Table_1_Intracranial Pressure and Cerebral Perfusion Pressure in Large Spontaneous Intracranial Hemorrhage and Impact of Minimally Invasive Surgery.DOCX

Introduction: We investigated the effect of hematoma volume reduction with minimally invasive surgery (MIS) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with large spontaneous intracerebral hemorrhage (ICH).
Methods:Post-hoc analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE III) study, a clinical trial with blinded outcome assessments. The primary outcome was the proportion of ICP readings ≥20 and 30 mmHg, and CPP readings <70 and 60 mm Hg. Secondary outcomes included major disability (modified Rankin scale >3) and mortality at 30 and 365 days. We assessed the relationship between proportion of high ICP and low CPP events and MIS using binomial generalized linear models, and outcomes using multiple logistic regression.
Results: Of 499 patients enrolled in MISTIE III, 72 patients had guideline based ICP monitors placed, 34 in the MIS group and 38 in control (no surgery) group. Threshold ICP and CPP events ≥20/ <70 mmHg occurred in 31 (43.1%) and 52 (72.2%) patients respectively. On adjusted analyses, proportion of ICP readings ≥20 and 30 mmHg were significantly lower in the MIS group vs. control group [Odds Ratio (OR) 0.27, 95% Confidence Interval [CI] 0.11–0.63 (p = 0.002); OR = 0.18, 0.04–0.75, p = 0.02], respectively. Proportion of CPP readings <70 and 60 mm Hg were also significantly lower in MIS patients [OR 0.31, 95% CI 0.15–0.63 (p = 0.001); OR 0.30, 95% CI 0.11–0.83 (p = 0.02)], respectively. Higher proportions of CPP readings <70 and 60 mm were significantly associated with short term mortality (p = 0.04), and (p = 0.006), respectively. Long term mortality was significantly associated with higher proportion of time with ICP ≥ 20 (p = 0.04), ICP ≥ 30 (p = 0.04), and CPP <70 mmHg (p = 0.01).
Conclusion: Our results are consistent with the hypothesis that surgical reduction of ICH volume decreases proportion of high ICP and low CPP events and that these variables are associated with short- and long-term mortality.

引言：本研究探讨了微创手术（Minimally Invasive Surgery, MIS）降低血肿体积对自发性大量脑内出血（spontaneous intracerebral hemorrhage, ICH）患者颅内压（intracranial pressure, ICP）及脑灌注压（cerebral perfusion pressure, CPP）的影响。
方法：本研究为一项设盲结局评估的临床试验——微创外科手术联合阿替普酶治疗脑内血肿清除术（Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation, MISTIE III）研究的事后分析。主要结局指标为颅内压读数≥20 mmHg、≥30 mmHg的占比，以及脑灌注压读数<70 mmHg、<60 mmHg的占比。次要结局指标包括30天及365天的重度残疾（modified Rankin scale）评分>3与死亡率。我们采用二项分布广义线性模型评估高颅内压、低脑灌注压事件占比与微创手术之间的关联，并通过多重logistic回归分析结局指标。
结果：MISTIE III研究共纳入499例患者，其中72例放置了指南推荐的颅内压监测仪，微创手术组34例，对照组（未行手术）38例。达到阈值的颅内压≥20 mmHg、脑灌注压<70 mmHg事件分别发生于31例（43.1%）和52例（72.2%）患者。校正后分析显示，微创手术组颅内压读数≥20 mmHg和≥30 mmHg的占比均显著低于对照组[比值比（Odds Ratio, OR）0.27，95%置信区间（Confidence Interval, CI）0.11~0.63，p=0.002；OR=0.18，95%CI 0.04~0.75，p=0.02]。微创手术组脑灌注压读数<70 mmHg和<60 mmHg的占比亦显著更低[OR 0.31，95%CI 0.15~0.63，p=0.001；OR 0.30，95%CI 0.11~0.83，p=0.02]。脑灌注压读数<70 mmHg和<60 mmHg的占比升高分别与短期死亡率显著相关（p=0.04）及（p=0.006）。长期死亡率则与颅内压≥20 mmHg时长占比升高（p=0.04）、颅内压≥30 mmHg时长占比升高（p=0.04）及脑灌注压<70 mmHg时长占比升高（p=0.01）显著相关。
结论：本研究结果支持下述假说：手术清除脑内血肿体积可降低高颅内压与低脑灌注压事件的占比，且上述指标与短期及长期死亡率存在关联。