作者：季猛，孙吉林，卓健伟，张闻闻，王凯，徐亦农，季晶

单位：

1.210029江苏省南京市，南京医科大学第一附属医院神经外科　2.225300江苏省泰州市第四人民医院神经外科

Units：

1.Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China2.Department of Neurosurgery, Taizhou Fourth People's Hospital, Taizhou 225300, China

关键词：

血肿，硬膜下，慢性；微创穿刺引流术；尿激酶；复发；影响因素分析；列线图

Keywords：

Hematoma, subdural, chronic; Minimally invasive puncture and drainage; Urokinase; Recurrence; Rootcause analysis; Nomograms

CLC：

R 651.155

DOI：

10.12114/j.issn.1008-5971.2023.00.153

Funds：

江苏省自然科学基金杰出青年项目（BK20160047）

摘要：

目的　探讨接受微创穿刺引流术联合尿激酶治疗的慢性硬膜下血肿（CSDH）患者术后复发的影响因素，构建其风险预测列线图模型并进行验证。方法　回顾性收集2015—2021年于泰州市第四人民医院接受单侧微创穿刺引流术联合尿激酶治疗的CSDH患者145例为研究对象，收集所有患者的临床资料，包括一般资料、入院时格拉斯哥昏迷量表评分、实验室检查指标、影像学检查指标、术中及术后情况，记录患者术后3个月内复发情况。采用LASSO回归法筛选影响因素，采用多因素Logistic回归分析探讨接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的影响因素；采用R 4.1.2软件包构建接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的风险预测列线图模型；采用ROC曲线分析该列线图模型对接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的预测价值；采用Hosmer-Lemeshoe拟合优度检验评价该列线图模型的拟合程度；绘制校准曲线以评估该列线图模型预测接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的性能；绘制决策曲线以评价该列线图模型的临床有效性。结果　145例患者中，复发19例（13.1%），将其归为复发组；未复发126例（86.9%），将其归为未复发组。两组血肿均匀度、术前血肿量、硬膜下间隙复张率、尿激酶用量比较，差异有统计学意义（P＜0.05）。通过LASSO回归模型最终筛选出4个潜在的影响因素，分别为血肿均匀度、术前血肿量、硬膜下间隙复张率、尿激酶用量。多因素Logistic回归分析结果显示，血肿均匀度为混合型、术前血肿量、硬膜下间隙复张率、尿激酶用量是接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的影响因素（P＜0.05）。基于多因素Logistic回归分析结果，构建接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的风险预测列线图模型。ROC曲线分析结果显示，该列线图模型预测接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的AUC为0.915〔95%CI（0.861，0.976）〕。Hosmer-Lemeshoe拟合优度检验结果显示，该列线图模型拟合较好（χ2=4.939，P=0.764）。校准曲线分析结果显示，该列线图模型预测接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发率与实际复发率基本吻合。决策曲线分析结果显示，当该列线图模型预测接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发风险阈值概率＜65%时，患者的净获益率大于0。结论　血肿均匀度为混合型、术前血肿量、硬膜下间隙复张率、尿激酶用量是接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发的影响因素，基于上述影响因素构建的列线图模型对接受微创穿刺引流术联合尿激酶治疗的CSDH患者术后复发具有较高的区分度及校准度，有助于临床医生早期识别复发风险高的CSDH患者。

Abstract：

Objective To analyze the influencing factors of postoperative recurrence in chronic subdural hematoma(CSDH) patients treated by minimally invasive puncture combined with urokinase, and construct and validate the nomogrammodel for predicting its risk. Methods A total of 145 CSDH patients treated by unilateral minimally invasive puncture combinedwith urokinase in Taizhou Fourth People's Hospital from 2015 to 2021 were retrospectively collected. Clinical data of patients were collected, including general information, Glasgow Coma Scale score at admission, laboratory examination indexes, imagingexamination indexes, intraoperative and postoperative conditions, the recurrence within 3 months after surgery was recorded.LASSO regression analysis was used to screen influencing factors, and multivariate Logistic regression analysis was used toanalyze the influencing factors of postoperative recurrence in CSDH patients treated by minimally invasive puncture combinedwith urokinase. The nomogram model for predicting the risk of postoperative recurrence in CSDH patients treated by minimallyinvasive puncture combined with urokinase was constructed by using the R 4.1.2 software package. ROC curve was used toanalyze the predictive value of the nomogram model for postoperative recurrence in CSDH patients treated by minimally invasivepuncture combined with urokinase. Hosmer-Lemeshow goodness of fit test was used to evaluate the fitting degree of the nomogrammodel. Calibration curve was used to evaluate the reliability of the nomogram model for predicting postoperative recurrence inCSDH patients treated by minimally invasive puncture combined with urokinase. The decision curve was drawn to evaluate theclinical effectiveness of the nomogram model. Results Among the 145 patients, 19 (13.1%) patients had recurrence and wereclassified as recurrence group; 126 (86.9%) patients had no recurrence and were classified as non-recurrence group. Therewere significant differences in hematoma uniformity, preoperative hematoma volume, subdural space re-expansion rate, andurokinase dosage between the two groups (P < 0.05) . LASSO regression model was used to screen out four potential influencingfactors, namely hematoma uniformity, preoperative hematoma volume, subdural space re-expansion rate, and urokinase dosage.Multivariate Logistic regression analysis showed that hematoma uniformity of mixed type, preoperative hematoma volume, subduralspace re-expansion rate, and urokinase dosage were the influencing factors of postoperative recurrence in CSDH patients treatedby minimally invasive puncture combined with urokinase (P < 0.05) . The nomogram model for predicting postoperative recurrencein CSDH patients treated by minimally invasive puncture combined with urokinase was constructed based on the results ofmultivariate Logistic regression analysis. The results of ROC curve analysis showed that the AUC of the nomogram model forpredicting the occurrence of postoperative recurrence in CSDH patients treated by minimally invasive puncture combined withurokinase was 0.915 [95%CI (0.861, 0.976) ] . The results of Hosmer-Lemeshow goodness of fit test showed that the nomogrammodel fit well (χ2=4.939, P=0.764) . The results of calibration curve analysis showed that the incidence of postoperativerecurrence in CSDH patients treated by minimally invasive puncture combined with urokinase predicted by the nomogram modelwas basically consistent with the actual incidence of postoperative recurrence in CSDH patients treated by minimally invasivepuncture combined with urokinase. The results of decision curve analysis showed that when the high risk threshold of thenomogram model for predicting the postoperative recurrence in CSDH patients treated by minimally invasive puncture combinedwith urokinase was < 65%, the standardized net benefit of patients was greater than 0. Conclusion Hematoma uniformity ofmixed type, preoperative hematoma volume, subdural space re-expansion rate, and urokinase dosage are the influencing factorsof postoperative recurrence in CSDH patients treated by minimally invasive puncture combined with urokinase. The nomogrammodel constructed based on the above influencing factors has a high degree of discrimination and calibration for the postoperativerecurrence in CSDH patients treated by minimally invasive puncture combined with urokinase, which is helpful for clinicians toidentify CSDH patients at high risk of recurrence in the early stages.

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