| BACKGROUND:Intracranial aneurysmal subarachnoid hemorrhage(a SAH)is one of the most critical and severe diseases in neurosurgery and neurological intervention department.After the occurrence of SAH,rebleeding and a series of serious complications such as cerebral vasospasm(CVS)[1],cerebral edema,delayed ischemic neurological damage(DIND)[2],and shunt-dependent hydrocephalus(SDHC)[3]caused by bloody cerebrospinal fluid in the subarachnoid result in a SAH mortality rate of 30% to 50% [4-6].Compared with craniotomy,intravascular embolization can significantly reduce the disability and fatality rate,which makes more and more a SAH patients choose intravascular embolization[7,8].Although intravascular embolization can control the aneurysmal rupture and bleeding in time,the blood in the subarachnoid cannot be removed with interventional surgery.At present,many studies have shown that lumbar drainage(LD)can effectively drain bloody cerebrospinal fluid in the subarachnoid space in a timely manner,and has important clinical significance in replacing bloody cerebrospinal fluid,reducing intracranial pressure and reducing SAH complications,and improving prognosis[11-14].However,there are still many complications of LD,which need to be further discussed and prevented[15-17].Among them,the incidence of LD-associated CSF infection is reported in the literature 1%-18%[18-20],and has attracted widespread attention due to its high incidence and mortality.Many centers have also explored factors related to catheter infection,such as the relationship between catheter operation and catheter-related infections,the relationship between the length of catheterization and the risk of infection,whether daily CSF testing increases the risk of infection,and whether prophylactic antibiotics can reduce CSF infection rate,etc[20-22].Among them,many studies suggest that the drainage tube indwelling time is an important risk factor for CSF infection[20,23,24].Reviewing previous literature,for patients with a SAH,there are no definite standards for the timing of extubation and time of continuous drainage of LD,which poses a major challenge for the prevention and management of LD-related CSF infection.Therefore,it is necessary to furtherly investigate the timing of extubation a lumbar drainage tube after a SAH.OBJECTIVE:Retrospectively analyze the case data of LD application after anterior circulation intracranial ruptured aneurysm embolization in a continuous period of time,find the appropriate timing of extubation of LD after a SAH embolization,and explore the relationship between the extubation timing of LD and CSF infection and clinical prognosis.At the same time,it also gives advice on whether to replace LD in cases of accidental detubation or obstruction.METHODS:The cases of SAH which applicated LD after embolization of anterior circulation intracranial ruptured aneurysms were collected from the Department of Neurosurgery of Huaihe Clinical College of Henan University and the First Affiliated Hospital of Zhengzhou University since January 1,2017 to July 31,2019,the disease involves the aneurysms on the internal carotid artery,the anterior aneurysm,the M1 segment of the middle cerebral artery and its bifurcation aneurysms.In all cases,LD was placed after embolization of aneurysm.Collect the patients’ age,sex,duration of catheterization,RBC count in cerebrospinal fluid during extubation,during of catheterization before CSF infection,cerebral infarction after extubation,hydrocephalus,and m RS scores 6 months after discharge.Data analysis was performed using SPSS 23.0 statistical software.Measurement data are expressed as percentages,median(lower quartile,upper quartile)and mean ± standard deviation(± s).Comparison between groups use One-Way-ANOVA test and independent sample nonparametric test,Crosstables-Pearson test and multi-sample Kruskal-Wallis test are used for comparison of count data,interrelation of variables using linear regression analysis.all tests were statistically significant with P <0.05.RESULT:1.A total of 332 cases were collected(128 male,204 female,male: female ≈ 1: 1.6;age range,34-80 years;average age,59.11 ± 10.76 years).There were 190,97,and 45 cases in Hunt-Hess grades II,III,and IV respectively;among them,36 cases had CSF infection after LD,with a total infection rate of 10.84%.2.The infection time of 36 patients with CSF infection was mainly concentrated on the 6th to 9th days after intubation,accounting for 72.2%;In the follow-up treatment of CSF