Clinical Observation On Therapy Of Traumatic Subarachnoid Hemorrhage With Early Lumbar Drainage In Combination With Methylprednisolone

Objective: Traumatic Subarachnoid Hemorrhage(t SAH) is a common clinical manifestation and pathological changes after traumatic brain injury. Cerebral vasospasm(CVS) caused by t SAH is not only a common complication but also the leading cause of disability and death in patients, so the key to the treatment is to remove causes of CVS as soon as possible, so as to reduce the incidence of CVS and duration of CVS. CVS caused by t SAH is divided into acute and chronic phase. The acute phase of CVS occurs only a few minutes after t SAH, and usually lasts less than 1 hour. The chronic phase of CVS appears 72 hours after t SAH, and reaches the peak at 7d, CVS generally lasts 2-3W, which is the leading cause of disability and death in patients. At present the mechanisms of CVS after t SAH is multifaceted, for instance, the releasing of oxygen hemoglobin caused by red cells’ disintegrating after t SAH; the secretion increasing of endothelin; the decreasing of nitric oxide generation and inactivation increasing;(4, 5), inflammation(3, 5), potassium ion channel and calcium ion channel dysfunction, expression of specific cytokines, apoptosis mechanism etc. Obviously, it is extremely effective to remove subarachnoid hematocele as soon as possible, to smooth cerebrospinal fluid circulation, to clear up the spasmogen materials as soon as possible and to implement anti-inflammatory treatment simultaneously for the prevention and treatment of CVS. The current treatment of t SAH with spasmolysis, hemostasis, decreasing intracranial pressure, cerebral protection and lumbar puncture treatment is limited for cerebrospinal fluid replacement, and it is difficult to quickly remove hematocele of cerebrospinal fluid. The therapy of Lumbar Drainage is seldom performed nowadays and there is no uniform standard about carrying it out. That is usually performed 48 ~ 72 h after the incidence. What’ more, there are different opinions about a large dose of steroid pulse therapy. Therefore, it’s very urgent and necessary to find a scientific, reasonable, practical methods for the research of lumbar cistern drainage time and it is combined with a large dose of methylprednisolone impact treatment.Method: 160 cases of t SAH patients were randomly divided into treatment group and control group during the period of time, from October 2013 to September 2014. Inclusion criteria: ①clinical standards of t SAH are in line with the second national cerebrovascular disease association conference, regarding trauma as the cause, with the exclusion of spontaneous subarachnoid hemorrhage; ② 12 hours after injury for admission; ③ Glasgow(GCS) score > 8 points; ④Skull CT confirms that t SAH is the one which is isolated or combined with mild brain contusion or a small amount of intracerebral hematoma, no obvious shift center line, without signs of cerebral hernia; ⑤No history of hypertension; ⑥ No history of spontaneous subarachnoid hemorrhage; ⑦The age ranges from 17 to 58. 80 cases of the control group, treated with routine therapy, are performed the lumbar puncture once daily 24 hours after the incidence, releasing 20~30ml bloody cerebrospinal fluid, and intrathecal injected with 0.9% sodium chloride injection, 2 times in a row, which can release the bloody cerebrospinal fluid 40~60ml every day, lasts 7~14d. 80 cases of treatment group, in addition to the above conventional drug treatment, are performed lumbar cistern drainage within 24 hours, In the injured early local anesthesia downlink lumber cistern catheterization(within 24 h after trauma), generally choose fourth, fifth lumbar intervertebral puncture, catheter, catheter drainage of the depth of about 5~8cm, regulate the drainage speed, increase intracranialpressure maintained at between 110~150 mm H2O(1.1~1.5Kpa), drainage volume control in the speed of about 200 ml in general every day. In general the indwelling time in 10~14d(less than 2 week). After admission given methylprednisolone injection 30mg/kg, intravenous injection of every 6h, continuous administration of 3D, followed by methylprednisolone injection 