Gerner Stefan T, Kuramatsu Joji B, Abel Henning, Kloska Stephan P, Lücking Hannes, Eyüpoglu Ilker Y, Doerfler Arnd, Schwab Stefan, Huttner Hagen B
Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
Neurocrit Care. 2014 Dec;21(3):435-43. doi: 10.1007/s12028-014-9961-3.
Intraventricular fibrinolysis (IVF) in subarachnoid hemorrhage (SAH) is an emerging strategy aiming to hasten clot lysis, treat hydrocephalus, and reduce permanent shunt rates. Because of clinical heterogeneity of investigated patient effects of IVF on permanent shunt incidence and functional outcome are widely debated. The present study is the first to investigate solely endovascular-treated SAH patients.
Overall, 88 consecutive patients with aneurysmal SAH requiring external ventricular drain placement and endovascular aneurysm closure were included. Functional outcome and shunt dependency were assessed 90 days after event. A matched controlled sub-analysis was carried out to investigate the effects of IVF treatment (n = 14; matching criteria: age, neuro-status and imaging). Multivariate modeling was performed to identify independent predictors for permanent shunt dependency.
In IVF-patients neurological status was significantly poorer [Hunt&Hess: IVF = 4(3-5) vs. non-IVF = 3(1-5); p = 0.035] and the extent of ventricular hemorrhage was increased [Graeb Score: IVF = 7(6-8) vs. non-IVF = 3(1-4); p ≤ 0.001]. Consecutive matched controlled sub-analysis revealed no significant therapeutic effect of IVF with respect to shunt dependency rate and functional outcome. Multivariate analysis revealed Graeb score [OR = 1.34(1.02-1.76); p = 0.035] and sepsis [OR = 11.23(2.28-55.27); p = 0.003] as independent predictors for shunt dependency, whereas IVF did not exert significant effects (p = 0.820).
In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome.
蛛网膜下腔出血（SAH）患者的脑室内纤溶治疗（IVF）是一种新兴的治疗策略，旨在加速血凝块溶解、治疗脑积水并降低永久性分流率。由于所研究患者的临床异质性，IVF对永久性分流发生率和功能结局的影响存在广泛争议。本研究首次仅对接受血管内治疗的SAH患者进行调查。
总共纳入了88例连续的需要进行脑室外引流和血管内动脉瘤栓塞治疗的动脉瘤性SAH患者。在事件发生90天后评估功能结局和分流依赖性。进行了匹配对照亚分析，以研究IVF治疗的效果（n = 14；匹配标准：年龄、神经状态和影像学）。进行多变量建模以确定永久性分流依赖性的独立预测因素。
IVF治疗的患者神经状态明显较差[Hunt&Hess分级：IVF组= 4（3 - 5），非IVF组= 3（1 - 5）；p = 0.035]，脑室出血范围增加[Graeb评分：IVF组= 7（6 - 8），非IVF组= 3（1 - 4）；p≤0.001]。连续匹配对照亚分析显示，IVF在分流依赖性率和功能结局方面没有显著治疗效果。多变量分析显示，Graeb评分[比值比（OR）= 1.34（1.02 - 1.76）；p = 0.035]和败血症[OR = 11.23（2.28 - 55.27）；p = 0.003]是分流依赖性的独立预测因素，而IVF没有显著影响（p = 0.820）。
在接受血管内治疗的SAH患者中，IVF既未降低永久性分流依赖性，也未影响功能结局。尽管IVF对脑室内血凝块溶解有既定效果，但与脑出血相比，其在SAH中的作用似乎较小。鉴于报道的腰大池引流（LD）在SAH中的积极作用，对IVF联合后续腰大池引流的联合治疗方法进行前瞻性分析似乎很有必要，旨在减少永久性分流并改善功能结局。
