動(dòng)脈瘤性蛛網(wǎng)膜下腔出血腦灌注壓與遲發(fā)性腦梗死相關(guān)性研究
發(fā)布時(shí)間：2018-08-28 10:23
【摘要】：背景:遲發(fā)性腦梗死(DCI)是影響動(dòng)脈瘤性蛛網(wǎng)膜下腔出血(a SAH)預(yù)后的重要因素,治療效果多不理想,預(yù)防其發(fā)生具有很大意義。動(dòng)脈瘤破裂后,由于腦血管自動(dòng)調(diào)節(jié)功能受損、腦血管痙攣等原因,腦血流量(CBF)的維持更加依賴于腦灌注壓(CPP)的改變(CBF=CPP/CVR),如果灌注不足可能導(dǎo)致腦缺血缺氧,甚至引起不可逆性腦梗死。目前美國(guó)及歐洲動(dòng)脈瘤性蛛網(wǎng)膜下腔出血處理指南均未提出合適的預(yù)防遲發(fā)性腦梗死的腦灌注壓閾值范圍,而且國(guó)內(nèi)外少有相關(guān)研究。目的:探索腦灌注壓與遲發(fā)性腦梗死的相關(guān)性,初步獲得能夠降低遲發(fā)性腦梗死發(fā)生的腦灌注壓范圍,并驗(yàn)證遲發(fā)性腦梗死的發(fā)生除了與腦灌注壓閾值有關(guān)外,是否還與灌注壓過(guò)低持續(xù)的時(shí)間有關(guān)。方法:前瞻性收集2014年2月至2014年12月就診我科并行腦灌注壓監(jiān)測(cè)的動(dòng)脈瘤性蛛網(wǎng)膜下腔出血患者的灌注壓數(shù)值及臨床資料。將50mm Hg~80mm Hg范圍內(nèi)的腦灌注壓以5mm Hg為間隔劃分出7個(gè)特定閾值(50mm Hg、55mm Hg...75mm Hg、80mm Hg),統(tǒng)計(jì)每個(gè)病人低于各閾值的時(shí)間比例,并通過(guò)繪制ROC曲線及二元logistic回歸分析其與遲發(fā)性腦梗死之間的相關(guān)性。結(jié)果:共有44例病人符合納入排除標(biāo)準(zhǔn)并進(jìn)行腦灌注壓監(jiān)測(cè),其中11例發(fā)生遲發(fā)性腦梗死。通過(guò)繪制ROC曲線獲得腦灌注壓低于50mm Hg、55mm Hg、60mm Hg、65mm Hg、70mm Hg高危發(fā)生遲發(fā)性腦梗死的時(shí)間比分別為超過(guò)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回歸分析中均與遲發(fā)性腦梗死相關(guān)。灌注壓低于75mm Hg和80mm Hg高危發(fā)生遲發(fā)性腦梗死的時(shí)間比分別為48.8%(AUC=0.674)、54.3%(AUC=0.623),logistic回歸分析中與遲發(fā)性腦梗死未見相關(guān)(P=0.08,P=0.339)。結(jié)論:動(dòng)脈瘤性蛛網(wǎng)膜下腔出血后遲發(fā)性腦梗死的發(fā)生除了與低于閾值的腦灌注壓相關(guān)外,還與其持續(xù)的時(shí)間有關(guān)。腦灌注壓閾值與患者對(duì)遲發(fā)性腦梗死的耐受時(shí)間呈正相關(guān),即腦灌注壓閾值越低,患者可以耐受的在低于該閾值以下腦灌注壓的持續(xù)時(shí)間也會(huì)縮短。為了減少遲發(fā)性腦梗死的發(fā)生,應(yīng)避免低腦灌注壓及其所持續(xù)的時(shí)程。維持腦灌注壓在75mm Hg以上可能有助于減少遲發(fā)性腦梗死的發(fā)生,但尚需進(jìn)行前瞻性的隊(duì)列研究進(jìn)一步驗(yàn)證。在多模態(tài)監(jiān)測(cè)下獲取“個(gè)體化”的腦灌注壓可能更有意義。
[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.
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R743.3
本文編號(hào)：2209110
[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.
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R743.3
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