15mg/kg, intravenous injection of every 8h, continuous administration of 2d, methylprednisolone injection 7.5mg/kg, intravenous injection of every 12 h, drug 1d, methyl prednisolone injection 3mg/kg, intravenous injection once a day, taking medicine 1d, throughout the course of 7d. Two groups of cases are examined respectively through transcranial doppler after the onset of 1d, 3d, 5d, 7d, 10 d, 14 d to monitor the middle cerebral artery blood flow velocity, to observe the degree of CVS and the duration of the CVS. Do the daily routine and biochemical assay of cerebrospinal fluid, and regularly do cerebrospinal fluid culture and drug sensitive test. Skull CT examinations are performed respectively after onset of 1d, 3d, 7d, 14 d to observe the hemorrhage and the presence of cerebral infarction and hemorrhage. At the same time, ET, the content of NO in plasma and CSF are monitored in order to explore the role of ET, NO in cerebral vascular spasm.Results:1 After 14 days’ treatment observation, the incidence of CVS in control group was 52.5%(42 cases). The incidence of CVS in treatment group was 16.3%(13 cases). The difference was statistically significant(P < 0.05).2 After 14 days’ treatment observation, the incidence of cerebral infarction in control group was 20%(16 cases) and the incidence of cerebral infarction in treatment group was 5%(4cases). The incidence of hydrocephalus in control group was 8.8%(7cases) and the incidence of hydrocephalus in treatment group was 5%(2 cases). The contrast difference was statistically significant(P < 0.05) as to the incidence of cerebral infarction and hydrocephalus for two groups of patients. The incidences of cerebral infarction and hydrocephalus in treatment group were significantly lower than that in control group.3 On 1d, 3d, 5d, 7d, 10 d, 14 d of onset, VMCA in control group were respectively: 96.8±12.7cm/s、135.8±21.4 cm/s、189.2±22.9 cm/s、161.3±19.6 cm/s、140.7±17.7 cm/s、120.7±17.7cm/s, the treatment group of 80: 97.1±12.8 cm/s、107.3±16.5 cm/s、150.8±18.2 cm/s、130.6±17.912 cm/s、0.1±10.8 cm/s、69.1±10.8 cm/s. CVS appeared on 3d of onset for the patients in control group and CVS duration was longer, about 10 days or so. CVS appeared on 5d of onset for the patients in treatment group and CVS duration was shorter, about 5 days or so. VMCA contrast differences between two groups of patients was statistically significant(P < 0.05).4 On 1d, 3d, 5d, 7d, 10 d of onset, ET-1 contents in cerebrospinal fluid in control group were respectively: 47.0±8.21 pg/ml、76.8±13.6 pg/ml、69.1±11.9 pg/ml、63.3±7.16 pg/ml、46.6±5.71 pg/ml, and ET-1 contents in cerebrospinal fluid in treatment group were respectively: 47.1±8.14pg/ml 、 58.5±11.81 pg/ml、59.1±5.87 pg/ml、53.1±6.27 pg/ml、38.8±5.69 pg/ml. The ET-1 contents in cerebrospinal fluid in treatment group was significantly lower than the control group, and restored normal in a relatively short period of time. By contrast, the difference was statistically significant(P < 0.05).5 The incidence of 1d, 3d, 5d, 7d, 10 d, NO contents in cerebrospinal fluid of the control groups respectively: 56.0±7.8 umol/L、45.4±5.6 umol/L、42.1±5.7 umol/L、45.7±5.6 umol/L、51.1±4.9 umol/L, the content of NO in cerebrospinal fluid in the treatment group were: 56.1±7.7umol/L、52.3±5.9 umol/L、49.0±6.7 umol/L、57.3±5.1 umol/L、59.6±7.6 umol/L. The content of NO in cerebrospinal fluid in the treatment group was significantly higher than that in the control group, and returned to normal in the shorter period of time. By contrast, the difference was statistically significant(P < 0.05).Conclusion: The therapy of Early Lumbar Drainage can be as soon as possible drainage of accumulated blood in the subarachnoid and spasm factor, effectively reduce the content of ET-1 in CSF, improve the level of NO, decrease the incidences of CVS and cerebral infarction, and shorten the duration of CVS.The therapy of methylprednisolone injection can effectively inhibit the inflammatory reaction, reduce CVS and arachnoid adhesion, and decrease the incidence of hydrocephalus.The therapy of Early Lumbar Drainage in Combination with large dose methylprednisolone injection can effectively reduce the complications of t SAH and improve the prog is of patients.