主观评价对特发性正常压力脑积水行脑室–腹腔分流术预后的预测价值研究

Study on the Predictive Value of Subjective Evaluation for the Prognosis of Ventriculoperitoneal Shunt in Idiopathic Normal Pressure Hydrocephalus

摘要: 目的：采用日常活动能力量表(ADL)、神经功能量表(GCS)、核心症状改善情况的主观评价指标，从多维角度对脑室–腹腔分流术(VPS)治疗特发性正常压力脑积水(iNPH)患者的预后进行评价。方法：选取福建中医药大学附属第二人民医院神经外科2022年1月~2024年6月收治的32例iNPH患者作为观察对象，按照放液试验反应结果分为客观改善组及仅主观改善组。采用ADL、GCS、症状改善问卷术前、术后进行动态评分，记录主观评分、症状改变及并发症等情况，采集术前颅内压，并经统计学方法判断主观指标与预后的关联性及预测价值。结果：在对32例接受脑室–腹腔分流术(VPS)治疗的特发性正常压力脑积水(iNPH)患者的相关临床资料中，从术后第3月和第12月其ADL评分及GCS评分变化可见，与术前比较有统计学意义(P < 0.001)，且随时间递增，术后3个月的总有效率为67.9%，12个月提升至81.25%，其中步态、认知、尿失禁改善率分别为75%、62.5%、56.25%；术前放液试验无效者术后有效率为13.7%，明显低于有效者术后有效率(42.9%)，差值有统计学意义(P = 0.018)，据此提出以放液试验评定VPS治疗效果较可靠；经单因素Logistic回归发现：术前ADL ≤ 60分(P = 0.003)、放液试验无效(P = 0.001)、术前GCS < 13分(P = 0.009)均为不良预后的独立危险因素。以ADL为术后疗效的独立危险因素，取值为65分(临界值)，以获得最大AUC值即AUC = 0.86 (灵敏度82.1%、特异度78.6%)时获得最佳判别效能；同时加入ADL评分和术前GCS评分建立多指标模型(AUC = 0.95)，综合3个指标进行评价，其判别效能得到较好的评价。具体来看，客观改善组和仅主观改善组术前颅内压比较也未见明显差异(P = 0.81)，提示术前颅内压并不是造成术后核心症状改善的原因之一。结论：ADL、GCS和核心症状改善程度等主观评价指标能够较好地预测iNPH患者VPS术后的预后，术前ADL评分低、GCS评分低或腰穿试验无效预示着不良的预后；术前颅内压高低及放液试验是否有效与术后核心症状的改善无关；而术前ADL评分低、GCS评分低或腰穿试验无效同样预示着不良的预后，GCS评分低可能导致术后并发症发生率较高，多维度、多方式的动态评估有利于施行个性化治疗。

Abstract: Objective: To evaluate the prognosis of patients with idiopathic normal pressure hydrocephalus (iNPH) treated with ventriculoperitoneal shunt (VPS) from a multidimensional perspective using the Activities of Daily Living (ADL) scale, Glasgow Coma Scale (GCS), and subjective evaluation indicators of core symptom improvement. Methods: Thirty-two iNPH patients from the Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine between January 2022 and June 2024 were selected as the study subjects and divided into objective improvement and subjective improvement groups based on CSF drainage test results. Pre- and post-operative dynamic scoring was done with ADL, GCS, and symptom improvement questionnaires, and subjective scores, symptom changes, and complications were recorded. Pre-operative intracranial pressure was collected, and statistical methods were used to determine the association and predictive value of subjective indicators with prognosis. Results: In the 32 iNPH patients treated with VPS, changes in ADL and GCS scores at post-operative 3 and 12 months showed statistically significant improvements compared to pre-operatively (P < 0.001), with the overall efficacy rate rising from 67.9% at 3 months to 81.25% at 12 months. Gait, cognition, and urinary incontinence improved by 75%, 62.5%, and 56.25% respectively. The postoperative efficacy rate for patients with negative pre-operative drainage tests was 13.7%, significantly lower than those with positive results (42.9%), with a statistically significant difference (P = 0.018), suggesting the drainage test reliably predicts VPS effectiveness. Univariate Logistic regression identified pre-operative ADL ≤ 60 (P = 0.003), negative drainage test (P = 0.001), and pre-operative GCS <13 (P = 0.009) as independent risk factors for poor prognosis. ADL was identified as an independent risk factor for postoperative efficacy, with a cutoff value of 65 points, yielding the optimal discriminative performance when the maximum AUC value was achieved, that is, AUC = 0.86 (sensitivity 82.1%, specificity 78.6%). Additionally, a multi-indicator model combining ADL and pre-operative GCS scores achieved an AUC of 0.95, showing better discriminative ability when assessing all three indicators. Specifically, no significant difference in pre-operative intracranial pressure was found between the objective improvement and subjective improvement groups (P = 0.81), indicating that preoperative intracranial pressure is not one of the causes of post-operative core symptom improvement. Conclusion: Subjective evaluation indicators, including ADL, GCS, and the degree of core symptom improvement, can effectively predict the prognosis of iNPH patients after VPS. Preoperative factors such as low ADL and GCS scores, or a negative lumbar puncture test, indicate a poor prognosis. However, preoperative intracranial pressure levels and the effectiveness of the drainage test are not linked to improvements in core symptoms after surgery. Additionally, low preoperative ADL and GCS scores, or a negative lumbar puncture test, also suggest a poor prognosis, with low GCS scores possibly increasing the risk of postoperative complications. Dynamic evaluation from multiple dimensions and using various methods can aid in implementing personalized treatment.