动脉瘤性蛛网膜下腔出血的影像学特征及早期临床诊断

目的探讨动脉瘤性蛛网膜下腔出血(SAH)的影像学特征及早期病因学诊断方法,并客观评价其优缺点。方法对115例动脉瘤性SAH采用CT、CTA、MRI、MRA、DSA等影像学检查并结合病史、临床表现进行早期临床诊断。结果115例SAH均在急性出血期内(7天)被早期诊断,其中有96例患者在7天内被DSA检查诊断为动脉瘤,早期病因诊断率83.5%,另19例在7天后二次造影诊断。全组9例行MRA,6例发现动脉瘤;12例行CTA,9例发现动脉瘤。结论采用CT及DSA可以对动脉瘤性SAH进行早期病因学诊断;该方法安全、准确,对动脉瘤性SAH的早期诊断、早期治疗具有重要的应用价值。     

急诊室蛛网膜下腔出血误诊20例临床分析

目的 为提高急诊科医生对蛛网膜下腔出血(SAH)的诊断准确率.方法 对急诊科误诊其他疾病,经CT或腰椎穿刺确诊为SAH 20例患者的病历资料进行分析.结果 本组SAH患者分别被误诊为偏头痛4例,高血压性头痛3例,病毒性脑炎2例,脑出血2例,上呼吸道感染2例,椎基底动脉供血不足1例,眩晕症3例,酒精过量1例,癫痫2例.结论 CT诊断SAH有局限性,应重视老年患者不明原因的头痛、眩晕、意识障碍、癫痫等症状,对头颅CT阴性、临床不能排除SAH的患者及时行腰穿以明确诊断.     

低水平的血清胱抑素C与脑动脉瘤关系密切

目的:探讨血清胱抑素C(CysC)水平与蛛网膜下腔出血(SAH)及颅内动脉瘤的关系。方法:随机选取非动脉瘤性SAH患者(SAH组)52例,动脉瘤非SAH患者(动脉瘤组)81例,动脉瘤性SAH患者(aSAH组)75例,良性位置性眩晕患者124例(对照组)。对所有患者血清CysC水平及相关临床资料行回顾性分析。结果:动脉瘤组及aSAH组血清CysC水平显著低于对照组和SAH组(P0.05);CysC水平与尿酸成正相关。结论:颅内动脉瘤患者血清CysC水平较低,血清CysC可能与脑动脉瘤的发生有关,与SAH无明显关系。     

连续腰椎穿刺引流在动脉瘤性蛛网膜下腔出血栓塞术后的作用

目的探讨连续腰椎穿刺引流对动脉瘤性蛛网膜下腔出血（a SAH）患者血管栓塞治疗后的作用。方法 42例a SAH患者接受颅内动脉栓塞治疗后,根据是否采取连续腰椎穿刺分为观察组20人和对照组22人。观察2组患者迟发性缺血性神经功能缺陷（DIDN）、头痛缓解和Rankin评分差异。结果观察组患者头痛缓解天数短于对照组（P〈0.05）;治疗期内,观察组患者DIDN发生率低于对照组（P〈00.05）,14 d时Rankin评分低于对照组（P〈0.05）。结论 a SAH患者栓塞治疗后行早期连续腰椎穿刺引流,能降低DIND发生风险,促进神经和认知功能早期恢复。     

首发症状不典型的老年蛛网膜下腔出血17例误诊分析

目的 探讨首发症状不典型的老年蛛网膜下腔出血(subarachnoid hemorrhage, SAH)的误诊原因.方法 分析我院17例因首发症状不典型而误诊误治的老年SAH临床资料.结果 本组误诊为偏头痛、病毒性脑炎及脑积水各4例;误诊为药物中毒2例;误诊为癫痫大发作、精神病及颈椎病各1例.16例经腰椎穿刺检查证实为SAH,1例经CT检查确诊SAH.4例经数字减影血管造影(DSA)检查证实为动脉瘤,再出血死亡2例,另2例转上级医院手术或介入治疗后转回我院;余13例经保守治疗后好转出院6例,因卧床并发肺部感染、电解质紊乱死亡6例,并发消化道出血死亡1例.结论 老年SAH首发症状不典型,误诊率高,临床医生需提高警惕,以减少误诊误治.     

