摘要：

目的: 探讨重症动脉瘤性蛛网膜下腔出血患者行颅内压监测下脑室外引流术联合腰大池引流术的有效性和安全性。方法: 纳入2019年3月至2023年3月河南省人民医院收治的106例重症动脉瘤性蛛网膜下腔出血患者, 采用随机数字表法随机予以颅内压监测下脑室外引流术联合腰大池引流术(颅内压监测组, 52例)和无颅内压监测下脑室外引流术联合腰大池引流术(无颅内压监测组, 54例), 记录术后第1~7天脑脊液引流量、住院期间并发症和术后6个月并发症发生率, 采用改良Rankin量表(mRS)和Glasgow预后分级-扩展版(GOS-E)评估术后6个月神经功能预后并计算预后良好率。结果: 颅内压监测组与无颅内压监测组患者术后脑脊液引流量差异有统计学意义(F=59.843, P=0.000), 术后不同测量时间点脑脊液引流量差异亦有统计学意义(F=5.352, P=0.000), 且处理因素与测量时间存在交互作用(F=19.800, P=0.000), 其中, 颅内压监测组术后第4天(P=0.000)、第5天(P=0.000)、第6天(P=0.000)和第7天(P=0.000)脑脊液引流量均低于无颅内压监测组; 无颅内压监测组术后脑脊液引流量逐渐减少, 术后第4、5、6和7天引流量均低于第1天(P=0.000, 0.000, 0.000, 0.000)、第2天(P=0.000, 0.000, 0.000, 0.000)和第3天(P=0.004, 0.036, 0.000, 0.007)。颅内压监测组患者住院期间脑血管痉挛(χ²=4.850, P=0.028)、脑积水(χ²=5.804, P=0.016)、迟发性脑梗死(χ²=6.722, P=0.010)、脑疝(χ²=5.681, P=0.017)、肾功能衰竭(χ²=5.903, P=0.015)、电解质紊乱(χ²=6.389, P=0.011)发生率, 以及术后6个月分流依赖性脑积水发生率(χ²=6.286, P=0.012)均低于无颅内压监测组; 术后6个月mRS评分低于无颅内压监测组(Z=-2.484, P=0.013), GOS-E评分(Z=-3.018, P=0.003)和预后良好率(χ²=5.403, P=0.020)高于无颅内压监测组。结论: 重症动脉瘤性蛛网膜下腔出血患者行颅内压监测下脑室外引流术联合腰大池引流术可以降低并发症发生率, 改善预后。

关键词: 颅内动脉瘤, 蛛网膜下腔出血, 危重病, 颅内压, 脑脊髓液, 引流术

Abstract:

Objective: To explore the clinical effect of external ventricular drainage combined with lumbar cistern drainage under intracranial pressure (ICP) monitoring in severe aneurysmal subarachnoid hemorrhage (SaSAH). Methods: From March 2019 to March 2023, 106 patients with SaSAH admitted to Department of Neurosurgical Intensive Care Unit of He'nan Provincial People's Hospital were randomly divided into ICP monitoring group (n = 52) and without ICP monitoring group (n = 54). The ICP monitoring group was treated with external ventricular drainage combined with lumbar cistern drainage under ICP monitoring, while without ICP monitoring group was treated with external ventricular drainage combined with lumbar cistern drainage under non-ICP monitoring. Cerebrospinal fluid drainage volume, the incidence of in-hospital and long-term complications were recorded. The modified Rankin Scale (mRS) and Glasgow Outcome Scale-Extended (GOS-E) were used to evaluate the neurological prognosis, and the good prognosis rate was calculated. Results: The cerebrospinal fluid drainage volume between ICP monitoring group and without ICP monitoring group was statistically significant (F = 59.843, P = 0.000), and the cerebrospinal fluid drainage volume at different measurement times was also statistically significant (F = 5.352, P = 0.000), and there was interaction between treatment factors and measurement time (F = 19.800, P = 0.000). There was no significant difference of cerebrospinal fluid drainage volume between the 2 groups on the 1-3 d (P > 0.05, for all), and the cerebrospinal fluid drainage volume of ICP monitoring group on the 4-7 d was lower than that of the without ICP monitoring group (P = 0.000, for all). In without ICP monitoring group, postoperative cerebrospinal fluid drainage volume gradually decreased, with drainage on postoperative 4-7 d being lower than on 1 d (P = 0.000, 0.000, 0.000, 0.000), 2 d (P = 0.000, 0.000, 0.000, 0.000) and 3 d (P = 0.004, 0.036, 0.000, 0.007). In ICP monitoring group, the incidence of cerebral vascular spasm (χ² = 4.850, P = 0.028), hydrocephalus (χ² = 5.804, P = 0.016), delayed cerebral infarction (χ² = 6.722, P = 0.010), brain hernia (χ² = 5.681, P = 0.017), renal failure (χ² = 5.903, P = 0.015), electrolyte disturbance (χ² = 6.389, P = 0.011) and shunt dependent hydrocephalus (χ² = 6.286, P = 0.012) were lower than without ICP monitoring group. At 6 months postoperatively, the ICP monitoring group had a lower mRS score (Z =-2.484, P = 0.013) and a higher GOS-E score (Z =-3.018, P = 0.003) than without ICP monitoring group. The good prognosis rate of ICP monitoring group was higher than that of without ICP monitoring group (χ² = 5.403, P = 0.020). Conclusions: External ventricular drainage combined with lumbar cistern drainage under ICP monitoring for SaSAH can reduce the incidence of complications and improve the prognosis.

Key words: Intracranial aneurysm, Subarachnoid hemorrhage, Critical illness, Intracranial pressure, Cerebrospinal fluid, Drainage