Nieuwkamp D J, de Gans K, Rinkel G J, Algra A
Department of Neurology, University Hospital Utrecht, The Netherlands.
J Neurol. 2000 Feb;247(2):117-21. doi: 10.1007/pl00007792.
Severe intraventricular hemorrhage caused by extension from subarachnoid hemorrhage or intracerebral hemorrhage leads to hydrocephalus and often to poor outcome. We conducted a systematic review to compare conservative treatment, extraventricular drainage, and extraventricular drainage combined with fibrinolysis. We carried out a search in Medline of the literature between January 1966 and December 1998 and an additional hand-search from January 1990 to December 1998. Pharmaceutical companies were contacted to gather unpublished data. We reviewed the reference lists of all relevant articles. Two authors independently assessed eligibility of the studies and extracted data on characteristics of study design, patients, and treatment. Patients with primary intraventricular hemorrhage were excluded. Main outcome measures were death and poor outcome (defined as death or dependency) at the end of follow-up. No randomized clinical trial has yet been conducted so far, and we therefore reviewed only observational studies. The case fatality rate for conservative treatment (ten studies) was 78%. For extraventricular drainage (seven studies) it was 58% [relative risk versus conservative treatment (RR) 0.74; 95% confidence interval (CI) 0.55-0.99]. For extraventricular drainage with fibrinolytic agents (five studies) the case fatality rate was 6% (RR 0.08; 95% CI 0.02-0.24). The poor outcome rate for conservative treatment was 90%, that for extraventricular drainage 89% (RR 0.98; 95% CI 0.75-1.30) and that for extraventricular drainage with fibrinolytic agents 34% (RR 0.38; 95% CI 0.21-0.68). All RR values remained essentially the same after adjusting for age, sex, World Federation of Neurological Surgeons scale, study design, and year of publication for the studies that provided these data. Outcome is thus poor in patients with intraventricular extension of subarachnoid or intracerebral hemorrhage. This meta-analysis suggests that treatment with ventricular drainage combined with fibrinolytics may improve outcome for such patients, although this impression is derived only from an indirect comparison between observational studies. A randomized clinical trial is warranted.
由蛛网膜下腔出血或脑出血扩展所致的严重脑室内出血可导致脑积水，且常常预后不良。我们进行了一项系统评价，以比较保守治疗、脑室外引流以及脑室外引流联合纤维蛋白溶解疗法。我们检索了1966年1月至1998年12月期间Medline数据库中的文献，并另外手工检索了1990年1月至1998年12月期间的文献。我们联系了制药公司以收集未发表的数据。我们查阅了所有相关文章的参考文献列表。两位作者独立评估研究的合格性，并提取有关研究设计、患者和治疗特征的数据。原发性脑室内出血患者被排除。主要结局指标为随访结束时的死亡和不良预后（定义为死亡或依赖）。目前尚未进行随机临床试验，因此我们仅回顾了观察性研究。保守治疗（10项研究）的病死率为78%。脑室外引流（7项研究）的病死率为58%[与保守治疗相比的相对危险度（RR）0.74；95%置信区间（CI）0.55 - 0.99]。脑室外引流联合纤维蛋白溶解剂治疗（5项研究）的病死率为6%（RR 0.08；95%CI 0.02 - 0.24）。保守治疗的不良预后率为90%，脑室外引流为89%（RR 0.98；95%CI 0.75 - 1.30），脑室外引流联合纤维蛋白溶解剂治疗为34%（RR 0.38；95%CI 0.21 - 0.68）。对于提供这些数据的研究，在对年龄、性别、世界神经外科医师联合会分级、研究设计和发表年份进行校正后，所有RR值基本保持不变。因此，蛛网膜下腔或脑室内出血扩展至脑室内的患者预后较差。这项荟萃分析表明，脑室内引流联合纤维蛋白溶解剂治疗可能改善此类患者的预后，尽管这一结论仅来自观察性研究之间的间接比较。有必要进行一项随机临床试验。