16排螺旋CT血管造影在自发性蛛网膜下腔出血诊断中的应用

[目的]探讨16排螺旋CT血管造影(MSCTA)在自发性蛛网膜下腔出血(SAH)患者病因诊断中的应用价值.[方法]回顾性分析38例临床急性原发性SAH患者的临床资料,均分别进行MSCTA和数字减影血管造影(DSA),所有患者均完成VR、MIP、SSD处理,并对照手术或介入结果评估其诊断价值.[结果]MSCTA发现7例动静脉畸形,23例共24个动脉瘤,其中21例为单个动脉瘤,1例为两个动脉瘤,1例合并有动静脉畸形.动脉瘤直径最小2.0 mm,最大20 mm.MSCTA能清晰显示动脉瘤的瘤体大小、瘤颈、瘤轴指向、载瘤动脉及其动脉瘤与邻近血管分支和骨性组织间的空间关系.DSA检查发现25个动脉瘤,MSCTA的吻合率为96%.[结论]MSCTA诊断颅内动脉瘤有较高准确性,可以帮助原发性SAH患者查找病因,指导临床诊断与治疗.     

自发性蛛网膜下腔出血诊治进展

自发性蛛网膜下腔出血(SAH)主要病因为颅内动脉瘤破裂。本文重点介绍SAH流行病的诊断、治疗及存在的问题。     

动脉瘤性蛛网膜下腔出血病人血清FSH LH PRL GH的浓度变化

目的　研究动脉瘤性蛛网膜下腔出血 (SAH)病人血清卵泡刺激素 (FSH)、黄体生成素 (LH)、泌乳素 (PRL)、生长激素 (GH)的浓度变化规律。方法　对 35例动脉瘤性SAH病人发病后 1～ 3、7～ 9、13～ 15d血清FSH、LH、PRL、GH的浓度进行动态观察 ,用TCD检测大脑中动脉血流速度 (VMCA)。结果　动脉瘤性SAH病人血清FSH、LH、PRL、GH浓度在发病后 1～3、7～ 9d各均值明显高于对照组 ,尤以发病后 7～ 9d变化最明显 ;术前、术后有脑血管痉挛 (CVS)组和非CVS组也有明显差异。结论　动脉瘤性SAH病人血清FSH、LH、GH、PRL含量与SAH的病情演变、CVS程度有关 ,并可判断预后。     

蛛网膜下腔出血早期误诊20例分析

目的探讨蛛网膜下腔出血(SAH)临床早期误诊原因,吸收经验教训。方法回顾分析解放军第425医院2010-03-2010-10收治80例SAH的临床资料。结果 20例分别误诊为高血压、上呼吸道感染、颈椎病、癫痫、梅尼埃病、脑出血、椎间盘脱出、脑血栓等疾病。结论 SAH临床表现往往不典型,首诊误诊率高,应及时行头颅CT检查或腰椎穿刺检查脑脊液(CSF),以提高早期诊断,减少延误诊治。     

蛛网膜下腔出血介入治疗的临床应用

蛛网膜下腔出血(SAH)是多种病因所至脑底部或脑表面血管破裂的急性出血性脑血管病,为神经科常见病之一,其常见病因:先天性脑动脉瘤,脑血管畸形,高血压动脉硬化性动脉瘤(梭形动脉瘤),脑底异常血管网(病),其中动脉瘤最多见.     

