Boon A J, Tans J T, Delwel E J, Egeler-Peerdeman S M, Hanlo P W, Wurzer H A, Avezaat C J, de Jong D A, Gooskens R H, Hermans J
Department of Neurology, Westeinde Hosptial, The Hague, The Netherlands.
J Neurosurg. 1997 Nov;87(5):687-93. doi: 10.3171/jns.1997.87.5.0687.
The authors examined whether measurement of resistance to outflow of cerebrospinal fluid (Rcsf) predicts outcome after shunting for patients with normal-pressure hydrocephalus (NPH). In four centers 101 patients (most of whom had idiopathic NPH) who fulfilled strict entry criteria underwent shunt placement irrespective of their level of Rcsf obtained by lumbar constant flow infusion. Gait disturbance and dementia were quantified by using an NPH scale and the patient's level of disability was assessed by using the modified Rankin scale (mRS). In addition the Modified Mini-Mental State Examination was performed. Patients were assessed prior to and 1, 3, 6, 9, and 12 months after surgery. Primary outcome measures were based on differences between the preoperative and last NPH scale scores and mRS grades. Improvement was defined as a change measuring at least 15% in the NPH scale score and at least one mRS grade. Intention-to-treat analysis of all patients at 1 year yielded improvement for 57% in NPH scale score and 59% in mRS grade. Efficacy analysis, excluding serious events and deaths that were unrelated to NPH, was performed for 95 patients. Improvement rose to 76% in NPH scale score and 69% in mRS grade. Six cut-off levels of Rcsf were related to improvement in NPH scale score using two-by-two tables. Positive predictive values were approximately 80% for an Rcsf of 10, 12, or 15 mm Hg/ml/minute, 92% for an Rcsf of 18 mm Hg/ml/minute, and 100% for an Rcsf of 24 mm Hg/ml/minute. Negative predictive values were low. More important was the highest likelihood ratio of 3.5 for an Rcsf of 18 mm Hg/ml/minute. Extensive comorbidity was a major prognostic factor. Measurement of Rcsf reliably predicts outcome if the limit for shunting is raised to 18 mm Hg/ml/minute. At lower Rcsf values the decision depends mainly on the extent to which clinical and computerized tomography findings are typical of NPH.
作者研究了脑脊液流出阻力（Rcsf）的测量是否能预测正常压力脑积水（NPH）患者分流术后的预后。在四个中心，101例符合严格入选标准的患者（大多数为特发性NPH）接受了分流手术，无论其通过腰椎恒定流量输注获得的Rcsf水平如何。使用NPH量表对步态障碍和痴呆进行量化，并使用改良Rankin量表（mRS）评估患者的残疾程度。此外，还进行了改良简易精神状态检查。在手术前以及术后1、3、6、9和12个月对患者进行评估。主要结局指标基于术前和末次NPH量表评分及mRS分级之间的差异。改善定义为NPH量表评分至少变化15%且mRS分级至少改善一级。对所有患者进行1年的意向性分析，结果显示NPH量表评分改善率为57%，mRS分级改善率为59%。对95例患者进行了排除与NPH无关的严重事件和死亡后的疗效分析。NPH量表评分改善率升至76%，mRS分级改善率升至69%。使用二乘二表将六个Rcsf截断水平与NPH量表评分的改善相关联。Rcsf为10、12或15mmHg/ml/分钟时，阳性预测值约为80%；Rcsf为18mmHg/ml/分钟时，阳性预测值为92%；Rcsf为24mmHg/ml/分钟时，阳性预测值为100%。阴性预测值较低。更重要的是，Rcsf为18mmHg/ml/分钟时，最高似然比为3.5。广泛的合并症是一个主要的预后因素。如果将分流的阈值提高到18mmHg/ml/分钟，Rcsf的测量可可靠地预测预后。在较低的Rcsf值时，决策主要取决于临床和计算机断层扫描结果符合NPH的程度。
