蜘蛛膜下腔出血死亡率逐漸下降


  June 4, 2009 — 研究者報告,蜘蛛膜下腔出血診斷與治療的技術進步,使得這個疾病的死亡風險下降了17%。這些研究發現,儘管這些病患的平均年齡增加,但在過去30年間的死亡可能性卻是下降的。這項令人鼓舞的研究結果線上發表在6月4日的Lancet神經學期刊。
  
  來自荷蘭Utrecht大學醫學中心的Dennis Nieuwkamp醫師向Medscape神經學與神經外科學表示,我們期待看到死亡率是下降的。血管內置放線圈與鈣離子阻斷劑確實改善預後。
  
  他表示,尋找病例的方法也有所進步,且可以確認出比較不嚴重的蜘蛛膜下腔出血。而更準確的診斷技術,例如電腦斷層掃描(CT)及核磁共振造影(MRI)都與死亡率下降有關。
  
  【診斷與治療技術的進步】
  研究團隊進行了一項來自33個對比、前瞻性、以群眾為基礎的綜合分析,針對蜘蛛膜下腔出血病患進行研究。這項研究收納了來自19個國家、超過8,700位病患,研究團隊校正如年齡、性別等因素,並且檢驗地區性差異。
  
  他們發現,日本的病例死亡率顯著低於美國、歐洲、澳大利亞與紐西蘭。日本病患死亡率低了11.8%。研究者們也觀察到其他地區的病例死亡率並沒有顯著差異。他們認為這樣的差異可能源自於病患入院的速度變異。
  
  Nieuwkamp醫師表示,我們希望收納研究方法盡可能相似,因此,我們限制這個綜合分析收納前瞻性研究。然而,這些收納的研究在尋找病例方法的完整度上是有差異的,對於蜘蛛膜下腔出血的診斷標準也有差異。
  
  這些病患的平均年齡從52歲增加到62歲。但是儘管年齡增加,未校正的病例死亡率仍然是下降的,除了日本的數據,是每年0.6%(95%信賴區間為0.0-1.1)。
  
  在隨後的反應與回應文章中,來自蘇格蘭愛丁堡大學綜合醫院的Rustam Al-Shahi Salman與Cathie Sudlow博士同意在過去30年間死亡率的下降是因為樂觀。
  
  他們附帶表示,至少,直到你遇到下一個蜘蛛膜下腔出血病患,他在一個月內仍然有三分之一的死亡機會。
  
  【疾病的負擔】
  在高所得國家,估計蜘蛛膜下腔出血每年每10萬人影響8人,造成5%至10%的意外中風病例,且與不良預後有關。
  
  雖然正在進行的研究尋找改善預防遲緩失智的方法,以及耐久性線圈與血管鉗夾的安全性,但主編們表示還有兩項重大的挑戰。
  
  首先,動脈瘤治療的效果在老年病患身上相對是未知的,這些病患現在變成最大的一個族群。其次,低收入到中收入經濟體幾乎都在這個綜合分析中。
  
  因為這些區域擁有最大群的蜘蛛膜下腔出血病患,且這也是最需要有效介入的地方。
  
  Nieuwkamp醫師表示,當診斷與治療技術越來越好,高收入國家的病例死亡率下降地更多。但焦點不該只放在病例死亡率,還有併發疾病率。
  
  這項研究由荷蘭科學研究組織與ZonMw贊助。研究者們與主編們表示沒有相關資金上的往來。
  

Subarachnoid-Hemorrhage Death Rate on the Decline

By Allison Gandey
Medscape Medical News

June 4, 2009 — Improvements in diagnosis and treatment have led to a 17% decrease in the risk for death from aneurysmal subarachnoid hemorrhage, report researchers. The findings suggest that despite an increase in the average age of patients, the likelihood of death has declined over the past 30 years. The encouraging results are published online June 4 in the Lancet Neurology.

"We expected to find a decrease in case-fatality rates," lead author Dennis Nieuwkamp, MD, from the University Medical Centre Utrecht, in the Netherlands, told Medscape Neurology & Neurosurgery. "Endovascular coiling and calcium-channel blockers have considerably improved outcomes."

He noted that case-finding methods have also improved and can identify patients with less severe subarachnoid hemorrhage. And more accurate diagnostic methods such as computed tomography (CT) and magnetic resonance imaging (MRI) have also contributed to lower fatality rates.

Improvements in Diagnosis and Treatment

Investigators conducted a meta-analysis of data from 33 comparable, prospective, population-based studies of subarachnoid-hemorrhage outcome. The studies included more than 8700 patients from 19 countries. Researchers adjusted the findings for confounding factors such as age and sex and also examined regional differences.

They found that case-fatality rates in Japan were significantly lower than in the United States, Europe, Australia, and New Zealand. The rate was 11.8% lower for Japanese patients. Researchers observed no other regional differences in case fatality. The authors suggest that these differences may be the result of variation in the speed of patients' admission to the hospital.

"We wanted the methods of the studies included to be as similar as possible," Dr. Nieuwkamp noted. "Therefore, we restricted the meta-analysis to prospective studies. However, the studies included were heterogeneous with regard to the completeness of the case-finding methods." The studies also varied with regard to the diagnostic criteria for subarachnoid hemorrhage.

The mean age of patients increased from 52 to 62 years. But despite this increase, the unadjusted decline in case fatality, excluding the data for Japan, was 0.6% per year (95% CI, 0.0 – 1.1).

In an accompanying Reflection and Reaction article, Drs. Rustam Al-Shahi Salman and Cathie Sudlow, from the University of Edinburgh Western General Hospital, in Scotland, agree that the apparent decline in case fatality over the past 3 decades is cause for optimism.

"At least," they add, "until you meet your next patient with subarachnoid hemorrhage who still has a 1 in 3 chance of dying within a month."

Burden of Illness

In high-income countries, subarachnoid hemorrhage affects an estimated 8 in 100,000 people every year. It causes 5% to 10% of incident stroke cases and is associated with a poor outcome.

Although ongoing research seeks to improve the prevention of delayed ischemia and the safety and durability of coiling and clipping, the editorialists suggest that 2 major challenges remain.

"First, the effectiveness of aneurysm treatment is relatively unknown in elderly people, who are becoming a larger proportion of the caseload. Second, low-income to middle-income economies were scarcely represented in the meta-analysis."

This is an important problem, they note, because these regions bear the greatest global burden of subarachnoid hemorrhage, and that is where the delivery of effective interventions is most needed.

Dr. Nieuwkamp suggests that case fatalities may decrease even more in high-income countries as diagnosis and treatment continue to improve. But the focus, he says, should not only be on case fatality, but on case morbidity.

This study was funded by the Netherlands Organization for Scientific Research and ZonMw. The researchers and editorialists have disclosed no relevant financial relationships.

Lancet Neurol. Published online June 4, 2009.

    
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