DATI DEMOGRAFICI
Group A Group B p-value
Demographic data
median age (years)
[range] 76.9 [65-88] 76.3 [64-86] 0,298
M:F 19:10 11:15 0,106
Figura 51 – Tabella con dati demografici del nostro studio
Nei dati demografici abbiamo riportato il numero di pazienti del Gruppi A e B omogenei per età e sesso.
Gruppo A - pazienti della nostra casistica con sospetto idrocefalo
cronico dell’adulto
Gruppo B - pazienti controllo a cui è stato efettuato un esame TC
cranio basale per
traumi minori, in assenza di reperti degni di nota (focolai contusivi,
raccolte ematiche intra/extraparenchimali, etc).
I pazienti del gruppo B, oltre ad avere TC negative, clinicamente non presentavano nessuna delle sintomatologie delle triade di Hakim & Adams.
Calcolando sia in A che B il silver index, siamo andati cosi a valutare se efetivamente vi fosse una correlazione statisticamente significativa tra
i valori del silver index e la malattia.
3.4. RISUTLTATI E DISCUSSIONE
I pazienti del gruppo A al momento della diagnosi presentavano almeno una delle 3 sintomatologie della triade di Hakim & Adams, ventricolomegalia e indice di Evans > 0.3 alla TC, mentre i pazienti del gruppo B di controllo presentavano nessuna sintomatologia della
Il risultato del valore cut of ottenuto su costruzione dell curva ROC, si è dimostrato essere di 3. 7550, valore a cui corrisponde ad una sensibilità di 0.828 ed una specificità di 0.962
Figura 52 – Tabella con valore cut-of per migliore sensibilità e specificità
box-plot (diagramma degli estremi e dei quartili) per silver
Figura 53 – box-plot (diagramma degli estremi e dei quartili)
Dati radiologici ottenuti:
Group A Group B p-value
Demographic data
n° of patients 29 26
median age (years)
[range] 76.9 [65-88] 76.3 [64-86] 0,298
M:F 19:10 11:15 0,106
Radiologic data
Evans ratio median
[range] 0,36 [0,31-0,43] 0,25 [0,15-0,29] SILVER INDEX median
Figura 55 – parametri statistici utilizzati per lo studio
Sulla base dei risultati ottenuti possiamo concludere che esiste una correlazione statisticamente significativa ( con p-value <0,0001 ) tra un valore del silver index > 3. 7550 e la malattia di idrocefalo cronico dell’ adulto.
Sensibilità e specificità del valore oltre il cut of, sono molto alte. L’ indice silver quindi si è dimostrato essere un indicatore fortemente valido di alta probabilità di malattia.
A dare una prova indiretta che i pazienti del Gruppo A avessero davvero un idrocefalo cronico dell’ adulto idiopatico, è anche il fatto che in seguito all’ intervento di derivazione ventricolo-peritoneale a cui sono stati sottoposti, questi hanno mostrato un buon outcome postchirurgico inteso come miglioramento clinico in termini di regressione parziale della sintomatologia la quale ricordiamo avviene solo nei pazienti che hanno malattia certa.
Nei pazienti con sospetta malattia, quindi del gruppo A, abbiamo voluto inoltre verificare se vi fosse una correlazione statisticamente significativa tra silver index e gravità di sintomatologia, in altri termini se vi fosse una diferenza statisticamente significativa tra indice silver di pazienti in cui sono presenti una/due sintomatologie e quello di pazienti in cui sono presenti tutte e tre le sintomatologie della triade di Hakim (quadro clinico più grave quindi).
Riportiamo il box-plot (diagramma degli estremi e dei quartili) efettuato:
Figura 56 – box-plot (diagramma degli estremi e dei quartili) Sintomi:
a - disturbi della deambulazione; b – demenza; c - incontinenza sfinteriale
1= sottogruppo di pazienti con sintomi
non abc 2=sottogruppo con sintomi “abc” (triadedi Hakim)
a; b; c; ab; ac; bc; abc
Riferendoci ai risultati ottenuti possiamo concludere che non esiste una diferenza o correlazione statisticamente significativa ( p-value
<0,727 ) tra silver index di pazienti in cui sono presenti una/due sintomatologie (sottogruppo 1, quadro clinico piu lieve) e quello di pazienti in cui sono presenti tutte e tre le sintomatologie della triade di Hakim (sottogruppo 2, quadro clinico piu grave).
Il valore del silver index quindi risulta indipendente dalla coesistenza o meno di tutti e tre i sintomi insieme e quindi in altre parole dalla
gravità clinica di malattia.
3.5. CONCLUSIONI E PROSPETTIVE FUTURE
Dai risultati ottenuti con il nostro studio, possiamo definire il silver index come un nuovo parametro radiologico per la diagnosi di idrocefalo cronico dell’ adulto ed ipotizzare che in futuro possa entrare far parte degli esami diagnostici di primo livello per questa patologia. Infatti l’indice presenta sensibilità e specificità molto elevate. Rappresenta una metodologia di studio del DESH molto agevole e valida in pazienti con sospetto idrocefalo cronico dell’adulto idiopatico.
Diventerebbe di grande ausilio non solo per il neurochirurgo, ma anche per il neurologo a cui il paziente di solito si rivolge per la clinica che gli si presenta; permetterebbe cosi di porre una diagnosi più accurata, precoce e senza costi ed esami aggiuntivi. Ricordiamo che diagnosi tempestiva significa anche eventuale intervento di derivazione ventricolo - peritoneale precoce, quindi migliore outcome postchirurgico e qualità di vita del paziente.
Una buona collaborazione tra la neurologia e la neurochirurgia, quale quella stabilita nel nostro ambulatorio tra i due dipartimenti delle unità operative ospedaliera ed universitaria pisane, risulta fondamentale nel processo di coordinazione tra la diagnosi clinica, timing chirurgico ed outcome.
I limiti di questo studio consistono nella sua natura retrospettiva e nell’uso di un software privo ancora di approvazione FDA-CE per
utilizzo sanitario.
Molto interessante e gia in fase di elaborazione nel nostro gruppo, risultano anche il quesito e la ricerca di una eventuale correlazione statisticamente significativa tra valore di silver index e miglior oucome postichirurgico ed il quesito riguardo alla precocità d’insorgenza di silver index che.
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