| BackgroundAneurysmal subarachnoid hemorrhage(aSAH)is a critical systemic disease with a high incidence rate of death and disability.Poor-grade aSAH refers to patients withⅣ-Ⅴ grade according to the World Federation of Neurosurgery(WFNS)grade or HuntHess grade,accounting for 18-30%of all aSAH patients,with a higher mortality and disability rate.In recent years,with the improvement of the quality of medical care,the fatality rate of poor-grade aSAH has decreased,but most of the surviving patients remain with varying degrees of long-term dysfunction.The poor prognosis of the patients may be closely related to the common postoperative complications of shuntdependent hydrocephalus(SDHC).As a life-saving first aid technique,external ventricular drainage(EVD)can not only monitor and reduce intracranial pressure,but also remove intraventricular hemorrhage and its metabolites.It is widely used in poorgrade aSAH patients.However,the placement of external ventricular drainage,large amount of cerebrospinal fluid drainage and prolonged external ventricular drainage may increase the risk of shunt-dependent hydrocephalus.At present,the effect of shuntdependent hydrocephalus after poor-grade aSAH on the prognosis is still unclear,and the effect of poor-grade aSAH placement into external ventricular drainage on shuntdependent hydrocephalus is still unclear.There is no clear quantitative standard on how to control the drainage volume and duration of external ventricular drainage.ObjectivesThe main aim of this study was to explore the relation of the complications of shunt-dependent hydrocephalus after poor-grade aSAH with the placement of external ventricular drainage,drainage volume and drainage duration,so as to provide clinical reference for determining the best drainage volume and drainage duration and reducing the occurrence of shunt-dependent hydrocephalus.A further aim was to clarify the influence of shunt-dependent hydrocephalus on the prognosis of patients after poorgrade aneurysmal subarachnoid hemorrhage.MethodsThe first part of this study was a case-control study,and the second part was a retrospective cohort study.Part Ⅰ:A total of 99 poor-grade aSAH patients admitted to the Department of Neurosurgery,No.904 Hospital of China People’s Liberation Army Joint Logistics Support Force in the past ten years(from October 2011 to December 2020)were recruited.According to the outcome of patients,the patients were divided into the group with shunt-dependent hydrocephalus(case group)and the group without shuntdependent hydrocephalus(control group).The medical records of the patients were reviewed to collect the general data,disease-related data and information related to external ventricular drainage(whether or not external ventricular drainage is placed,drainage volume and drainage duration).Univariate analysis was firstly applied,and thereafter the factors with P<0.1 were included in multivariate logistic regression,to clarify the relation of the complications of shunt-dependent hydrocephalus after poorgrade aSAH with the placement of external ventricular drainage and its drainage volume,drainage duration;The diagnostic efficiency was compared by ROC curve method,and the best cutoff value of drainage flow and drainage duration were determined.Part Ⅱ:The poor-grade aSAH patients screened in the first part of the study were followed up for one year to obtain the prognosis of the patients.According to the exposure factors,the patients were divided into two groups:the group with shuntdependent hydrocephalus(exposure group)and the group without shunt-dependent hydrocephalus(non-exposure group).Firstly,univariate analysis was applied,and thereafter the factors with P<0.1 were included in the modified possion regression to clarify the influence of shunt-dependent hydrocephalus after poor-grade aSAH on the prognosis.ResultsIn this study,307 cases of poor-grade aSAH patients were reviewed,among which 99 cases(40 males and 59 females)met the inclusion and exclusion criteria,with an average age of 56±12 years.According to Hunt-Hess classification,there were 66 cases at grade Ⅳ and 33 cases at grade Ⅴ.Part Ⅰ1.The relationship between the external ventricular drainage placement and shunt-dependent hydrocephalus after poor-grade aSAH.1.1 Baseline and disease-related data of subjects in case group and control groupAmong