Emergency Diagnosis of Subarachnoid Hemorrhage: An Evidence-Based Debate

Background

The diagnosis of subarachnoid hemorrhage is of paramount concern in patients presenting to the Emergency Department (ED) with acute headache. Computed tomography followed by lumbar puncture is a time-honored practice, but recent technologic advances in magnetic resonance imaging with magnetic resonance angiography and computed tomography with computed tomography angiography can present alternatives for clinicians and patients.

Objective

The aim of this article was to compare diagnostic strategies for ED patients in whom subarachnoid hemorrhage is suspected.

Methods

We analyze and discuss current protocols, in addition to summarizing the advantages and disadvantages of each method.

Results

Through our residency's journal club, we organized an evidence-based debate that pitted proponents of the three subarachnoid hemorrhage diagnostic strategies against one another. Proponents of each strategy described its advantages and disadvantages. Briefly, computed tomography/lumbar puncture is time honored and effective, but is limited by complications and indeterminate lumbar puncture results. Magnetic resonance imaging with magnetic resonance angiography might be more effective in late presentations and can visualize aneurysms, yet has limited availability. Computed tomography with computed tomography angiography offers rapid diagnosis and is considered the most sensitive for diagnosing aneurysms, but has the highest radiation exposure.

Conclusions

Each of the three strategies used to diagnose subarachnoid hemorrhage has advantages and disadvantages with which clinicians should be familiar. Patient factors (e.g., age, body habitus, and risk factors), presentation factors (e.g., time from headache onset and severity of presentation), and institutional factors (availability of magnetic resonance imaging with magnetic resonance angiography) can influence the choice of protocol.     

Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report

The lumbar puncture is considered as a safe routine procedure in widespread clinical use for nearly a century. To the best of our knowledge, intracranial and intraspinal subarachnoid hemorrhage has never been reported as a complication after a lumbar puncture. We presented a case of a 76-year-old woman who fell in a deep coma after a lumbar puncture with diffuse subarachnoid hemorrhage and acute obstructive hydrocephalus on computed tomographic scans. Magnetic resonance imaging studies of the whole spine showed the hematoma spread along the spinal cord upward to the intracranial subarachnoid space. Remarkably, an extravasation of contrast medium presented at the level of L1 through L2, which was subsequently evaluated using the spinal angiography. There was an ongoing bleeding at the terminus of L1 lumbar segmental artery that lay within the spinal cord. Then a transarterial embolization followed and the hemorrhage stopped immediately. This case reminds us that although lumbar puncture is safe and simple, severe potential complication, such as intracranial and intraspinal subarachnoid hematoma, could occur.     

The forgotten lumbar puncture

Lumbar puncture is crucial in two distinct clinical situations in the diagnosis of the headache patient. The first is the patient who is suspected of having a symptomatic headache; the second is the patient with a chronic intractable or atypical headache disorder. This review discusses the usefulness of the lumbar puncture in the diagnosis of headache secondary to subarachnoid hemorrhage, meningitis, and intracranial hypotension and hypertension. The value of lumbar puncture in the presence of a normal CT/MRI scan is discussed.     

持续腰穿外引流防治脑血管痉挛的观察与护理

目的　探讨持续腰穿外引流对防治脑血管痉挛的疗效与护理。方法　 6 4例动脉瘤性蛛网膜下腔出血患者 ,在超早期行电解可脱卸弹簧圈 (guglielmidetachablecoil,GDC)栓塞术后 ,34例行持续腰穿外引流 ,另 30例行间断腰穿作为对照组 ,2组同样给予常规的尼莫通及 3H治疗 ,通过临床症状及经颅多谱勒超声 (TCD)判断血管痉挛的发生率及严重程度。结果　引流组发生症状性血管痉挛 4例 ,对照组 8例 ,其中 1例遗留神经功能障碍。引流组的脑血管痉挛发生率明显低于对照组。无引流相关并发症发生。结论　腰穿持续外引流可以有助于清除蛛网膜下腔积血 ,严密观察及合理护理对于减少并发症是必要的。     

Does 16-Detector Computed Tomography Improve Detection of Non-traumatic Subarachnoid Hemorrhage in the Emergency Department?

