长程脑室外引流术治疗结核性脑膜炎合并脑积水的临床效果

doi:10.19982/j.issn.1000-6621.20220264

摘要/Abstract

摘要：

目的: 探讨皮下隧道长程脑室外引流术(long tunnelled external ventricular drainage, LTEVD)对结核性脑膜炎合并脑积水的治疗效果。方法: 收集2018年1月至2021年5月深圳市第三人民医院神经外科应用脑室外引流术治疗的结核性脑膜炎合并脑积水的43例患者临床资料,其中,26例采用传统脑室外引流术(EVD)治疗(传统EVD组),17例采用LTEVD治疗(LTEVD 组)。比较两组患者治疗效果和并发症情况。结果: 17例LTEVD组患者引流时间为16~67d,平均(28.12±13.86)d;其中,5例(29.4%)拔管后脑积水加重,行二期脑室腹腔分流术。26例传统EVD组患者单次引流时间均未超过14d;其中,16例(61.5%)拔管后脑积水复发,行二期脑室腹腔分流术。LTEVD 组患者住院时间[30.00(24.00,33.50)d]与传统EVD组[30.50(26.00,39.25)d]差异无统计学意义(Z=0.847,P=0.397),但引流期间LTEVD组患者脱管频率和脑脊液漏发生率及颅内感染发生率[均为0.0%(0/17)]、置管频率和二次分流手术的实施率[分别为100.0%(17/17)和29.4%(5/17)]均低于传统EVD组[分别为30.8%(8/26)、30.8%(8/26)、26.9%(7/26)、180.8%(47/26)和61.5%(16/26)],差异均有统计学意义(χ²=6.426,P=0.014;χ²=6.426,P=0.014;χ²=5.467,P=0.031;χ²=5.932,P=0.000;χ²=4.246,P=0.039)。两组患者出院后均随访1~2年,其中LTEVD组总有效率为82.4%(14/17),与传统EVD组(69.2%,18/26)差异无统计学意义(χ²=0.368,P=0.544)。结论: LTEVD治疗结核性脑积水较传统EVD引流时间长、并发症少,是一种安全有效的方法。

关键词: 结核,脑膜, 脑积水, 脑室引流术, 治疗结果, 病例对照研究

Abstract:

Objective: To investigate the effect of long tunnelled external ventricular drainage (LTEVD) for tuberculous meningitis complicated with hydrocephalus. Methods: The clinical data of 43 tuberculous meningitis patients with hydrocephalus were retrospectively collected. All of them were treated with external ventricular drainage (EVD) in the Department of Neurosurgery, The Third People’s Hospital of Shenzhen from January 2018 to May 2021. Of them, 26 were treated with traditional EVD (traditional EVD group) and 17 were treated with LTEVD (LTEVD group). The therapeutic effect and complications were compared between the two groups. Results: Seventeen patients’s drainage time was 16-67 days in the LTEVD group, with an average of (28.12±13.86) days. Among them, 5 patients (29.4%) had aggravated hydrocephalus after the removal of the long-distance external drainage tube and was treated with ventriculoperitoneal shunt surgery. The 26 patients’s single drainage time did not exceed 14 days in the traditional EVD group. Among them, 16 patients (61.5%) had recurrence of hydrocephalus after extubation and then underwent ventriculoperitoneal shunt surgery. The hospital stay of patients in LTEVD group was 30.00 (33.50, 24.00) d, which was lower than that in traditional EVD group (30.50 (39.25, 26.00) d), the difference was not statistically significant (Z=0.847, P=0.397). However, the rate of unexpected extubation, cerebrospinal fluid leakage and intracranial infection, the incidences of catheterization and secondary shunt surgery in LTEVD group were all significantly lower or less than those in traditional EVD group (0.0% (0/17) vs. 30.8% (8/26), χ²=6.426, P=0.014; 0.0% (0/17) vs. 30.8% (8/26), χ²=6.426, P=0.014; 0.0% (0/17) vs. 26.9% (7/26), χ²=5.467, P=0.031; 100.0% (17/17) vs. 180.8% (47/26), χ²=5.932, P=0.000; 29.4% (5/17) vs. 61.5% (16/26), χ²=4.246, P=0.039; respectively). Patients in both groups were followed up for 1-2 years after discharge. The total effective rate was 82.4% (14/17) in LTEVD group, and was 69.2% (18/26) in the traditional EVD group, there was no significant difference between the two groups (χ²=0.368, P=0.544). Conclusion: LTEVD is a safe and effective technology for tuberculous hydrocephalus, which with longer drainage time and fewer complications compared to the traditional EVD.

