Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
Neurocrit Care. 2021 Jun;34(3):760-768. doi: 10.1007/s12028-020-01059-2. Epub 2020 Aug 26.
Current guidelines do not support the routine use of corticosteroids in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, corticosteroids use in aSAH has been practiced at some centers by convention. The aim of the study was to determine the incidence of hydrocephalus requiring ventriculoperitoneal shunt (VPS) placement as well as functional outcome on discharge and adverse events attributed to corticosteroids in patients with aSAH treated with different dexamethasone (DXM) treatment schemes.
We retrospectively analyzed 206 patients with aSAH stratified to three groups based on the DXM treatment scheme: no corticosteroids, short course of DXM (S-DXM; 4 mg every 6 h for 1 day followed by a daily total dose reduction by 25% and then by 50% on last day), and long course of DXM (L-DXM; 4 mg every 6 h for 5-7 days followed by reduction by 50% every other day). The primary outcome measure was the placement of a VPS, and the secondary outcome was a good functional outcome [modified Rankin Scale (mRS) 0-3] at hospital discharge. Safety measures were the incidence of infection (pneumonia, urinary tract infection, ventriculitis, meningitis), presence of delirium, and hyperglycemia.
There was no difference in the rate of external ventricular drain (EVD) (p = 0.164) and VPS placement (p = 0.792), nor in the rate of good outcome (p = 0.928) among three defined treatment regimens. Moreover, the median duration of treatment with EVD did not differ between subjects treated with no corticosteroids, S-DXM, and L-DXM (p = 0.905), and the probability of EVD removal was similar when stratified according to treatment regimens (log-rank; p = 0.256). Patients who received L-DXM had significantly more complications as compared to patients, who received no corticosteroids or S-DXM (78.4% vs. 58.6%; p = 0.005). After adjustment, L-DXM remained independently associated with increased risk of combined adverse events (OR = 2.72; 95%CI, 1.30-5.72; p = 0.008), infection (OR = 3.45; 95%CI, 1.63-7.30; p = 0.001) and hyperglycemia (OR = 2.05; 95%CI, 1.04-4.04; p = 0.039).
DXM use among patients with aSAH did not relate to the rate of EVD and VPS placement, duration of EVD treatment, and functional disability at discharge but increased the risk of medical complications.
目前的指南不支持在蛛网膜下腔出血（aSAH）患者中常规使用皮质类固醇。然而，一些中心根据惯例在 aSAH 中使用皮质类固醇。本研究的目的是确定不同地塞米松（DXM）治疗方案治疗的 aSAH 患者中需要脑室-腹腔分流术（VPS）放置的脑积水发生率以及出院时的功能结局和归因于皮质类固醇的不良事件。
我们回顾性分析了 206 例 aSAH 患者，根据 DXM 治疗方案分为三组：无皮质类固醇、DXM 短期疗程（S-DXM；第 1 天每 6 小时 4mg，然后每天总剂量减少 25%，最后一天减少 50%）和 DXM 长期疗程（L-DXM；第 1 天每 6 小时 4mg，然后每 5-7 天减少 50%）。主要结局测量指标是 VPS 的放置，次要结局是出院时的良好功能结局（改良 Rankin 量表[mRS]0-3）。安全性措施包括感染（肺炎、尿路感染、脑室炎、脑膜炎）、谵妄和高血糖的发生率。
三组治疗方案中，外引流管（EVD）的放置率（p=0.164）和 VPS 放置率（p=0.792）、良好结局率（p=0.928）均无差异。此外，无皮质类固醇、S-DXM 和 L-DXM 治疗组之间 EVD 治疗的中位持续时间无差异（p=0.905），根据治疗方案分层时 EVD 去除的可能性相似（对数秩；p=0.256）。与未接受皮质类固醇或 S-DXM 的患者相比，接受 L-DXM 治疗的患者并发症发生率显著更高（78.4% vs. 58.6%；p=0.005）。调整后，L-DXM 与联合不良事件的风险增加独立相关（OR=2.72；95%CI，1.30-5.72；p=0.008）、感染（OR=3.45；95%CI，1.63-7.30；p=0.001）和高血糖（OR=2.05；95%CI，1.04-4.04；p=0.039）。
aSAH 患者使用 DXM 与 EVD 和 VPS 放置率、EVD 治疗持续时间和出院时的功能残疾无关，但会增加医疗并发症的风险。