the 99 poor-grade aSAH patients,41 cases(41.4%)developed shuntdependent hydrocephalus after operation(case group),while 58 cases(58.6%)did not(control group).In the case group,33 cases had shunt-dependent hydrocephalus within 3 months after operation,5 cases from 3 to 6 months,and 3 cases from 6 to 12 months.Among all the patients,80 cases(80.8%)were implanted with external ventricular drainage,and 19 cases(19.2%)were not.Compared with the control group,the case group had significantly more patients over 60 years old,with a history of hypertension,intraventricular hemorrhage,acute hydrocephalus and the placement of external ventricular drainage,with statistical significance(P<0.05).1.2 Multivariate Logistic regression analysis of shunt-dependent hydrocephalusAfter adjusting for age,history of hypertension,intraventricular hemorrhage,acute hydrocephalus,Hunt-Hess classification,decompressive craniectomy and postoperative cerebral infarction,it was found that placing external ventricular drainage increased the risk of shunt-dependent hydrocephalus compared with not placing external ventricular drainage,and the difference was statistically significant(OR=6.715,95%CI 1.120-40.248,P=0.037).2.Relationship between external ventricular drainage related data and shuntdependent hydrocephalus after poor-grade aSAH in the subgroup with external ventricular drainage2.1 Baseline and disease-related data of subjects with and without shuntdependent hydrocephalus in the subgroup with external ventricular drainageAmong the 80 patients with external ventricular drainage,there were 39 cases(48.8%)with shunt-dependent hydrocephalus,and 41 cases(51.2%)without shuntdependent hydrocephalus.Compared with those without shunt-dependent hydrocephalus,the proportion of patients with shunt-dependent hydrocephalust who were over 60 years old,with a history of hypertension,intraventricular hemorrhage and acute hydrocephalus was significantly higher,and the difference was statistically significant(P<0.05).2.2 External ventricular drainage related data in two groups of patientsThe average daily ventricular drainage volumes in patients with shunt-dependent hydrocephalus in the first three days after operation(244±61ml in the first day,210±48ml in the first two days,and 199±49ml in the first three days)was significantly higher than those without shunt-dependent hydrocephalus(166±51ml,166±54ml,and 159±52ml).The differences was statistically significant(P<0.05).The average daily drainage volume in patients with shunt-dependent hydrocephalus was 162±44ml,which was significantly higher than that without shunt-dependent hydrocephalus(141±45ml).The differences was statistically significant(P<0.05).There was no significant difference in drainage duration between patients with shunt-dependent hydrocephalus[11(10,14)days]and those without shunt-dependent hydrocephalus[10(9,12)days].2.3 Multivariate Logistic regression analysis of shunt-dependent hydrocephalus based on variables related to external ventricular drainageAfter adjusting for age,history of hypertension,acute hydrocephalus,intraventricular hemorrhage,Hunt-Hess classification,mFisher classification and postoperative cerebral infarction,the results showed that the increase of drainage volume on the first day after operation increased the risk of shunt-dependent hydrocephalus,with statistical significance(OR=1.030,95%CI 1.013-1.047,P<0.001).The results of daily average drainage volume in the first two days(OR=1.019,95%CI 1.005-1.034,P=0.008)and three days(OR=1.018,95%CI 1.002-1.034,P=0.027)after operation were consistent with those in the first day.However,statistical difference in the association of shunt-dependent hydrocephalus was found neither with the average daily drainage volume within 4 days after operation,nor with the average daily drainage volume throughout the catheterization and the drainage duration.2.4 ROC curve analysis of the predictive value of external ventricular drainage for shunt-dependent hydrocephalus after poor-grade aSAH.External ventricular drainage volume on the first day after operation had a good predictive ability for shunt-dependent hydrocephalus after poor-grade aSAH,and its AUC was 0.829(95%CI 0.731-0.928,P<0.001),which was higher than the average daily drainage volume on the second day after operation(AUC,0.724;95%CI 0.6080.841,P=0.001)and the