Clinical Analysis And Research On Related Influence Factors Of The Short-term Prognosis Of Primary Intraventricular Hemorrhage

Background and purpose:Primary intraventricular hemorrhage(PIVH)is a rare type of hemorrhagic stroke that is defined as bleeding confined to the ventricular system without associated parenchymal or subarachnoid hemorrhage.It is reported that PIVH accounts for 2–4%[1,2] of all intracranial hemorrhages,and the common etiology of this disease is hypertension,arteriovenous malformation(AVM)s,moyamoya disease,aneurysms,dural arteriovenous fistulas(d AVF),etc.Despite the fact that more attention has been paid to the necessity of angiography in PIVH patients,an accurate incidence of these etiological causes is still not well established.Moreover,hemorrhagic stroke in Chinese patients has been considered to have distinctive features compared with patients in Western countries;however,relatively little is known about the features of PIVH in Chinese patients.External ventricular drainage(EVD)combined with lumbar puncture(LD)has become a routine surgical treatment for PIVH,and its effectiveness and practicality have been recognized by the industry.However,there is a lack of a comprehensive and systematic study on the clinical characteristics of PIVH and the short-term prognosis and prognostic factors of PIVH.Therefore,we performed this 6-year retrospective studies to explore the clinical features,etiological causes,prognostic factors and the order of the influence of each factors of this disease in China,so as to provide a more reasonable treatment plan and to judge prognosis more accurately.Materials and methods:From June 2010 to June 2016,adult patients who had intraventricular hemorrhage without recognizable intraparenchymal or subarachnoid hemorrhage on initial computed tomography(CT)scan underwent routine thin-slice CT scan(2 mm)in our hospital.Patients with intraparenchymal hemorrhage or subarachnoid hemorrhage on thin-slice CT scan were excluded,even though the hemorrhage was small or very close to the ventricular system,as were patients with a history of head trauma.Clinical data,including age,gender,the main symptoms of admission,admission GCS score,blood pressure,blood glucose,inducing factors,neurological signs,past medical history,coagulation function,preoperative imaging findings,possible etiological causes,complications during the hospitalization,and GOS scores after three months of surgery were all noted.The modified Graeb(m Graeb)score [53,54]was used to assess the volume of intraventricular blood.Computed tomography angiography(CTA)and digital subtraction angiography(DSA)were performed as routine except for those patients who had a contraindication or an emergent condition,such as brain herniation.A neuroimaging expert evaluated the yield of angiography to identify the etiological causes.Patients with PIVH caused by cerebrovascular disease were diagnosed as having vascular structural abnormality(VSA)-related PIVH;otherwise,idiopathic PIVH(IPIVH)etiology of which included hypertension and unknown causes was considered.Treatments,including consecutive treatment,surgery(external ventricular drainage,EVD),endovascular therapy and craniotomy were all noted.All the patients underwent routine follow-up at 30 days(short term)after onset.GOS score was used to evaluate the neurological outcome.The data obtained was double entered by the Epi Date3.1 software,and APSS13.0 software was used for data analysis,t test and variance analysis were used to compare the mean values,enumeration data was compared using X2 test.Univariate and multivariate regression analyses were performed to determine the significance of the relationships between variables and favorable neurological outcome(three months GOS score=3,4,5).Multivariate regression was assessed in terms of odds ratios.,test level α=0.0.5,p<0.05 was considered statistically significant.Result:From June 2010 to June 2016,a total of 144 patients were admitted to our hospital due to PIVH without recognizable intraparenchymal or subarachnoid hemorrhage on initial non-contrast CT scan(slice: 10 mm).After thin-slice CT scanning(slice: 2 mm).,32 patients with a small volume of intraparenchymal hemorrhage undetected on initial CT scan were excluded.Consequently,only 112 patients were confirmed with the diagnosis of PIVH and enrolled in our study,which constituted 4.5% of contemporary patients with hemorrhagic stroke(n = 2488)treated in our hospital.Overall,75men(66.9%)and 37 women(33.1%)had a mean age of 62.19± 13.13 years(range 34–82years).The peak age of onset was between 45-75 years old.The most common symptom was coma(50.8%)and headache(45.5%);other symptoms and neurological signs included vomiting(36.6%),drowsiness(19.6%),seizure(8.9%).,aphasia(8%),high fever(22.3%),.pathological signs(44.6%)and pupillary changes(32.1%).The mean GCS score was 10.21±4.15,and the mean m Graeb score was 7.42 ± 3.83.A significant correlation was observed between GCS and m Graeb score,which implied that patients with a larger blood clot size were associated with a lower GCS score.47 patients(41.9%)presented with acute hydrocephalus.Hypertension was identified in 93 patients(83%),diabetes in 34(30%)respectively.Coagulopathy caused by Warfarin and antiplatelet agents was observed in 25 patients.6 patients did not received angiography due to brain herniation.The VSA-related PIVH occurred in 39 patients(34.8%),while IPIVH in 73(65.2%),and the etiological causes confirmed by angiography included AVM in 7 patients(6.2%),Moyamoya disease in 12 patients(10.7%),aneurysms in 20(17.8%).In our series,47 patients received conservative treatment,and 65 patients underwent extraventricular drainage(EVD).Among the patients with aneurysms,12 received endovascular embolization,5 underwent Microsurgical clipping.In patients with AVM,5 patients underwent endovascular embolization after a stable condition,2 received craniotomy.In patients with Moyamoya disease,treatment included revascularization surgery in8 patients and meningeal inversion,temporal muscle sticking in 4 after the hemorrhage was absorbed.A total of 26 patients died during hospitalization and follow-up,with 13 in each phase.Complications included pneumonia in 67 patients(59.8%),catheter-related infectionsin 33 patients(29.4%),mainly intracranial infection,chronic hydrocephalus requiring ventriculo-peritoneal shunt occurred in 47 patients(41.9%),for which no risk factors could be identified,41 patients complicated with gastrointestinal bleeding(36.6%),27 patients complicated with urinary tract infection(24.1%).At the 30-day follow-up,64 patients(57.2%)achieved favorable outcome(GOS score3,4,5),whereas 48 patients(42.8%)had a poor outcome(GOSscore1,2).Univariate analysis showed that there were 9 factors related to the prognosis of patients with primary intraventricular hemorrhage(P<0.05),including: age,admission GCS score(a GCS),coma,lateral ventricle hemorrhage,lateral ventricle and the three ventricle and the four ventricle hemorrhage,modified Graeb score(m Graeb),oral anticoagulant history(NOACS),pneumonia,aneurysm pathogenesis.Multivariate regression analysis showed that only age,m Graeb score,pneumonia and aneurysm were the prognostic factors for patients with PIVH.Among these,aneurysm had the greatest influence(β=8.485),the descending order of the influence of the other factors was as follows: pneumonia(β=-5.338)>m Graeb(β=2.002)>age(β=0.400).That is to say the patient with an aneurysm pathogenesis,older,more ventricular system blood volume and pneumonia during hospitalization,had a poorer prognosis.Conclusion:1,Primary intraventricular hemorrhage(PIVH)good hair in elderly patients,the high incidence of age in PIVH is between 45-75 years old,with gender bias,more men than women,the proportion of gender is about 2:1.2,CT is the preferred way to diagnose PIVH.2mm thin CT scanning was recommended,in order to exclude SIVH.CTA or DSA should be used for the diagnosis of PIVH as routine check methods.3,Whether or not to perform external ventrical drainage(EVD)should be judged according to the degree of coma and the imaging findings in CT,such as modified Graeb score(m Graeb score).4,Univariate analysis showed that 9 factors adopted in our study can affect the prognosis of intraventricular hemorrhage,including age,admission GCS score(a GCS),coma,lateral ventricle hemorrhage,lateral ventricle and the three ventricle and the four ventricle hemorrhage,modified Graeb score(m Graeb),oral anticoagulant history(NOACS),pneumonia,aneurysm pathogenesis.5,Multiple linear regression analysis showed that only age,m Graeb score,pneumonia and aneurysm were the prognostic factors of patients with PIVH.Among these,aneurysm had the greatest influence(β=8.485),the descending order of the influence of the other factors was as follows: pneumonia(β=-5.338)>m Graeb(β=2.002)>age(β=0.400).