| Objective:Cerebrovascular disease represents a serious disease that carries a high mortality and morbidity, it also severely imperil the health of human being, and one of the leading cause of death worldwide as the same as ischemic heart disease and all types of cancer. SAH is a cerebrovascular disease which occurs when a bottom or cortex of the cerebral artery leaks blood into the subarachnoid space surrounding the brain, about 10%of acute phase of stroke. For all of the congenital intracranial aneurysms, cerebral aneurysms, high blood pressure, cerebral arteriosclerosis, intracranial tumors, blood diseases, Moyamoya disease, arteritis, encephalitis, meningitis, etc. could result in SAH,but the percentage is much higher which caused by ruptured aneurysm. Anatomical particularity and hemodynamic reasons likely to cause intracranial aneurysms rather than extracranial arteries aneurysms. Intracranial aneurysm is a serious hazard to human health, cause of its acute occurrence, seriousness of process, approximately 90% of patients onset with SAH, on the condition that the survivors for the initial bleed did not get the timely and correct treatment, there are 40% of rebleeding, 80% of morbidity and mortality in 3 weeks, as we see intracranial aneurysms with high morbidity and mortality brought unpredictable burden to the family and society. Therefore, the study that influence the prognosis of relevant factor and early prediction is very significant.Aneurismal SAH related some main complications contains such as CVS, hydrocephalus,rebleeding, a few patients may also have seizures, upper gastrointestinal stress ulcer,pulmonary edema and so on, Of which CVS is a common and severe one. Aneurysmal SAH related CVS is a pathophysiological status that generated by the constriction of one or more cerebral vascular artery’s smooth muscle. Cerebrovascular constriction reduce the blood flow of affected area,and than leads delayed ischemic neurological deficit becoming a primary cause of morbidity, mortality and prognostic factor. Once CVS occurs,it is generally difficult to reverse, and poor response to the vasodilation drug,furthermore leading a secondary ischemic brain injury. People utilize medicine and surgery to cure the a SAH related CVS, there are also some drug trail which treat the CVS in progress. Among them, only a handful of method is proved to be feasible. Although the study of pathophysiology of vascular spasm never ceased, the treatment of CVS still is a challenging problem. At present, leading risk factors of CVS are ambiguous,therefore bring a lot of inconvenient. It is very meaningful through taking the study of CVS risk factors, for the early phase predict and early constitute the targeted therapeutic measure,to prevent the CVS, furthermore descend the morbidity and mortality. Recently, more and more attention focused on the role of cerebrovascular inflammation after aneurysmal SAH to the occurrence and progress of CVS. Endothelin wildly accepted that the vasospasm substance, and 10 fold strength compare with the angiotensin, nerve vasopressin and neuropeptide, as well as can evoke severe and permanent cerebral vasoconstriction. Via Rho/Rho kinase and protein kinase C may play a critical role in the signal transduction pathway of vasoconstriction, Rho kinase activity increased in humans and animals, furthermore play an vital role in the pathogenesis of CVS. IL-6 derived from multi-functional factor generated by Monocyte-macrophages, Lymphocytes and blame drenchs kind of cells, in addition it plays an important funtion in immune regulation. It has been reported that IL-6 speculated one prediction index of CVS resulting from SAH.For some reason that defectiveness of large sample control study, testing of IL-6 in cerebrospinal fluid can not be classified the routine index of CVS in clinic practice.TNF-α is a sensitive marker that response to the severity of CVS, also it has toxic effect to the capillaries, and enhance the permeability of capillaries, furthermore accelerate the coagulation and CVS, hence TNF-α takes an significant impact on development and prognosis of CVS. Studied in this paper