【作者】 杨柳；

【导师】 宋治；

【作者基本信息】 中南大学 ， 临床医学， 2014， 硕士

【摘要】 目的：本研究通过回顾性分析考察湖南地区三类不同级别医院(一级、二级、三级)蛛网膜下腔出血(SAH)患者在诊断技术的应用、治疗路径的选择和近期预后等的差异,为我国制订蛛网膜下腔出血实用的、规范化的诊疗技术与流程,以及为政府卫生资源的投入决策提供参考。方法：采用回顾性分析对2009年1月--2012年7月期间,来自湖南省、区(县)、乡(镇)三类不同级别医院(一级、二级与三级医院共5家医院)总共399例蛛网膜下腔出血(SAH)患者的病史资料、实验室资料、病因学、症状学、诊断技术的应用、治疗路径的选择、以及近期预后进行调查分析,并进行统计学处理。结果：1、人口学资料：三类不同级别(一级、二级、三级)医院蛛网膜下腔出血(SAH)患者在性别、年龄、身高、体重、体重指数等人口学资料比较无统计学意义(P>0.05)。2、既往疾病史资料：在脑卒中史、冠心病史、糖尿病史、高血压病史、脑血管病家族史、服用抗血小板药物等比较,无统计学差异意义(P>0.05)。但三类不同级别医院蛛网膜下腔出血(SAH)患者的吸烟史和饮酒史相互比较有统计学差异(P<0.05)。二级医院蛛网膜下腔出血(SAH)患者吸烟史比例明显高于一、三级医院,一级医院蛛网膜下腔出血(SAH)患者饮酒史比例明显高于二、三级医院。3、症状学资料：399例患者中各种首发症状的比例为：头痛(81.7%)、意识障碍(6.5%)、抽搐(3.8%)、头晕(2.5%)、枕颈部胀痛(1.8%)、其它表现(3.8%)。经统计学分析,一级、二级、三级中的SAH症状学比较无统计学意义(P>0.05)。4、诊断技术的应用：三类不同级别医院均应用CT扫描诊断SAH,但发病后24小时内,一、二、三级医院应用CT检查SAH使用率分别为：17.8%、27.5%、42.7%,经统计学比较,有显著性差异。其他三个时间点(48、72、96小时)无统计学差异。应用腰椎穿刺诊断SAH,一级医院均未做此项检查、二级与三级医院应用率也较低(小于5%),未行统计学处理。5、病因学调查：三类医院中,一级医院未能做SAH出血的病因学检查,二级医院120例蛛网膜下腔出血患者52例行CTA检查28例发现动脉瘤(23.3%)。三级医院165例完成CTA(92.7%)、95例完成的DSA(53.4%),共发现动脉瘤124例(69.4%),动-静脉畸形24例(13.4%),其他病因30例(16.8%)。6、治疗路径：一、二级医院均行内科治疗；三级医院行动脉瘤夹闭手术96例(53.9%),介入填塞47例(26.4%),内科治疗35例(19.7%)。7、近期预后：一、二、三级医院1个月内的病死率分别19.8%、23.8%、6.8%;一、二、三级医院预后良好者分别36.6%、41.7%、69.1%；二项指标经统计学处理有显著性差异(P<0.05)。而且三级医院的不同治疗途径近期预后相比,差异有统计学意义(P<0.05)。结论：湖南地区三类不同级别医院在蛛网膜下腔出血(SAH)的诊断技术应用、治疗路径的选择、近期预后等方面存在明显的差别。及早确立SAH诊断,及早查明出血病因,同时及早处理病变血管(结扎或填塞),这“三个及早”是改善SAH近期预后的关键,我国现阶段三类不同级别医院均存在较大的提升空间,在一、二级医院尤其突出。更多还原

