腰大池持续引流治疗蛛网膜下腔出血的系统评价

Continuous Lumbar Drainage for Subarachnoid Hemorrhage: A Systematic Review

目的评价腰大池持续引流脑脊液治疗蛛网膜下腔出血(SAH)的疗效及安全性。方法在Cochrane图书馆(1992年1月-2013年5月)、Medline(1950年1月-2013年5月)、中国生物医学文献数据库(1979年1月-2013年5月)、中国学术期刊全文数据库(1979年1月-2013年5月)、中文科技期刊全文数据(1989年1月-2013年5月)、万方数据库(1979年1月-2013年5月)等数据库检索采用腰大池持续引流治疗SAH的随机对照试验(RCT)进行系统评价。结果共纳入12个符合纳入标准的RCT,共计患者857例,但试验方法学质量普遍低下。只有2个研究提及随访期末(至少3个月)SAH患者死亡、植物状态或残疾等不良结局。其余指标Meta分析结果显示:在治疗和随访期末引流+常规治疗组的总病死率、脑血管痉挛(CVS)发生率、脑积水发生率、脑梗死发生率均低于对照组,其差异有统计学意义[总病死率:RR=0.27,95%CI(0.12,0.59),P=0.001;CVS发生率:RR=0.20,95%CI(0.14,0.30),P<0.000 01;脑积水发生率:RR=0.24,95%CI(0.13,0.41),P<0.000 01;脑梗死发生率:RR=0.27,95%CI(0.16,0.45),P<0.000 01]。仅1篇文献报道了该疗法的不良反应包括颅内感染和低颅压反应的发生,其余试验未提及不良反应;3个研究报告了总有效率,5个研究报告了头痛缓解情况。结论该系统评价纳入RCT质量均较低,虽然腰大池持续引流脑脊液有降低SAH患者病死率和大部分并发症的趋势,但不能评价其对远期功能性结局的影响以及不良反应的指标,尚不能对其疗效是否有效、安全作出定论,还需要更多设计严格的多中心、大样本的RCT对其疗效和安全性作出验证。

Objective To assess the ef ectiveness and safety of continuous lumbar drainage of cerebrospinal l uid for subarachnoid hemorrhage（SAH）. Methods The Cochrane Library（January 1992 to May 2013）, Medline（January 1950 to May 2013）, Sino Med（January 1979 to May 2013）, CNKI（January 1979 to May 2013）, and Wanfang Database（January 1979 to May 2013） were searched for randomized controlled trials（RCTs） on continuous lumbar drainage for SAH. The method of Cochrane systematic review was used to evaluate all the included RCTs. Results Twelve RCTs（857 patients） met the inclusion criteria, but the general methodological quality of trials was poor. Only two studies addressed the outcomes about SAH patients’ death, vegetative state or disability and other adverse events at the end of the followup period（at least 3 months）. Meta-analysis of fatality showed a better effect of lumbar continuous drainage of the cerebrospinal l uid for SAH than the control group with statistical signifficance [RR=0.27, 95%CI（0.12, 0.59）, P=0.001]. Meta-analysis of complications also showed a better ef ect of lumbar continuous drainage of the cerebrospinal l uid for SAH than the control group with statistical signifficance（except re-bleeding） [cerebral vasospasm： RR=0.20, 95%CI（0.14, 0.30）, P 〈 0.000 01; hydrocephalus： RR=0.24, 95%CI（0.13, 0.41）, P 〈 0.000 01; cerebral infarction： RR=0.27, 95%CI（0.16, 0.45）, P 〈 0.000 01]. Only one trial reported the adverse events of lumbar continuous drainage of the cerebrospinal l uid including intracranial infection and intracranial hypotension reaction, while the others did not report the adverse events. Conclusions WitThpoor quality of the most included trials, insuficient evidence is obtained to support the conclusionthat lumbar continuous drainage of the cerebrospinal fluid is safe and effective in the treatment of SAH. Further highquality RCTs should be carried out to provide more reliable evidences.