臺灣博碩士論文加值系統

背景：出血性腦中風多因高血壓引起腦血管破裂所致，如果症狀嚴重、意識快速喪失，是死亡率很高的疾病，造成個人、家人甚至社會嚴重的不便與負擔，病人到院醫師進行治療時，考量病人特質與臨床症狀，選擇不同的治療方式，但這些重點考量因素在醫師治療方法選擇決策影響程度尚少有系統性分析。
目標：本研究針對高血壓性腦基底核出血病人之個人特質、臨床表徵、入院後病況，探討不同因素在醫師選擇治療方式決策之影響。
方法：採回溯病歷方式，針對台北市某醫學中心於2003年1月1日至2006年3月31日期間，由診斷為ICD-9-CM-431出血性腦中風（intracerebral hemorrhage）病人中篩選出高血壓性腦基底核出血的病人共計110人，分析病人年齡、性別、合併疾病、到院血壓、到院昏迷指數、出血量、出血側別、入院後病況等。利用χ2、T-Test及邏吉斯回歸檢定，分析與治療方式選擇之相關性。
結果：樣本中接受外科治療者49人、內科治療者61人，二者之出血量（P＝0.03）及到院昏迷指數（P＜0.001）呈現統計上差異，迴歸分析結果呈現，45-65歲採外科治療是65歲以上的3.042倍（P＝0.026）。出血量＞30㏄採外科治療是＜20㏄的25.297倍（P＝0.018）。到院昏迷指數9-12分病情穩定者採外科治療是到院昏迷指數≧13分病情穩定者的4.329倍（P＝0.011），到院昏迷指數9-12分病情轉壞採外科治療是到院昏迷指數≧13分穩定者的7.415倍（P＝0.015），到院昏迷指數≧13分轉壞者採外科治療是到院昏迷指數≧13分穩定者的6.275倍（P＝0.041）。
結論：本個案醫院對於其高血壓性腦基底核出血病人，醫師在考量內外科治療方式選擇時，以病人年齡，到院昏迷指數、出血量，昏迷指數中度（9-12分）及輕度（≧13分）住院後轉壞為主要影響因素。

Background:Hemorrhagic strokes are mostly caused by ruptures of cerebral vessels. The critical symptoms and signs as well as the quick loss of conscience may result in high mortality rate, the disease comes with severe ramifications of patients, family members and even the society concerning the inconvenience and liability. There have been few systemic studies and analysis for choosing alternative therapeutic approaches considering the individual patient condition and clinical presentation when patients are put under treatment.
Objective:This study aimed at studying the various factors affecting the alternative therapies decision making targeting the hypertensive basal ganglia bleeding patients with the individualized characteristics and clinical presentation.
Method:This study applied the retrospective chart review on a medical center located at Taipei from January 1 2003 to March 31 2006. Patients’ diagnosed as ICD-9-CM-431(intracerebral hemorrhage）were screened to select one hundred and ten individuals who had the hypertensive basal ganglia bleeding. These patients were put under analysis in the areas of age, gender, accompanied diseases, blood pressure upon arrival, GCS up on arrival, bleeding volume, the anatomical side of bleeding and admission conditions. The analysis was carried out with X2 ,T-Test, regression analysis to study the correlation of selecting alternative therapies.
Result:Forty nine patients were subject to surgical treatment and sixty one patients were subject to medical treatment. The bleeding volume(p=0.03) and GCS(p<0.001) upon arrival presented statistical difference; Regressions analysis showed patient population aged between 45 to 65 had 3.042 times adopting surgical approaches versus population over 65 years old(p=0.026). In surgical treatment group, the patient number with bleeding volume greater than 30 cc was 25.297 times versus those with less than 20 cc bleeding volume(p=0.018); the surgical treatment group patient number of on-arrival GCS ranged 9-12 with variation less or equal to 1 was 4.329 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(P=0.011); the surgical treatment group patient number of on-arrival GCS ranged 9-12 with variation greater or equal to 2 was 7.415 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(P=0.011); The surgical treatment group patient number of on-arrival GCS ranged 9-12 and variation greater or equal to 2 was 7.415 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(p=0.015); The surgical treatment group patient number of on-arrival GCS greater or equal to 13 and variation greater or equal to 2 was 6.275 times versus those with on-arrival GCS greater or equal to 13 and variation less or equal to 1(p=0.041)
Conclusion:This study demonstrated the physicians in the subject hospital adopted patient age, on-arrival GCS, bleeding volume ,GCS severity score(9-12 and 13 or greater) and patients’ condition after admission to select alternative therapeutic approaches for hypertensive basal ganglia bleeding patients.

