影響高血壓性腦基底核出血病人治療方法的相關因素探討

Abstract

背景：出血性腦中風多因高血壓引起腦血管破裂所致，如果症狀嚴重、意識快速喪失，是死亡率很高的疾病，造成個人、家人甚至社會嚴重的不便與負擔，病人到院醫師進行治療時，考量病人特質與臨床症狀，選擇不同的治療方式，但這些重點考量因素在醫師治療方法選擇決策影響程度尚少有系統性分析。 目標：本研究針對高血壓性腦基底核出血病人之個人特質、臨床表徵、入院後病況，探討不同因素在醫師選擇治療方式決策之影響。 方法：採回溯病歷方式，針對台北市某醫學中心於2003年1月1日至2006年3月31日期間，由診斷為ICD-9-CM-431出血性腦中風（intracerebral hemorrhage）病人中篩選出高血壓性腦基底核出血的病人共計110人，分析病人年齡、性別、合併疾病、到院血壓、到院昏迷指數、出血量、出血側別、入院後病況等。利用χ2、T-Test及邏吉斯回歸檢定，分析與治療方式選擇之相關性。 結果：樣本中接受外科治療者49人、內科治療者61人，二者之出血量（P＝0.03）及到院昏迷指數（P＜0.001）呈現統計上差異，迴歸分析結果呈現，45-65歲採外科治療是65歲以上的3.042倍（P＝0.026）。出血量＞30㏄採外科治療是＜20㏄的25.297倍（P＝0.018）。到院昏迷指數9-12分病情穩定者採外科治療是到院昏迷指數≧13分病情穩定者的4.329倍（P＝0.011），到院昏迷指數9-12分病情轉壞採外科治療是到院昏迷指數≧13分穩定者的7.415倍（P＝0.015），到院昏迷指數≧13分轉壞者採外科治療是到院昏迷指數≧13分穩定者的6.275倍（P＝0.041）。 結論：本個案醫院對於其高血壓性腦基底核出血病人，醫師在考量內外科治療方式選擇時，以病人年齡，到院昏迷指數、出血量，昏迷指數中度（9-12分）及輕度（≧13分）住院後轉壞為主要影響因素。

Background:Hemorrhagic strokes are mostly caused by ruptures of cerebral vessels. The critical symptoms and signs as well as the quick loss of conscience may result in high mortality rate, the disease comes with severe ramifications of patients, family members and even the society concerning the inconvenience and liability. There have been few systemic studies and analysis for choosing alternative therapeutic approaches considering the individual patient condition and clinical presentation when patients are put under treatment. Objective:This study aimed at studying the various factors affecting the alternative therapies decision making targeting the hypertensive basal ganglia bleeding patients with the individualized characteristics and clinical presentation. Method:This study applied the retrospective chart review on a medical center located at Taipei from January 1 2003 to March 31 2006. Patients’ diagnosed as ICD-9-CM-431(intracerebral hemorrhage）were screened to select one hundred and ten individuals who had the hypertensive basal ganglia bleeding. These patients were put under analysis in the areas of age, gender, accompanied diseases, blood pressure upon arrival, GCS up on arrival, bleeding volume, the anatomical side of bleeding and admission conditions. The analysis was carried out with X2 ,T-Test, regression analysis to study the correlation of selecting alternative therapies. Result:Forty nine patients were subject to surgical treatment and sixty one patients were subject to medical treatment. The bleeding volume(p=0.03) and GCS(p<0.001) upon arrival presented statistical difference; Regressions analysis showed patient population aged between 45 to 65 had 3.042 times adopting surgical approaches versus population over 65 years old(p=0.026). In surgical treatment group, the patient number with bleeding volume greater than 30 cc was 25.297 times versus those with less than 20 cc bleeding volume(p=0.018); the surgical treatment group patient number of on-arrival GCS ranged 9-12 with variation less or equal to 1 was 4.329 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(P=0.011); the surgical treatment group patient number of on-arrival GCS ranged 9-12 with variation greater or equal to 2 was 7.415 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(P=0.011); The surgical treatment group patient number of on-arrival GCS ranged 9-12 and variation greater or equal to 2 was 7.415 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(p=0.015); The surgical treatment group patient number of on-arrival GCS greater or equal to 13 and variation greater or equal to 2 was 6.275 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(p=0.041) Conclusion:This study demonstrated the physicians in the subject hospital adopted patient age, on-arrival GCS, bleeding volume ,GCS severity score(9-12 and 13 or greater) and patients’ condition after admission to select alternative therapeutic approaches for hypertensive basal ganglia bleeding patients.