Stroke:基底节出血体积>18ml,丘脑>8ml,将是外科手术入排标准?

2019-09-15 杨中华 脑血管病及重症文献导读

自发性脑出血(intracerebral hemorrhage,ICH)仍然是最具破坏力的卒中类型,并且治疗措施没有被证明获益。ICH 的临床试验常采用 ICH 出血量的 cutoff 值和出血部位(脑叶 vs 深部)作为治疗措施的纳入标准,因为这时候治疗措施收益可能最大,这种方法已经在缺血性卒中试验中获得了成功。因为其严重性以及病理生理机制相同(长期高血压引起的脑小血管病), 最近的临床试验对深

自发性脑出血(intracerebral hemorrhage,ICH)仍然是最具破坏力的卒中类型,并且治疗措施没有被证明获益。ICH 的临床试验常采用 ICH 出血量的 cutoff 值和出血部位(脑叶 vs 深部)作为治疗措施的纳入标准,因为这时候治疗措施收益可能最大,这种方法已经在缺血性卒中试验中获得了成功。因为其严重性以及病理生理机制相同(长期高血压引起的脑小血管病), 最近的临床试验对深部 ICH 更加感兴趣。不过,在这些研究中的选择标准并未把影像和临床特征(丘脑和基底节)考虑进去,而这对概念验证试验是非常重要的。

在临床上大家都知道,深部脑神经核的小量出血也会造成灾难性后果,但是这个现象被未被仔细研究过,也没有进行过量化以用于临床试验的入排标准中。

2019年8月来自美国的Audrey C. Leasure等在 Stroke 上公布了他们的研究结果,目的在于探讨预测深部脑出血不良预后的最佳血肿体积 cutoff 值。

他们首先利用 ERICH 试验(导出队列)数据定义预测不良预后最佳敏感性和特异性的 cutoff 值,然后利用 ATACH-2试验(验证队列)数据验证这个 cutoff 值。

ERICH 试验中纳入了3000例患者,1564例为深部 ICH,其中1305例有完整的影像学和预后数据(660例丘脑出血,645例基底节出血)。经 ROC 曲线分析鉴定,丘脑出血8ml(area under the curve, 0.79; sensitivity, 73%; specificity, 78%)和基底节出血18ml(area under the curve, 0.79; sensitivity, 70%; specificity, 83%)是预测不良预后的最佳 cutoff 值。

在验证队列中,ATACH-2试验中834例患者为深部 ICH(353例丘脑出血,431例基底节出血)并且有完整的影像学数据。在丘脑 ICH 中,验证队列多元预后模型二分 ICH 体积c-statistic为0.80 (95% CI, 0.75–0.85)。在基底节 ICH 中,c-statistic为0.81 (95% CI, 0.76–0.85)。
最终作者认为在深部 ICH 中,预测不良预后的优化血肿体积 cutoff 值随着深部特殊脑核团累及而变化。利用部位-特异性体积(location-specific volume) cutoff 值将会提高临床试验的设计,以便针对深部 ICH 的治疗措施获益最大。

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    2019-09-16 xlwang2696
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    2019-09-16 xlwang2696
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