by collecting the xinjiang medical university first affiliated hospital of a SAH patients admitted in neurosurgery general demographic data and clinical data, analysis of a SAH related clinical features, and discusses the influencing factors, and the severity of a SAH for a SAH clinical diagnosis, treatment and prognosis of clinical epidemiological studies provide important basis to improve the prognosis and quality of life of the people. At the same time, by using single factor and multiple factors logistic model, the influence factors of CVS occurred after a SAH, were retrospectively analyzed for the study of the etiology and prognosis of CVS can provide an important basis for reference.By choosing in the acute phase of SAH(less than 72 hours) to clip of microsurgical craniotomy surgery or endovascular micro spring coil, treatment of aneurysmal SAH patients to detect patients with postoperative IL–6, ET-1, TNF alpha level in cerebrospinal fluid in the different time periods, and determined the CVS happens to patients, analyze the correlation between them, discusses the prediction effect of three inflammatory indexes of acute cerebral vasospasm after SAH, for such patients provide a new basis for the prevention and treatment of vasospasm, as well as clinically for the treatment of vasospasm may provides a new train of thought, perfect for the standardization of the acute SAH the same deadly disease treatment.Methods:(1) Xinjiang medical university first affiliated hospital neurosurgery for the biggest neurosurgical treatment units in xinjiang,,the cerebrovascular disease and tumor were its characteristics, every year for the vast majority of patients with spontaneous subarachnoid hemorrhage receive treatment in xinjiang, collected in our hospital neurosurgery patients have certain representativeness. From January 1, 2013 to December30, 2014 in xinjiang medical university first affiliated hospital of neurosurgery were selected in 457 patients accordance with a SAH from all of SAH patients. Collect patients’ age, sex, smoking history, hypertension, the size of the aneurysm, the number of the aneurysm, the site of aneurysm, aneurysm rupture, head of subarachnoid hemorrhage on CT Fisher grading, Hunt- Hess grade on admission,theraputic method(surgical operation clipping or endovascular embolization), intervention time of aneurysm(including craniotomy surgery clipping and endovascular embolization), with small dose of Nimotop,dehydrant, electrolyte changes, blood glucose, blood lipid, onset temperature, blood calcium levels, white blood cell count, and platelet count and related indicators. Analysis of a SAH patients clinical epidemiology features.(2) The above 457 patients divided into two group that CVS and nonevent, and than utilize the single factor and multiple. Logistic regression model, analysis the influence factors of CVS in patients with a SAH.(3)Choosing xinjiang medical university first affiliated hospital neurosurgery after the whole cerebral angiography(DSA) diagnosis of 89 patients with acute phase of aneurysmal SAH, all give Hunt- Hess score on admission to determine the injury to the patients with SAH. Each patient has been examined head CT scan within 24 hours before preoperative to determine the degree of intracranial hemorrhage, and ranking Fisher scale. All 89 patients who conducted microsurgery clipping or endovascular coiling, Both of them received intravenous injection of Nimodipin routinely postoperation for spasmoplysis,and use 3H therapy for volume expansion treatment.7th day of postoperation, All of patients received TCD examination of middle cerebral artery M2 section via temporal window for spasm stuation, furthermore according to the consequence, all of the patients separated into twuo group that CVS and nonevent.The first day of postoperation, whole patients placed in Arrow lumber drainage device. First and seventh day of postoperation draw off 10 ml CSF and centrifuge, after that take 4ml of supernatant preserve in refrigerator with 80 degrees Celsius, what is more adopt double antibody sandwich Elisa technic testing the content of IL-6、ET-1、TNF-α in the cerebrospinal fluid, and also compare between group.