一家医疗机构基底节出血治疗策略和疗效的最新趋势

IF 1.3 Q4 CLINICAL NEUROLOGY Brain Hemorrhages Pub Date : 2024-10-01 DOI:10.1016/j.hest.2024.03.001
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引用次数: 0

摘要

目的早期微创清除脑内出血(ENRICH)试验旨在评估微创经胼胝体筋膜旁手术(MIPS)方法,该技术经宣传可安全进入大脑深部结构,并使用 BrainPath® 和 Myriad® 设备(NICO 公司,印第安纳州印第安纳波利斯)清除 ICH。然而,基底节出血(BGH)被确定为符合先验无用性规则,因此被排除在进一步的试验注册考虑之外。由于ICH筛查是在有症状的患者出现后立即开始的,因此治疗的缩减是为了最好地保护剩余的神经功能。我们试图确定,尽管进行了最佳的内科或外科治疗,但立即被排除在试验考虑范围之外是否会导致患者预后较差。方法:我们对本机构颅内出血(ICH)筛查日志中的数据进行了回顾性、观察性、队列分析。纳入本研究的所有患者要么(1)因不符合ENRICH试验纳入标准而被排除在外,要么(2)在2019年2月27日及之后出现BGH。这个时间拐点是根据 ENRICH 试验制定先验无效规则的决定选定的。通过病历审查收集了所有患者的人口统计学特征、合并症、发病特征、治疗特征和结果。通过单变量和多变量统计方法对这些二分法分组进行了比较。主要研究结果是90天后的功能状态,用改良Rankin量表来衡量。结果在临时排除决定之前,有52例BGH患者,在临时排除决定之后,有67例患者。脑室内出血(IVH)占任一侧脑室50%的患者比例在 "前 "组中更高(40.4% vs 20.9%,P = 0.026)。在采用的排空方法上有明显差异,"术后 "组中接受开颅手术的患者更多(10.5% 对 0%,P = 0.018)。临时排除后就诊的患者 90 天 mRS 评分为 0-2 分的比例明显较低(16.4% 对 36.5%,p = 0.019)。两组患者的 180 天死亡率无明显差异(p = 0.56)。在多变量逻辑回归中,糖尿病、发病时的血肿量和发病日期是预测神经系统预后 "良好"(90 天 mRS 评分为 0-2)的重要因素。发病时血肿体积每增加 1 毫升,预后良好的可能性就会降低 4%(OR = 0.960,95 % CI = 0.924-0.997,p = 0.033)。与临时排除前的患者相比,临时排除后就诊的患者获得 "良好 "神经功能预后的可能性降低了 79.5%(OR = 0.205,95 % CI = 0.063-0.669,p = 0.009)。
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Recent trends of treatment strategies and outcomes of basal ganglia hemorrhages at a single institution

Objective

The Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) Trial was designed to evaluate the minimally invasive trans-sulcal parafascicular surgery (MIPS) approach, a technique advertised for safe access to deep brain structures and ICH removal using the BrainPath® and Myriad® devices (NICO Corporation, Indianapolis, IN). However, basal ganglia hemorrhages (BGHs) were determined to meet the a priori futility rule, resulting in exclusion from further trial enrollment consideration. Since screening for ICH is initiated immediately upon presentation of symptom bearing patients, treatment is curtailed to best preserve remaining neurological function. We sought to determine whether immediate exclusion from consideration of trial enrollment resulted in poorer patient outcomes despite best medical or surgical management.

Methods

A retrospective, observational, cohort analysis was performed on data extrapolated from our institution’s intracranial hemorrhage (ICH) screening log. All patients included in this study either (1) were excluded from the ENRICH trial for not meeting trial inclusion criteria or (2) presented on and after February 27th, 2019 when BGHs. This inflection point in time was chosen based on the ENRICH trial’s decision to enact an a priori futility rule. Demographical, medical comorbities, presenting features, treatment characteristics, and outcomes were collected by chart review on all patients. These dichotimized groups were compared by univariate and multivariate statistical approaches. The main outcome of interest was functional status at 90 days as measured by the modified Rankin Scale.

Results

There were 52 patients with BGHs who presented before the interim exclusion decision, and 67 patients who presented after. The proportion of patients with intraventricular hemorrhage (IVH) occupying > 50 % of either lateral ventricle was higher in the “before” group (40.4 % vs 20.9 %, p = 0.026). There was a significant difference in the evacuation method used, with more patients in the “after” group undergoing craniotomy (10.5 % vs 0 %, p = 0.018). The 90-day mRS scores of 0–2 were significantly lower for patients who presented after the interim exclusion (16.4 % vs 36.5 %, p = 0.019). The 180-day mortality was not significantly different between the two groups (p = 0.56). In multivariate logistical regression, diabetes mellitus, hematoma volume at presentation, and presentation date were significant predictors of a “good” neurological outcome (90-day mRS score of 0–2). A 1 mL increase in hematoma volume at presentation was associated with a 4 % decrease in the likelihood of a good outcome (OR = 0.960, 95 % CI = 0.924–0.997, p = 0.033). Patients who presented after the interim exclusion had a 79.5 % lower likelihood of a “good” neurological outcome compared to those who presented before the interim exclusion (OR = 0.205, 95 % CI = 0.063–0.669, p = 0.009).

Conclusion

Those who presented after the interim decision had a significantly lower likelihood of achieving a 90-day mRS score of 0, 1, or 2, suggesting a possible change in care.
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来源期刊
Brain Hemorrhages
Brain Hemorrhages Medicine-Surgery
CiteScore
2.90
自引率
0.00%
发文量
52
审稿时长
22 days
期刊最新文献
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