average daily drainage volume on the third day after operation(AUC,0.720;95%CI 0.601-0.838,P=0.001).On the first day after operation,the drainage volume of external ventricular drainage was 208ml,which was the best cutoff value for predicting shunt dependence.The sensitivity was 79.4%,the specificity was 81.6%,and the Youden index was 0.61.The drainage volume on the first day after operation>208ml would increase the risk of shunt-dependent hydrocephalus after poor-grade aSAH.Part ⅡThe influence of shunt-dependent hydrocephalus after poor-grade aSAH on the prognosis of patients.1.Baseline and disease-related data of subjects in exposed group and non-exposed group.Among 99 poor-grade aSAH patients,41 cases developed shunt-dependent hydrocephalus(exposure group)and 58 cases did not develop shunt-dependent hydrocephalus(non-exposure group).Compared with the non-exposed group,the proportion of age ≥60 years,history of hypertension,intraventricular hemorrhage,acute hydrocephalus and the placement of external ventricular drainage in the exposed group increased significantly,with statistical significance(P<0.05).The proportion of decompressive craniectomy and postoperative cerebral infarction in exposed group was slightly higher than that in non-exposed group(P=0.055 and 0.057,respectively).2.One-year follow-up clinical outcome and length of hospital stay of two groups of patients.After one year’s follow-up,it was found that 57 cases(57.6%)had good prognosis(GOS ≥4)and 42 cases(42.4%)had poor prognosis(GOS<4).When mRankin score was used to evaluate the prognosis,49 cases(49.5%)had good prognosis(mRankin score<3)and 50 cases(50.5%)had poor prognosis(mRankin score≥3).In the exposed group,32 cases(78.0%)had GOS<4,which was significantly higher than that in the non-exposed group(17.2%),and the difference was statistically significant(P<0.001).There were 34 cases(82.9%)with mRankin score≥3 in the exposed group,which was significantly higher than 16 cases(27.6%)in the non-exposed group,and the difference was statistically significant(P<0.001).The hospital stay in the exposed group[40(31,63)days]was significantly longer than that in the non-exposed group[28(23,37)days],and the difference was statistically significant(P<0.001).3.Modified possion regression analysis based on prognostic related variables of shunt-dependent hydrocephalus3.1 Possion regression analysis with adjustments of prognosis related variables when GOS was set as prognosis indicatorAfter adjusting for age,history of hypertension,intraventricular hemorrhage,acute hydrocephalus,the placement of external ventricular drainage,Hunt-Hess classification,decompressive craniectomy and postoperative cerebral infarction,the results showed that postoperative shunt-dependent hydrocephalus significantly increased the risk of poor prognosis,and the difference was statistically significant(RR=1.393,95%CI 1.205-1.610,P<0.001).3.2 Possion regression analysis with adjustments of prognosis related variables when mRankin score was set as prognosis indicatorAfter adjusting for age,history of hypertension,intraventricular hemorrhage,acute hydrocephalus,the placement of external ventricular drainage,Hunt-Hess classification,decompressive craniectomy and postoperative cerebral infarction,the results showed that postoperative shunt-dependent hydrocephalus significantly increased the risk of poor prognosis,and the difference was statistically significant(RR=1.372,95%CI 1.206-1.561,P<0.001).Conclusions1.The placement of external ventricular drainage is an independent risk factor for shunt-dependent hydrocephalus after poor-grade aSAH.2.Larger drainage volume in the first three days after placement of external ventricular drainage is an independent risk factor for shunt-dependent hydrocephalus after poor-grade aSAH,especially in the first day after operation,the drainage volume of external ventricular drainage>208ml is the best cutoff value for the increased risk of shunt-dependent hydrocephalus after poor-grade aSAH.3.There is no direct association between the duration of external ventricular drainage and shunt-dependent hydrocephalus after poor-grade aSAH.4.Shunt-dependent hydrocephalus after poor-grade aSAH is the strongest independent risk factor for poor prognosis of patients,and it will prolong hospital stay. |
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