infection,The 6-month prognosis of cases without drainage tube removal and cases of continuous lumbar puncture and repositioning of LD was tested by independent sample non-parametric test,the P values were 0.049,0.028 respectively,<0.05,the difference was statistically significant.Combining the m RS scores of each group,the prognosis of non-removal of the drainage tube is worse than that of continuous lumbar puncture after drainage tube removal or that of relocation of LD after drainage tube removal;continuous lumbar puncture after drainage tube removal compared with cases where LD is repositioned after drainage tube removal,P>0.05,indicating that the treatment of these two groups has no significant difference in prognosis.3.Linear correlation analysis showed that 296 patients without CSF infection had a linear regression relationship between RBC count in CSF and 6-month follow-up m RS score during extubation,suggesting that RBC count in CSF greatly affected m RS score.Therefore,we can analyze the effect of LD in a SAH patients based on the RBC count in CSF at the time of extubation,and select the most appropriate RBC count range for extubation.4.The Kruskal-Wallis test showed that the prognosis H value of 173 Hunt-Hess Ⅱ patients without CSF infection was 7.748,and the P =0.257 >0.05.The difference was not statistically significant,it shows that there is no significant difference in the prognostic m RS score of RBC counts in different CSF for Hunt-Hess grade a SAH.5.The non-paramentric test was performed on 87 Hunt-Hess grade III patients without CSF infection,showing that about the RBC count in CSF during extubation bitween the 3,000～5999/mm3 group and the 6000～9999/mm3 group,the prognosis H value was 3.610,P = 0.005 <0.05.The difference was statistically significant,suggesting a difference in prognosis between the 3000～5999/mm3 group and the 6000～9999/mm3 group,indicating that the extubation timing for Hunt-Hess III patients was the RBC count in CSF<6000/mm3.6.The non-paramentric test was performed on 36 Hunt-Hess grade IV patients without CSF infection.The prognosis H value was 4.333 between the RBC count 3,000～5999/mm3 group and the RBC count 6000～9999/mm3 group,and the P = 0.037 <0.05.The difference was statistically significant.It suggest that the prognosis of the 3000～5999 / mm3 group is different from that of the 6000～9999 / mm3 group,and indicate that the extubation timing for Hunt-Hess III patients is the RBC count in CSF <6000/mm3.7.Among 296 patients without CSF infection,there were 18 cases of DIND with an incidence rate of 6.08%.There were 10 cases of RBC counts <6000 / mm3 in CSF at extubation and 8 cases of RBC counts ≥6000 / mm3,χ2=4.993,P = 0.025 <0.05,the difference was statistically significant.It is considered that the incidence of DIND with the RBC count of less than 6000/mm3 in CSF and the RBC count of more than 6000/mm3 is different.Combined with the incidence rate of DIND in each group(10/218 <8/60),it is suggested that the RBC count in CSF is <6000 / mm3 could reduce the incidence of DIND.8.Among 296 patients without CSF infection,a total of 30 cases of SDHC occurred with an incidence rate of 10.14%.There were 16 cases of RBC counts <6000 / mm3 in CSF during extubation and 14 cases of RBC counts ≥6000 / mm3,χ2 =10.591,P = 0.001 <0.05,The difference was statistically significant.It is considered that the incidence of SDHC with the RBC count of less than 6000 / mm3 in CSF and the RBC count ≥6000 / mm3 is different.Combined with the incidence rate of SDHC in each group(16/212 <14/54),it is suggested that the RBC count in CSF at extubation is <6000 / mm3 could reduce the incidence of SDHC.CONCLUSION:1.For patients with a SAH in Hunt-Hess II,the placement of LD may have no effect on the prognosis,and LD is not recommended to reduce complications such as LD-related infections.2.For a SAH patients with Hunt-Hess III and Hunt-Hess IV,placement of LD is conducive to good clinical prognosis,the extubation timing is the RBC count in CSF <6000 / mm3,which reduces the retention time.This may be beneficial in preventing CSF infection caused by indwelling drainage tube.3.For patients with a SAH,the RBC count in CSF during extubation <6000 / mm3 could reduce the incidence of DIND and SDHC.4.For cases of CSF infection,our recommendation is to directly remove the drainage tube,reposition a new lumbar drainage tube or perform continuous lumbar puncture to replace the cerebrospinal fluid,and use sensitive antibiotics to treat infection. |