【Abstract】 Objective:This study was a retrospective analysis to examine the difference of the applications of diagnostic technology, the choice of treatment path and the recent prognosis of subarachnoid hemorrhage (SAH) patients in different levels Hospital of Hunan Province (three, two, one level), which provide a reference for develop a practical, standardized treatment technologies and process of subarachnoid hemorrhage in china and investment policy for the government health resources.Methods:A retrospective cross-sectional survey which comparative analysis. the differences of the clinical data, laboratory data, etiology, symptoms, complications, the applications of diagnostic technology, the choice of treatment path, as well as recent prognosis of a total of three different levels of hospital399cases of subarachnoid hemorrhage (SAH) patients from January2009to July2012.Results:(1) Demographic data:The differences of three different levels (three, two, one) hospital subarachnoid hemorrhage (SAH) patient’s gender, age and height, weight, body mass index and other demographic data was not statistically significant compared with each other (P>0.05).(2) Past medical history data:The differences of three different levels (three, two, one) hospital subarachnoid hemorrhage (SAH) patient’s history of stroke, coronary heart disease, diabetes, hypertension, family history of cerebrovascular disease, taking anti-platelet drugs was not statistically significant compared with each other (P>0.05).The differences of three different levels (three, two, one) hospital subarachnoid hemorrhage (SAH) patient’s history of smoking and drinking history had statistically significant compared with each other(P<0.05).two level hospital subarachnoid hemorrhage (SAH) patients with history of smoking was significantly higher than that of three level hospital and a hospital, The proportion of a hospital subarachnoid hemorrhage (SAH) of drinking history was significantly higher in patients with two level hospital and three level hospital.(3) Symptomatology data:The various ratio of first symptom in399cases of patients:Headache (81.7%), disturbance of consciousness (6.5%), convulsion (3.8%), dizziness (2.5%), neck pillow pain (1.8%), other manifestations (3.8%).The differences of three different levels (three, two, one) hospital subarachnoid hemorrhage (SAH) patient’s Symptomatology was not statistically significant compared with each other (P>0.05).(4)The applications of diagnostic technology:Three different levels of hospitals are using CT scanning in the diagnosis of SAH, But within24hours after onset, The utilization of CT examination in one, two, three hospitals SAH patients were:17.8%,27.5%,42.7%, the difference had statistically significant compared with each other(P<0.05). Application lumbar puncture diagnose SAH, a hospital cannot using lumbar puncture,and the rate of application lumbar puncture is low in two level hospital and three level hospital.Statistical analysis did not undergo.(5) Etiology investigation:In three types of hospitals, a hospital failed to do SAH bleeding etiology examination, and there are52cases of120SAH patients using CTA examination in two level hospital. And it found28case of aneurysms (23.3%).and there are165patients using CTA examination and95patients using DSA examination in three hospital. And it found124cases of aneurysms (69.4%),24cases of Venous malformations(13.4%),30cases of other causes(16.8%).(6) Treatment path:The SAH in a hospital and two level hospital underwent medical treatment, and there are96cases (53.9%) underwent aneurysm surgery,47cases (26.4%) underwent intervention tamponade;35cases (19.7%) underwent medical treatment in three level hospital.(7) The recent prognosis:The mortality of One,two level hospital and three level hospital were19.8%,23.8%,6.8%; The well recovered of One,two level hospital and three level hospital were36.6%,41.7%,69.1%; the difference had statistically significant compared with each other(P<0.05).And there are some differences in recent prognosis of different therapeutic approaches in three level hospital, the difference had statistically significant compared with each other(P<0.05). Conclusion:There are stark differences in the applications of diagnostic technology, the choice of treatment path and the recent prognosis of subarachnoid hemorrhage (SAH) patients in different levels Hospital of Hunan Province (three, two, one level) had statistically significant. Early identification of the diagnosis of SAH, early identification of the cause of bleeding, and early treatment of vascular lesions (ligation or tamponade), the "three early" is the key to improving the recent prognosis of SAH. and there is a large improvement in three different levels of the hospital. Specifically in one or,two level hospital.更多还原