Key words: Tuberculosis, meningeal, Hydrocephalus, Ventricular drainage, Treatment outcome, Case-control studies

中图分类号:

陈启富, 张圣坤, 廖广生, 唐忠, 詹森林, 邓国防, 张培泽, 初明. 长程脑室外引流术治疗结核性脑膜炎合并脑积水的临床效果[J]. 中国防痨杂志, 2022, 44(11): 1187-1192. doi: 10.19982/j.issn.1000-6621.20220264

Chen Qifu, Zhang Shengkun, Liao Guangsheng, Tang Zhong, Zhan Shenlin, Deng Guofang, Zhang Peize, Chu Ming. Clinical effect on the treatment of long tunnelled external ventricular drainage for tuberculous meningitis complicated with hydrocephalus[J]. Chinese Journal of Antituberculosis, 2022, 44(11): 1187-1192. doi: 10.19982/j.issn.1000-6621.20220264

图/表 3

参考文献 18

[1]	Thwaites GE, Van Toorn R, Schoeman J. Tuberculous meningitis:more questions,still too few answers. Lancet Neurol, 2013, 12(10):999-1010. doi: 10.1016/S1474-4422(13)70168-6. doi: 10.1016/S1474-4422(13)70168-6 pmid: 23972913
[2]	中华医学会结核病学分会结核性脑膜炎专业委员会. 2019中国中枢神经系统结核病诊疗指南. 中华传染病杂志, 2020, 38(7):400-408. doi: 10.3760/cma.j.cn311365-20200606-00645. doi: 10.3760/cma.j.cn311365-20200606-00645
[3]	张齐龙, 刘健民, 郭晓莹, 等. 侧脑室引流管在结核性脑膜炎脑积水治疗中放置时间的评估与研究. 中国现代医生, 2013, 51(32):48-50. doi: 1673-9701(2013)32-0048-03. doi: 1673-9701(2013)32-0048-03
[4]	吴中华, 王斌, 史锡文, 等. 腰大池引流的并发症及处理措施. 中国实用神经疾病杂志, 2016, 19(7):93-95. doi: 1673-5110(2016)07-0093-03. doi: 1673-5110(2016)07-0093-03
[5]	Kamat AS, Gretschel A, Vlok AJ, et al. CSF protein concentration associated with ventriculoperitoneal shunt obstruction in tuberculous meningitis. Int J Tuberc Lung Dis, 2018, 22(7):788-792. doi: 10.5588/ijtld.17.0008. doi: 10.5588/ijtld.17.0008 pmid: 29914605
[6]	Sanat B, Nirav M, Suneel S. Use of endoscopic third ventriculostomy in hydrocephalus of tubercular origin. Childs Nerv Syst, 2010, 26(12):1675-1682. doi: 10.1007/s00381-010-1183-1. doi: 10.1007/s00381-010-1183-1 URL
[7]	Ramanan M, Lipman J, Shorr A, et al. A Meta-analysis of ventriculostomy-associated cerebrospinal fluid infections. BMC Infect Dis, 2015, 15:3. doi: 10.1186/s12879-014-0712-z. doi: 10.1186/s12879-014-0712-z pmid: 25567583
[8]	Jamjoom A, Joannides AJ, Poon MT, et al. Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland. J Neurol Neurosurg Psychiatry, 2018, 89(2): 120-126. doi: 10.1136/jnnp-2017-316415. doi: 10.1136/jnnp-2017-316415 pmid: 29070645
[9]	Park J, Choi YJ, Ohk B, et al. Cerebrospinal fluid leak at percutaneous exit of ventricular catheter as a crucial risk factor for external ventricular drainage-related infection in adult neurosurgical patients. World Neurosurg, 2018, 109:e398-e403. doi: 10.1016/j.wneu.2017.09.190. doi: 10.1016/j.wneu.2017.09.190 URL
