蛛网膜下腔出血后早期脑损伤

蛛网膜下腔出血(subarachnoid hemorrhage,SAH)是一种致残率和病死率很高的疾病,临床仍缺乏有效的治疗手段.近年来的研究发现,早期脑损伤可能是导致SAH患者病死率较高和决定预后的首要原因.文章主要对SAH早期脑损伤的动物模型和发病机制做了综述.     

Sphenoid sinus pseudoaneurysm with carotid cavernous fistula presenting with delayed subarachnoid hemorrhage: A case report

Rationale:Sphenoid sinus pseudoaneurysm arising from the cavernous segment of the internal carotid artery (ICA) caused by traumatic vessel injury is rare, and rarer is a concomitant carotid-cavernous fistula (CCF). In particular, delayed subarachnoid hemorrhage (SAH) due to pseudoaneurysm rupture has not been reported to-date in literature. Here, we report a case of sphenoid sinus pseudoaneurysm with CCF presenting with delayed SAH.Patient concerns:A 73-year-old man presented with traumatic brain injury due to motorcycle accident.Diagnoses:Twenty-four days after admission, the patient''s neurological status suddenly deteriorated. Brain computed tomography (CT) showed acute SAH along interhemispheric cisterns and suprasellar intracerebral hematoma. Brain CT angiography and digital subtraction angiography revealed giant sphenoid sinus pseudoaneurysm with CCF and the daughter sac of the pseudoaneurysm extended to the intracranial part via fracture in the superior wall of the sphenoid sinus.Interventions:As the sphenoid sinus pseudoaneurysm and CCF shared one rupture point, endovascular treatment with intraarterial approach using coil and liquid embolic material by balloon assisted technique was performed simultaneously.Outcomes:The origin of the pseudoaneurysmal sac and CCF was sufficiently blocked after injection of liquid embolic material and the lesions completely resolved immediately after endovascular treatment.Lessons:Sphenoid sinus pseudoaneurysm and CCF rarely occur following head trauma through a series of processes involving fracture of the lateral wall of the sphenoid sinus and ICA cavernous segment injury. Sphenoid sinus pseudoaneurysm may present as SAH through intracranial rupture with concomitant superior wall fracture of the sphenoid sinus. Therefore, early diagnosis using CT or magnetic resonance angiography and appropriate treatment through understanding the disease mechanism is necessary.     

蛛网膜下腔出血后脑脊液中的致痉原与脑血管痉挛

脑血管痉挛是自发性蛛网膜下腔出血患者发生脑梗死和迟发性缺血性神经功能缺损的主要原因.对脑血管痉挛的研究目前相对集中于血性腩脊液中的致痉原方面.文章对蛛网膜下腔出血后血性脑脊液中的主要致痉原诱发脑血管痉挛的机制进行了综述.     

TCD动态观察局部亚低温对蛛网膜下腔出血后脑血管痉挛的影响

目的探讨局部亚低温(r-MHT)对蛛网膜下腔出血(SAH)后脑血管痉挛的影响。方法30例SAH患者随机分为对照组和亚低温组各15例,均给予常规治疗,亚低温组加用r-MHT治疗。行经颅多普勒(TCD)动态检测大脑中动脉、颈内动脉颅外段的平均血流速度及脉动指数。首次TCD检查在发病48h内进行,并且每天重复一次直到发病第14天。结果亚低温组的脑血管痉挛(CVS)发病率明显低于对照组(P<0.05),持续时间也明显缩短(P<0.05)。第7天及第10天时亚低温组平均血流速度(VMCA)较对照组有明显降低(P<0.05),两组间脉动指数(PI)值无明显差异(P>0.05)。结论r-MHT可以显著降低SAH患者的大脑中动脉血流速度(MCA),降低CVS发生的频率,缩短CVS持续时间,减弱CVS的强度,认为r-MHT治疗对防治CVS有显著作用。     

细胞凋亡与蛛网膜下腔出血后脑血管痉挛

脑血管痉挛是蛛网膜下腔出血的一种常见严重并发症,也是造成患者死亡和残疾的主要原因之一,但其发病机制尚未完全阐明.最近的研究表明,细胞凋亡在脑血管痉挛发生机制中起着重要作用.进一步研究蛛网膜下腔出血后脑血管痉挛的凋亡机制,对优化临床治疗方案具有重要意义.     

大剂量脑脊液等量置换及椎管内尿激酶注射救治蛛网膜下腔出血的临床研究

目的　探索救治蛛网膜下腔出血 (SAH)患者的有效方法。方法　对经头颅螺旋CT或磁共振成像及腰穿确定 ,有剧烈头痛、恶心、呕吐 ,应用常规降颅压及止痛无效的 2 8例SAH患者 ,用大剂量生理盐水置换脑脊液和椎管内尿激酶注射治疗 ,并与对照 1组单纯大剂量脑脊液置换 10例和对照 2组单纯小剂量生理盐水置换脑脊液 12例进行比较。结果　治疗组 18例即刻 (1h)、2 4h、72h、5d症状明显减轻至消失 ,72h缓解 2 7例 (96 .4 %) ,所有患者均未出现速发或迟发性脑血管痉挛 (CVS)现象。对照 1组 10例 72h缓解 6例 (6 0 %) ,1例发生迟发性CVS征象 ,与治疗组比较差异有显著性意义 (P <0 .0 5 )。对照 2组 2例 2 4h内症状明显减轻 ,72h基本缓解 ,其他患者症状持续时间均在 72h以上 ,最长持续达 1周 ,4例 (33%)发生迟发性CVS ,死亡 2例。结论　应用大剂量生理盐水置换脑脊液可快速消除SAH患者之急性症状 ,对CVS也有较好治疗和预防作用 ,而早期加用小剂量尿激酶椎管内注射 ,可以明显提高以上疗效 ,同时又不会增加再出血的危险     