序言……………………………………………………………………Ⅰ
中文摘要………………………………………………………………Ⅱ
英文摘要………………………………………………………………Ⅲ
目錄……………………………………………………………………Ⅴ
圖目錄…………………………………………………………………Ⅵ
表目錄…………………………………………………………………Ⅶ
第一章 前言…………………………………………………………1
第二章 相關文獻探討………………………………………………2
第三章 研究設計與方法……………………………………………7
第四章 研究結果……………………………………………………9
第五章 討論…………………………………………………………12
第六章 結論…………………………………………………………15
參考文獻………………………………………………………………16
附圖……………………………………………………………………20
附表……………………………………………………………………21

1.Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. New Engl J Med. 2001; 344:1450-60.

2.Hu HH, Sheng WY, Chu FL, Lan CF, Chiang BN. Incidence of stroke in Taiwan. Stroke. 1992；23:1237-41.

3.Manno EM, Atkinson JL, Fulgham JR, Wijdicks EF. Emerging medical and surgical management strategies in the evaluation and treatment of intracerebral hemorrhage., Mayo Clin Proc. 2005；80:420-33.

4.Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime cost of stroke in the United States. Stroke. 1996；27:1459-66.

5.廖建彰，李采娟，林瑞雄，宋鴻樟，2000年台灣腦中風發生率與盛行率的城鄉差異，台灣衛誌，2006，25，223-30.

6.衛生署網頁。http://www.doh.gov.tw。引用2007/1/20。

7.Mayo NE, Neville D, Kirkland S, Ostbye T, Mustard CA, Reeder B, Joffres M, Brauer G, Levy AR. Hospitalization and case-fatality rates for stroke in Canada from 1982 through 1991. The Canadian Collaborative Study Group of Stroke Hospitalizations. Stroke. 1996；27:1215-20.

8.Lampl Y, Gilad R, Eshel Y, Sarova-Pinhas I. Neurological and functional outcome in patients with supratentorial hemorrhages. A prospective study. Stroke. 1995；26:2249-53.

9.Butcher K, Baird T, Parsons M, Davis S. Medical Management of Intracerebral Hemorrhage. Neurosurg Quart. 2002；12:261-278.

10.Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke. 1988；19:1083-92.

11.Diringer MN, Edwards DF, Mattson DT, Akins PT, Sheedy CW, Hsu CY, Dromerick AW. Predictors of acute hospital costs for treatment of ischemic stroke in an academic center. Stroke. 1999；30:724-8.

12.Hemphill JC 3rd, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004；35:1130-4.

13.Dziedzic T, Bartus S, Klimkowicz A, Motyl M, Slowik A, Szczudlik A. Intracerebral hemorrhage triggers interleukin-6 and interleukin-10 release in blood. Stroke. 2002；33:2334-5.

14.Claassen J, Carhuapoma JR, Kreiter KT, Du EY, Connolly ES, Mayer SA. Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome. Stroke. 2002；33:1225-32.

15.Steiner T, Diringer MN, Schneider D, Mayer SA, Begtrup K, Broderick J, Skolnick BE, Davis SM. Dynamics of intraventricular hemorrhage in patients with spontaneous intracerebral hemorrhage: risk factors, clinical impact, and effect of hemostatic therapy with recombinant activated factor VII. Neurosurgery. 2006；59:767-73.

16.Broderick J, Brott T, Zuccarello M. Management of intracerebral hemorrhage. In: Batjer H, ed. Cerebrovascular Disease. Philadelphia, Pa:Lippincott-Raven; 1996:1–18.

17.Firsching R, Huber M, Frowein RA. Cerebellar haemorrhage: management and prognosis. Neurosurg Rev. 1991；14:191-4.

18.Broderick JP, Adams HP Jr, Barsan W, Feinberg W, Feldmann E, Grotta J, Kase C, Krieger D, Mayberg M, Tilley B, Zabramski JM, Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1999；30:905-15.

19.Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet. 1997；349:1269-76.

