Murthy Santosh B, Awad Issam, Harnof Sagi, Aldrich Francois, Harrigan Mark, Jallo Jack, Caron Jean-Louis, Huang Judy, Camarata Paul, Lara Lucia Rivera, Dlugash Rachel, McBee Nichol, Eslami Vahid, Hanley Daniel F, Ziai Wendy C
From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD.
Neurology. 2017 Jul 25;89(4):355-362. doi: 10.1212/WNL.0000000000004155. Epub 2017 Jun 28.
To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH).
Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days.
Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts.
Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.
研究与永久性脑脊液分流相关的因素，以及自发性脑室内出血（IVH）中分流与功能结局之间的关系。
开展了一项名为“脑室内出血加速溶解的凝块溶解评估（CLEAR III）”的随机、多中心、双盲、安慰剂对照试验，以确定与脑室外引流（EVD）加生理盐水相比，实际应用的EVD加脑室内阿替普酶是否能改善结局。结局指标包括分流的预测因素以及180天时死亡率和改良Rankin量表的盲法评估。
在500例IVH患者中，90例（18%）患者在中位时间18天（四分位间距[IQR] 13 - 30天）时进行了脑脊液分流。有分流和无分流患者的人口统计学特征和IVH特点相似。多因素分析中，黑人种族（比值比[OR] 1.98；95%置信区间[CI] 1.18 - 3.34）、EVD持续时间（OR 1.10；CI 1.05 - 1.15）、放置多个EVD（OR 1.93；CI 1.13 - 3.31）、每日脑脊液引流量每增加10 mL（OR 1.07；CI 1.04 - 1.10）以及颅内压>30 mmHg（OR 1.70；CI 1.09 - 2.88）与永久性脑脊液分流的较高几率相关。有脑脊液分流的患者180天死亡率几率相似，而与无分流的幸存者相比，有分流的幸存者功能结局不良的几率增加。
在需要紧急脑脊液分流的自发性IVH患者中，那些早期颅内压升高、脑脊液引流量大以及放置多个EVD的患者永久性脑室分流的几率增加。脑室内阿替普酶的应用、早期影像学表现和脑脊液指标并非永久性脑脊液分流的有效预测因素。
