医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R743.3

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