Long Fei, Qin Kunming, Liao Shengchao, Wu Jingzhan, Tang Chunhai, Liu Tao
Department of Neurosurgery, Second Affiliated Hospital of Guangxi Medical University, Nanning 530000, Guangxi Zhuang Autonomous Region, China. Corresponding author: Qin Kunming, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2019 Nov;31(11):1373-1377. doi: 10.3760/cma.j.issn.2095-4352.2019.11.012.
To investigate the clinical effect of modified Graeb criteria score and Glasgow coma score (GCS) in individualized treatment of intraventricular hemorrhage.
113 patients with intraventricular hemorrhage admitted to the department of neurosurgery of Second Affiliated Hospital of Guangxi Medical University from June 2014 to February 2018 were enrolled, and they were divided into 13-15, 9-12, and 3-8 groups according to GCS score at admission, and modified Graeb criteria score was classified as grade I, II and III at the same time. In GCS 9-12 and 3-8 groups, patients with modified Graeb criteria score grade III were treated with bilateral extra ventricular drainage, patients with modified Graeb criteria score grade II were treated with bilateral extra ventricular drainage or lumbar cistern drainage (GCS 9-12 group was more prior to lumbar cistern drainage, 3-8 group was given priority to extra ventricular drainage), and patients with modified Graeb criteria score grade I were treated conservatively. In GCS 13-15 group, bilateral extra ventricular cerebral drainage or lumbar cistern drainage was performed if the modified Graeb criteria score grade was III, lumbar cistern drainage or conservative treatment was performed if the modified Graeb criteria score grade was II, and conservative treatment was performed if the modified Graeb criteria score grade was I. The changes in GCS score at 1 month after individualized treatment and the favourable prognosis rate at 6 months after treatment were observed [favourable prognosis was defined as Glasgow outcome score (GOS) IV-V] as well as the basic clearance time of intraventricular hematomas, and the occurrence of complications such as intracranial infection, pulmonary infection and hydrocephalus were recorded.
113 patients with intraventricular hemorrhage were enrolled in the final analysis, including 39 patients in GCS 13-15 group, 27 in 9-12 group, and 47 in 3-8 group; 21 patients with the first grade of modified Graeb criteria score, 42 with the second grade and 50 with the third grade. At 1 month after individualized treatment, the GCS scores in GCS 13-15 and 9-12 groups were significantly higher than those at admission (14.8±0.2 vs. 13.7±0.8, 13.1±1.7 vs. 10.7±1.1, both P < 0.05). When comparing the GCS score of the same patient at admission with that of 1 month after treatment, the GCS scores of the three groups were significantly improved, indicating that the consciousness of patients with different coma levels at admission had been significantly improved after individualized treatment. The basic clearance time of intracerebroventricular hematomas in patients with the second grade of modified Graeb criteria score was (7.0±2.8) days, in patients with the third grade was (6.1±2.0) days. At 6 months after individualized treatment, among 113 patients, GOS score was grade I in 7 patients (6.2%), grade II in 13 patients (11.5%), grade III in 28 patients (24.8%), grade IV in 27 patients (23.9%), and grade V in 38 patients (33.6%), with the favourable prognosis rate of 57.5% (65/113). Among 113 patients, intracranial infection occurred in 5 patients (4.4%), pulmonary infection in 22 patients (19.5%), hydrocephalus in 2 patients (1.8%) and rebleeding in 4 patients (3.5%). In 83 patients with lumbar cistern drainage, 1 patient had post-drainage infection (1.2%), 3 patients had plugging (3.6%), 6 patients had accidental drop of drainage tube (7.2%), and none of them had occipital macroforamen hernia after drainage. Seven of the 113 patients died including 2 patients died of cerebral hernia caused by rebleeding, 5 patients died of severe pneumonia or automatic discharge from hospital.
The combination of modified Graeb criteria score and GCS score can individualize treatment for patients with intraventricular hemorrhage and effectively improve the prognosis of patients with intraventricular hemorrhage.
探讨改良Graeb标准评分与格拉斯哥昏迷评分（GCS）在脑室出血个体化治疗中的临床效果。
选取2014年6月至2018年2月广西医科大学第二附属医院神经外科收治的113例脑室出血患者，根据入院时GCS评分分为13 - 15分、9 - 12分、3 - 8分三组，同时将改良Graeb标准评分分为Ⅰ级、Ⅱ级和Ⅲ级。在GCS 9 - 12分和3 - 8分两组中，改良Graeb标准评分Ⅲ级患者采用双侧脑室外引流治疗，改良Graeb标准评分Ⅱ级患者采用双侧脑室外引流或腰大池引流（GCS 9 - 12分患者优先选择腰大池引流，3 - 8分患者优先选择脑室外引流），改良Graeb标准评分Ⅰ级患者采用保守治疗。在GCS 13 - 15分的患者中，改良Graeb标准评分Ⅲ级时行双侧脑室外引流或腰大池引流，改良Graeb标准评分Ⅱ级时行腰大池引流或保守治疗，改良Graeb标准评分Ⅰ级时行保守治疗。观察个体化治疗后1个月GCS评分变化、治疗后6个月的良好预后率[良好预后定义为格拉斯哥预后评分（GOS）Ⅳ - Ⅴ级]以及脑室内血肿基本清除时间，并记录颅内感染、肺部感染和脑积水等并发症的发生情况。
最终纳入113例脑室出血患者进行分析，其中GCS 13 - 15分组39例，9 - 12分组27例，3 - 8分组47例；改良Graeb标准评分Ⅰ级21例，Ⅱ级42例，Ⅲ级50例。个体化治疗后1个月，GCS 13 - 15分和9 - 12分两组的GCS评分均显著高于入院时（14.8±0.2对13.7±0.8，13.1±1.7对10.7±1.1，P均<0.05）。将同一患者入院时与治疗后1个月的GCS评分进行比较，三组患者的GCS评分均显著改善，表明入院时不同昏迷程度患者经个体化治疗后意识均有显著改善。改良Graeb标准评分Ⅱ级患者脑室内血肿基本清除时间为（7.0±2.8）天，Ⅲ级患者为（6.1±2.0）天。个体化治疗后6个月，113例患者中，GOS评分Ⅰ级7例（6.2%），Ⅱ级13例（11.5%），Ⅲ级28例（24.8%），Ⅳ级27例（23.9%），Ⅴ级38例（33.6%），良好预后率为57.5%（65/113）。113例患者中，颅内感染5例（4.4%），肺部感染22例（19.5%），脑积水2例（1.8%），再出血4例（3.5%）。在83例行腰大池引流的患者中，引流后感染1例（1.2%），堵塞3例（3.6%），引流管意外脱落6例（7.2%），引流后均未发生枕骨大孔疝。113例患者中7例死亡，其中2例死于再出血导致的脑疝，5例死于重症肺炎或自动出院。
改良Graeb标准评分与GCS评分相结合可对脑室出血患者进行个体化治疗，有效改善脑室出血患者的预后。