The diagnosis of subarachnoid hemorrhage remains difficult to establish, yet the sensitivity of increasingly available 16-detector computed tomography (CT) has not been evaluated. The objective of this study was to estimate the sensitivity of 16-detector CT for the diagnosis of non-traumatic subarachnoid hemorrhage in the Emergency Department (ED). A retrospective review was performed in an academic tertiary care hospital. Patients presenting to the ED from September 2003 through December 2004 with symptoms suggestive of subarachnoid hemorrhage and having a final diagnosis of non-traumatic subarachnoid hemorrhage were eligible for study. Diagnosis was established by positive 16-detector CT examination of the brain, or spinal fluid analysis. Patient demographics and results of CT, angiogram, and spinal fluid analysis were reviewed. Sensitivity of 16-detector CT was calculated by comparing CT results and cerebral angiogram results. Refined Wilson Simple Asymptotic 95% confidence intervals were calculated. Sixty-one consecutive patients met the study criteria and had a final diagnosis of non-traumatic subarachnoid hemorrhage. One of these patients did not have subarachnoid hemorrhage identified by 16-detector CT, but had a positive lumbar puncture and an aneurysm confirmed on cerebral angiography. Sensitivity of 16-detector CT for subarachnoid hemorrhage was 97% (95% confidence interval 84-100%). Sixteen-detector CT did not improve detection of non-traumatic subarachnoid hemorrhage when compared with studies using single-detector CT. If there is high clinical suspicion for non-traumatic subarachnoid hemorrhage and non-contrast 16-detector CT scan is negative, further evaluation is suggested.     

自发性蛛网膜下腔出血患者住院期间再出血相关因素分析与对策

目的：探讨住院期间自发性蛛网膜下腔出血患者再出血的相关因素和对策。方法：对42例自发性蛛网膜下腔出血患者住院期间引起再出血的各种相关因素进行分析。结果：再出血危险因素：34例持续高血压,14例情绪激动,7例下床排便用力,6例剧烈活动,7例睡眠不佳烦燥后出血,4例再出血发生在术前8小时,4例患者在腰穿时出血。结论：自发性蛛网膜下腔出血患者住院时高血压和和各种引起血压升高的诱因是引起再出血最主要原因.同时出血时间间隔和住院期间不适当的腰穿也是引起再出血的重要原因。     

腰椎穿刺置管稳压引流脑脊液治疗蛛网膜下腔出血的临床研究

目的 探讨蛛网膜下腔出血（SAH）的有效治疗方法。方法 对69例SAH患者进行治疗；治疗组（39例）腰椎穿刺置管稳压引流脑脊液，对照组（30例）间断腰椎穿刺放脑脊液。结果 治疗组头痛减轻程度、痊愈率明显优于对照组，脑血管痉挛、脑积水发生率明显低于对照组，而未增加再出血、脑疝发生率及病死率。结论 腰椎穿刺置管稳压引流脑脊液是一种安全、有效的治疗SAH的方法。     

The detection of nontraumatic subarachnoid hemorrhage: still a diagnostic challenge

Nontraumatic subarachnoid hemorrhage is one of the most elusive diagnoses in emergency medicine; it is a potentially lethal disease that is often considered and rarely found. The current practice as determined by the American College of Emergency Physicians 1996 Clinical Policy on Headache is a noncontrast head computed tomography (CT) followed by diagnostic lumbar puncture (LP) to exclude subarachnoid hemorrhage. Whereas the guideline does not consider pretest probability of subarachnoid hemorrhage in determining which patients require LP after negative head CT, patients' acceptance of LP, technical aspects of performing a LP in patients with nonideal anatomy, and risks associated with LP must all be considered when choosing to proceed with invasive testing. This article outlines the use of current testing modalities including CT, magnetic resonance imaging, angiography and LP to provide an up-to-date understanding of diagnostic testing for subarachnoid hemorrhage.