20.Department of Health. Taiwan public health report, 2003. Taipei: Department of Health, Executive Yuan, 2003；5.

21.Harwell TS, Oser CS, Okon NJ, Fogle CC, Helgerson SD, Gohdes D. Defining disparities in cardiovascular disease for American Indians: trends in heart disease and stroke mortality among American Indians and whites in Montana, 1991 to 2000. Circulation. 2005；112:2263-7.

22.Tournier-Lasserve E. New players in the genetics of stroke. New Engl Med. 2002；347:1711-2.

23.Saposnik G, Del Brutto OH. Stroke in South America: a systematic review of incidence, prevalence, and stroke subtypes. Stroke. 2003；34:2103-7.

24.台大醫院網頁。http://ntuh.mc.ntu.edu.tw。引用2007/1/20。

25.Chien KL, Sung FC, Hsu HC, Su TC, Lin RS, Lee YT. Apolipoprotein A-I and B and stroke events in a community-based cohort in Taiwan: report of the Chin-Shan Community Cardiovascular Study. Stroke. 2002；33:39-44.

26.Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, Glahn J, Brandt T, Hacke W, Diener HC. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke. 2001；32:2559-66.

27.MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990；335:765-74.

28.Hu HH, Chu FL, Chiang BN, Lan CF, Sheng WY, Lo YK, Wong WJ, Luk YO. Prevalence of stroke in Taiwan. Stroke. 1989；20:858-63.

29.Manson JE, Colditz GA, Stampfer MJ, Willett WC, Krolewski AS, Rosner B, Arky RA, Speizer FE, Hennekens CH. A prospective study of maturity-onset diabetes mellitus and risk of coronary heart disease and stroke in women. Arch Intern Med. 1991；151:1141-7.

30.Kitamura A, Iso H, Iida M, Naito Y, Sato S, Jacobs DR, Nakamura M, Shimamoto T, Komachi Y. Trends in the incidence of coronary heart disease and stroke and the prevalence of cardiovascular risk factors among Japanese men from 1963 to 1994. Am J Med. 2002；112:104-9.

31.Ueda K, Hasuo Y, Kiyohara Y, Wada J, Kawano H, Kato I, Fujii I, Yanai T, Omae T, Fujishima M. Intracerebral hemorrhage in a Japanese community, Hisayama: incidence, changing pattern during long-term follow-up, and related factors. Stroke. 1988；19:48-52.

32.Broderick JP. Natural history of primary intracerebral hemorrhage. In: Whisnant JP, ed. Stroke: populations, cohorts, and clinical trials. Oxford: Butterworth-Heinemann,1993：154–73.

33.Broderick JP, Brott T, Tomsick T, Miller R, Huster G. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg. 1993；78:188-91.


34.Brott T, Thalinger K, Hertzberg V. Hypertension as a risk factor for spontaneous intracerebral hemorrhage. Stroke. 1986；17:1078-83.

35.Muntner P, Garrett E, Klag MJ, Coresh J. Trends in stroke prevalence between 1973 and 1991 in the US population 25 to 74 years of age. Stroke. 2002；33:1209-13.

36.Jaillard AS, Hommel M, Mazetti P. Prevalence of stroke at high altitude (3380 m) in Cuzco, a town of Peru. A population-based study. Stroke. 1995；26:562-8.

37.Bharucha NE, Bharucha EP, Bharucha AE, Bhise AV, Schoenberg BS. Prevalence of stroke in the Parsi community of Bombay. Stroke. 1988；19:60-2.

38.Del Brutto OH, Campos X. Validation of intracerebral hemorrhage scores for patients with pontine hemorrhage. Neurology. 2004；62:515-6.

39.Broderick JP, Phillips SJ, Whisnant JP, O''Fallon WM, Bergstralh EJ. Incidence rates of stroke in the eighties: the end of the decline in stroke? Stroke. 1989；20:577-82.

40.Masdeu JC, Rubino FA. Management of lobar intracerebral hemorrhage: medical or surgical. Neurology. 1984；34:381-3.

41.Udekwu P, Kromhout-Schiro S, Vaslef S, Baker C, Oller D. Glasgow Coma Scale score, mortality, and functional outcome in head-injured patients. Journal of Trauma-Injury Infection & Critical Care. 2004；56:1084-9.