【摘要】 目的 探讨高分级（Hunt-Hess分级4-5级）动脉瘤性蛛网膜下腔出血（a SAH）治疗时机与临床预后的关系。方法 回顾性分析2018年1月至2022年1月收治的81例高分级aSAH的临床资料。术后随访3个月，根据临床表现或CT检查诊断迟发性脑缺血（DCI），采用改良Rankin量表（mRS）评分评估预后，其中3～5分为预后不良。结果 81例中，显微夹闭术治疗36例，血管内栓塞治疗45例；发病3 d内治疗54例，发病3～10 d治疗23例，发病>10 d治疗4例。术后随访3个月，32例发生DCI(39.5%,32/81)，其中夹闭术和血管内治疗的DCI发生率分别为41.7%(15/36)和37.8%(17/45);46例（46/81,56.8%）预后不良。多因素logistic回归分析显示，发病3～10 d接受治疗的病人DCI风险明显增高（OR=2.88;95%CI 1.03～8.00;P=0.043）。单因素分析显示治疗时机、年龄>55岁和脑室内出血量>30 ml与术后3个月预后不良有关（P<0.05）；亚组分析显示，年龄>55岁（OR=23.26;95%1.63～332.25;P=0.020）、合并急性脑积水（OR=9.29;95%CI 1.06～81.27;P=0.044）或脑室内出血（OR=7.43;95%CI 1.72～32.12;P=0.007）的病人，发病3～10 d接受治疗预后不良风险明显增加。结论 高分级a SAH病人发病3～10 d接受动脉瘤治疗可能与较差的预后相关。对于55岁以上、有急性脑积水或脑室内出血的病人，应尽早干预。更多还原

【Abstract】 Objective To investigate the relationship between the timing of treatment and clinical outcomes in patients with highgrade(Hunt-Hess grades 4-5) aneurysmal subarachnoid hemorrhage(aSAH). Methods A retrospective analysis was conducted on 81patients with high-grade aSAH admitted to our hospital from January 2018 to January 2022. Three months after surgery, delayed cerebral ischemia(DCI) was diagnosed based on clinical manifestations or CT findings, and the modified Rankin Scale(mRS) score was used to evaluate outcomes, with a score of 3～5 indicating poor prognosis. Results Of the 81 patients, 36 patients underwent microsurgical clipping and 45 underwent endovascular embolization. Treatment was initiated within 3 days of onset in 54 patients,between 3～10 days in 23 patients, and after 10 days in 4 patients. Thirty-two patients(39.5%, 32/81) had DCI, with DCI rates of 41.7%(15/36) and 37.8%(17/45) in the clipping and coiling groups, respectively. A total of 46 patients(56.8%) had poor outcomes.Multivariate logistic regression analysis showed a significantly increased risk of DCI in patients receiving treatment between 3～10 days of onset(OR=2.88; 95% CI 1.03-8.00; P=0.043). Univariate analysis indicated that treatment timing, age >55 years, and intraventricular hemorrhage volume >30 ml were associated with poor outcomes at 3 months after surgery(P<0.05). Subgroup analysis revealed that patients >55 years old(OR=23.26; 95% CI 1.63-332.25; P=0.020) and those with acute hydrocephalus(OR=9.29; 95% CI 1.06-81.27;P=0.044) or intraventricular hemorrhage(OR=7.43; 95% CI 1.72-32.12; P=0.007) had a significantly increased risk of poor outcomes when treated between 3～10 days of onset. Conclusions Treatment of high-grade a SAH within 3～10 days of onset may be associated with worse outcomes. Early intervention is recommended for patients over 55 years old with acute hydrocephalus or intraventricular hemorrhage.更多还原