[10]	Atkinson R, Fikrey L, Jones A, et al. Cerebrospinal fluid infection associated with silver-impregnated external ventricular drain catheters. World Neurosurg, 2016, 89: 505-509. doi: 10.1016/j.wneu.2016.01.034. doi: 10.1016/j.wneu.2016.01.034 pmid: 26805688
[11]	Dorresteijn K, Brouwer MC, Jellema K, et al. Bacterial external ventricular catheter-associated infection. Expert Rev Anti Infect Ther, 2020, 18 (3):219-229. doi: 10.1080/14787210.2020.1717949. doi: 10.1080/14787210.2020.1717949 pmid: 31994951
[12]	Korinek AM, Reina MA, Boch AL, et al. Prevention of external ventricular drain-related ventriculitis. Acta Neurochir(Wien), 2005, 147(1):39-46. doi: 10.1007/s00701-004-0416-z. doi: 10.1007/s00701-004-0416-z URL
[13]	Zhou YJ, Wu JN, Chen LJ, et al. Comparison of infection rate with tunneled vs standard external ventricular drainage: A prospective, randomized controlled trial. Clin Neurol Neurosurg, 2019, 184:105416. doi: 10.1016/j.clineuro.2019.105416. doi: 10.1016/j.clineuro.2019.105416
[14]	朱吉祥, 陈发军, 李贵福, 等. 耳后皮下潜行隧道在脑室外引流术中的临床运用. 中国老年学杂志, 2011, 31(13):2556. doi: 10.3969/j.issn.1005-9202.2011.13.079. doi: 10.3969/j.issn.1005-9202.2011.13.079
[15]	Umesh S, Jagadeesh VM, Savitr S, et al. Outcome of ventriculoperitoneal shunt placement in Grade Ⅳ tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients. Neurosurg Pediatr, 2009, 4(2):176-183. doi: 10.3171/2009.3.PEDS08308. doi: 10.3171/2009.3.PEDS08308
[16]	Phillip C, John E, Pasquale G, et al. Guideline for the management of long tunnelled external ventricular drains in chronic hydrocephalus. Br J Nurs, 2021, 30(7):416-421. doi: 10.12968/bjon.2021.30.7.416. doi: 10.12968/bjon.2021.30.7.416 pmid: 33830799
[17]	Tobin G, Ranjith KM, Vedantam R. Long tunnel external ventricular drain: an adjunct in the management of patients with infection associated hydrocephalus. Br J Neurosurg, 2019, 33(6):659-663. doi: 10.1080/02688697.2019.1667483. doi: 10.1080/02688697.2019.1667483 URL
[18]	Christian DE, John CH, Aabir C, et al. Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains. J Childs Nerv Syst, 2014, 30(10):1671-1678. doi: 10.1007/s00381-014-2523-3. doi: 10.1007/s00381-014-2523-3

组别	住院天数 [d,M(Q₁,Q₃)]	脑脊液漏[例 (发生率,%)]	脱管[次 (频率,%)]	置管[次 (频率,%)]	颅内感染[例 (发生率,%)]	二次分流术 [例(实施率,%)]	有效[例 (有效率,%)]
LTEVD组(17例)	30.00(24.00,33.50)	0(0.0)	0(0.0)	17(100.0)	0(0.0)	5(29.4)	14(82.4)
传统EVD组(26例)	30.50(26.00,39.25)	8(30.8)	8(30.8)	47(180.8)	7(26.9)	16(61.5)	18(69.2)
统计检验值	Z=0.847	χ²=6.426	χ²=6.426	χ²=5.932	χ²=5.467	χ²=4.246	χ²=0.368
P值	0.397	0.014	0.014	0.000	0.031	0.039	0.544