(4) Statistic approach: measurement data indicate in(average±standard deviation), If accord with normality and homogeneity of variance, multiple comparison between groups choose completely randomized design of single factor analysis of variance between groups; If did not accord with the normality and homogeneity of variance, choose the rank sum test; CVS influence factors analysis using multivariate logistic regression model。Using SPSS 13.0 statistical software for statistical analysis, inspection level of α=0.05, Noted(P<0.05) difference was statistically significant.Results:(1) in this study, in a total of 457 patients in 184 cases(40.3%) of men, 273 cases(59.7%) women, the average age was(52.34±11.56).All national distribution for Uyghur121(26.5%) patients with 248(54.3%) cases of the han nationality, 88(19.2%) cases of others. 71(15.5%) cases of patients hospitalized in spring,,128(28.0%) cases in summer,136(29.8%) cases in autumn,,122(26.7%) cases in winter.11(5.8%) patients with first stage hypertension, 36(18.8%) patients with second stage hypertension, 144(75.4%)patients with third stage hypertension, 256 cases(56.0%) without a history of high blood pressure.211(51.3%) cases with history of diabetes, 200(48.7%) cases without history of diabetes. Smokers among patients with 83(18.2%) cases. White blood cells, blood glucose, blood calcium, triglyceride, platelet in patients with abnormal respectively 57.5%,46.2%, 47.5%, 32.8% and 3.8%.K+ascended for 7(2.1%) cases, descended for 178(52.8%) cases. Na+ elevated in 39(11.6%) cases, reduced in the patients of 117(34.8%)cases. Cl- rised in 67(19.9%) cases, reduced in 39(11.6%)cases. Fisher scale on admission: 24(5.3%) cases with first level, 243(53.2%) cases with secondary level,80(17.5%) cases with third level,110(24.1%) cases with fourth level. HUNT- HESS grade On admission: 11(2.4%) cases with frist level, 291(63.7%) cases with second level,84(18.4%) cases with third level, 38(8.3%) cases with fourth level, 33(7.2%) cases with fifth level. Quantity of aneurysm: 383(83.8%) cases with one aneurysm, 62(13.6%) cases with two, 10(2.2%) cases with three, 2(0.4%) cases with four. Location of aneurysm: ACOA 181(39.6%) cases, MCA 89(19.5%) cases, PCOA 99(21.7%)cases, internal carotid artery aneurysms 40(8.8%) cases, basal aneurysm 12(2.6%) cases, cerebellum aneurysm 6(1.3%) cases, vertebral artery aneurysms 3(0.7%) cases, anterior cerebral artery aneurysm17(3.7%) cases, others 10(2.2%) cases. Size of aneurysm: small type157(34.4%) cases, medium type 145(31.7%) cases, large type 13(2.8%)cases, large type1(0.2%) case. aneurysm ruptured frequency: 1399(87.3%)cases ruptured one time, 58(12.7%) cases ruptured two time. 285(62.4%) cases conducted clipping treatment,88(19.3%) cases conducted endovascular treatment, and conservative treatment of61(13.3%) cases, withdrawing treatment of 9(2.0%) cases. dehydrating agent used for332(75.8%)cases and Nimotop for 400(91.7%) cases in the process of Treatment.Different gender, ethnicity, age group, admission season between Fisher grading and Hunt-Hess grade differences had no statistical significance(P > 0.05).History of hypertension and smoking history between Fisher grading and Hunt-Hess grade differences had no statistical significance(P > 0.05), but a history of diabetes was has statistically significant(P < 0.05).Blood potassium,serum sodium, chlorine between Fisher grade and Hunt-Hess grade differences had no statistical significance(P >0.05).Blood calcium, TG, platelet abnormalities between Fisher grading and Hunt-Hess grade differences had no statistical significance(P>0.05), although white blood cells abnormality in the Fisher grading difference was has statistically significant(P < 0.05),the difference between Hunt-Hess grade are no statistical significance(P > 0.05).Quantity,location and size of aneurysms between Fisher grading and Hunt and Hess grade differences had no statistical significance(P > 0.05), aneurysm ruptured frequency between Fisher grading and Hunt-Hess grade difference was has statistically significant(P < 0.05).