Tso Michael K, Ibrahim George M, Macdonald R Loch
Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
World Neurosurg. 2016 Feb;86:226-32. doi: 10.1016/j.wneu.2015.09.056. Epub 2015 Sep 30.
Shunt-dependent hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH). There is a need to identify patients who require ventriculoperitoneal shunt (VPS) insertion so that any modifiable risk factors can be addressed early after aSAH.
Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1, a prospective randomized controlled trial of patients with aSAH treated with clazosentan. The association between clinical and neuroimaging covariates and VPS placement was first determined by univariate analysis. Covariates with P < 0.15 on univariate analysis were then analyzed in a multivariate logistic regression model. Receiver operating characteristic curve analysis was used to define optimal predictive thresholds. The published literature was reviewed to determine the overall rate of VPS insertion after aSAH.
Overall, 17.2% (71/413) of patients required VPS insertion. Multivariate analysis demonstrated that insertion of an external ventricular drain (odds ratio, 6.21; 95% confidence interval, 2.51-16.91) and increasing volume of cerebrospinal fluid (CSF) drainage per day (odds ratio, 1.004; 95% confidence interval, 1.000-1.009) were associated with VPS insertion. Receiver operating characteristic curve analysis revealed an optimal daily CSF output threshold of 78 mL was predictive of VPS insertion. Among 41,789 patients with aSAH from 66 published studies, the overall VPS insertion rate was 12.7%.
The presence of an external ventricular drain and increased daily CSF output (above 78 mL/day) seems to be predictive of subsequent VPS insertion after aSAH. Although we could not identify modifiable risk factors for needing a VPS, nevertheless, these findings identify patients at greatest risk of VPS placement and inform treatment decisions as well as patient expectations.
依赖分流的脑积水是动脉瘤性蛛网膜下腔出血（aSAH）的常见并发症。需要识别出需要进行脑室腹腔分流术（VPS）的患者，以便在aSAH后尽早处理任何可改变的风险因素。
对纳入CONSCIOUS-1研究的413例患者进行探索性分析，CONSCIOUS-1是一项关于用克拉生坦治疗aSAH患者的前瞻性随机对照试验。首先通过单因素分析确定临床和神经影像学协变量与VPS置入之间的关联。然后，将单因素分析中P<0.15的协变量纳入多因素逻辑回归模型进行分析。采用受试者工作特征曲线分析来确定最佳预测阈值。查阅已发表的文献以确定aSAH后VPS置入的总体发生率。
总体而言，17.2%（71/413）的患者需要进行VPS置入。多因素分析表明，置入脑室外引流管（比值比，6.21；95%置信区间，2.51-16.91）和每日脑脊液（CSF）引流量增加（比值比，1.004；95%置信区间，1.000-1.009）与VPS置入相关。受试者工作特征曲线分析显示，每日CSF引流量阈值为78 mL时对VPS置入具有预测性。在66项已发表研究中的41789例aSAH患者中，VPS置入的总体发生率为12.7%。
脑室外引流管的存在以及每日CSF引流量增加（超过78 mL/天）似乎可预测aSAH后随后的VPS置入。尽管我们未能识别出需要VPS的可改变风险因素，但这些发现可识别出VPS置入风险最高的患者，并为治疗决策及患者预期提供依据。