(2) Single factor logistic regression analysis showed that hospitalized season,history of diabetes, leukocyte, aneurysm ruptured frequency, Fishergrade and Hunt–Hess grade has correlation with CVS in a SAH patients(P<0.05), the multi-factor logistic regression analysis results showed that the history ofhypertension(OR=4.44, 95% CI=1.84 10.69), smoking history(OR = 3.60, 95% CI = 1.15 10.69), improved Fisher grade(/Ⅳlevels OR = 0.061, 95% CI = 0.004 0.84; Ⅱ/Ⅳlevels OR =0.26, 95% CI = 0.09 0.76;Ⅲ/Ⅳlevels OR = 0.58, 95% CI = 0.19 1.71), Hunt- Hess grade on admission(Ⅰ/Ⅳ~Ⅴlevels OR=0.09, 95% CI = 0.007 0.97; Ⅱ/Ⅳ~Ⅴlevels OR = 0.17, 95% CI = 0.055 0.55;Ⅲ/Ⅳ ~ Ⅴlevels OR = 0.54, 95% CI = 0.16 1.79), small dose of Nimotop(OR = 0.052,95% CI = 0.004 0.75), the number of leukocyte(OR = 1.22, 95% CI = 1.09 1.35) as a risk factors of occurring the a SAH related CVS.(3) The content of IL-6, ET-1,and TNF-α in cerebrospinal fluid in some extant increased in first an seventh day of postoperation,among them increasing the content of IL-6, ET-1 in cerebrospinal fluid has statistically significant(P < 0.01), but the changing of TNF-α no statistical difference(P >0.01).First day of postoperation, the content of IL-6 and ET-1 higher in the group of occurring CVS rather than group of Nonevent, that difference was statistically significant(P < 0.01), but the TNF-α no statistical difference between these two group(P >0.01).Seventh day of postoperation, the content of IL-6 and ET-1 higher in the group of occurring CVS rather than group of Nonevent, that difference was statistically significant(P < 0.01), but the TNF-α no statistical difference between these two group(P > 0.01).As400 pg/ml for the division value, First day of postoperation, IL-6 predict aneurysmal SAH cerebral vasospasm,Its sensitivity was 75%, specificity was68%, positive predictive value was 73%.As 20 pg/ml for the division value, First day of postoperation,ET-1 predict aneurysmal SAH cerebral vasospasm, Its sensitivity was 65%, specificity was 98%,positive predictive value was 97%. As 500 pg/ml for the division value, First day of postoperation, TNF-α predict aneurysmal SAH cerebral vasospasm. Its sensitivity was58%, specificity was 78%, positive predictive value was 76%.Conclusion:(1) a SAH relatively onset in the middle-aged and elderly patients, especially female patients. a SAH is associated with high blood pressure, diabetes and smoking.occurring of a SAH leads The majority of patients’ quantity of leukocyte, blood calcium,platelet, blood lipid,and electrolyte abnormity.From Fisher grade and Hunt-Hess grade,condition can be seen that the severity of the a SAH is associated with the characteristics of aneurysms. Small and medium-sized aneurysm with SAH which located in ACOA is tend to occure. ASAH familiar clinical treatment including craniotomy clipping and endovascular embolization, what is more all patients are basically using nimotop and dehydrant.(2) A risk factor of SAH with CVS is more complex, and lead by many factors together. The results indicated that patients with a history of hypertension,smoking history, improved Fisher grade, Hunt- Hess grade on admission is independent risk factors for a SAH with CVS, however small dose of Nimotop is its protection factor,Leukocyte count is a predictive factor.Among patients with hypertension and smokers have high rates of CVS than no history of hypertension and smoking history; The high Fisher and Hunt- Hess grade, the higher possibility of CVS; Reduction of Nimotop dose is a protection factor of CVS, also increasing the quantity of leukocy herald a high risk of CVS.(3) Increasing of ET-1, IL-6 and TNF-α may play a crucial role in SAH with CVS,the first and seventh day of postoperation ET-1、IL-6 and TNF-α have the trend increase,and also have the relation with severity of CVS. Developed degree of CVS can be approximately predicted by examining the content of ET-1、IL-6、and TNF-α, among them ET-1 have a significant clinical value to diagnosis and prediction, and also IL-6 and TNF-α has certain clinical significancy, but need to conduct further research to prove the prediction value. |
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