Neonatal alloimmune thrombocytopenia: spontaneous in utero intracranial hemorrhage

Neonatal alloimmune thrombocytopenia is an uncommon but important cause of thrombocytopenia in infants. Because of the severity of the thrombocytopenia, some of these infants will have intracranial hemorrhage with resultant long-term disability. Obstetricians and neonatologists have recommended delivery by caesarean section and the rapid institution of appropriate treatment for the infant; however, it is theoretically possible that a hemorrhagic event could precede the delivery and consequently not be prevented by these perinatal interventions. In this report we describe a neonate in whom the diagnosis of alloimmune neonatal thrombocytopenia was suspected because of antenatal ultrasound evidence of intracerebral hemorrhage. This case demonstrates the importance of antenatal fetal assessment and indicates the need for the development of therapeutic strategies to maintain fetal hemostasis.     

自发性蛛网膜下腔出血数字减影血管造影的价值分析

目的分析自发性蛛网膜下腔出血(SAH)脑血管造影的特点。方法对136例经头颅CT、腰椎穿刺和临床诊断为SAH的患者,进行全脑数字减影血管造影术(DSA)检查,首次造影阴性结果的患者均进行2次DSA检查,对所有造影结果进行分析。结果DSA检查正常者38例(27.9%),阳性者98例(72.1%),阳性患者中颅内动脉瘤72例(73.5%)、颅内血管畸形23例(23.5%)、动脉炎3例;颅内动脉瘤和血管畸形为自发性SAH的主要病因。结论DSA检查是SAH病因诊断最有效的方法,并能为治疗提供可靠解剖形态依据。     

Lymphoepithelial cyst in the pancreas: A case report

A case of lymphoepithelial cyst in the pancreas was reported. A 64-year-old man without any specific compalints was found to have a cystic lesion in the anterior portion of the pancreas, as revealed by ultrasonography of the abdomen at an annual medical examination in 1988. This was dissected easily from the pancreas. Histologically, it was diagnosed to be a benign lymphoepithelial cyst in the pancreas. Cysts of this type are rare, and their histogenesis is also not well understood.     

Relationship between annualized case volume and in-hospital motality in subarachnoid hemorrhage: A systematic review and meta-analysis

Studies on the relationship between hospital annualized case volume and in-hospital mortality in patients with subarachnoid hemorrhage (SAH) have shown conflicting results. Therefore, we performed a meta-analysis to further examine this relationship.The authors searched the PubMed and Embase databases from inception through July 2020 to identify studies that assessed the relationship between hospital annualized SAH case volume and in-hospital SAH mortality. Studies that reported in-hospital mortality in SAH patients and an adjusted odds ratio (OR) comparing mortality between low-volume and high-volume hospitals or provided core data to calculate an adjusted OR were eligible for inclusion. No language or human subject restrictions were imposed.Five retrospective cohort studies with 46,186 patients were included for analysis. The pooled estimate revealed an inverse relationship between annualized case volume and in-hospital mortality (OR, 0.53; 95% confidence interval, 0.42–0.68, P < .0001). This relationship was consistent in almost all subgroup analyses and was robust in sensitivity analyses.This meta-analysis confirms an inverse relationship between hospital annualized SAH case volume and in-hospital SAH mortality. Higher annualized case volume was associated with lower in-hospital mortality.     

Severe ventricular dysfunction secondary to subarachnoid hemorrhage

A 39-year-old man was brought to the emergency department in a coma. The electrocardiogram showed partial left bundle-branch block and ST elevation in precordial leads, and serum creatinine kinase activity was elevated. Two-dimensional echocardiography revealed severe biventricular dysfunction. Autopsy demonstrated the presence of subarachnoid hemorrhage. Coronary arteries and the myocardium were macroscopically normal.     

Pseudomonas keratitis complicated with spontaneous expulsive suprachoroidal hemorrhage: A case report

Introduction:Spontaneous expulsive suprachoroidal hemorrhage (SESCH) is a rare condition. The correlation between SESCH and chronic glaucoma has been reported previously. However, few reports have indicated a correlation between infective keratitis and SESCHs.Patient concerns:Here, we report the case of an 82-year-old woman with a corneal ulcer who presented with left eye pain for 6 days.Diagnosis:We found that she has Pseudomonas keratitis and history of chronic glaucoma.Interventions and Outcomes:During admission, her left eye showed elevated intraocular pressure (IOP). Three days later, the eyeball began to bleed and became painful. She had high blood pressure on that day. Hours after complaints of eye pain, intraocular tissue exposure related to eyeball rupture, and SESCH. The patient underwent evisceration and insertion of a silicone ball for the socket reconstruction. Histopathological evaluation revealed acute inflammation of the cornea and the choroidal vessels.Conclusion:In elderly patients with infective keratitis and a history of glaucoma and hypertension, it is important to control intraocular pressure and blood pressure and pay attention to the risk of spontaneous expulsive suprachoroidal hemorrhage.     

氧合血红蛋白在自发性蛛网膜下腔出血脑血管痉挛中的作用

目的 研究蛛网膜下腔出血(SAH)后脑脊液中氧合血红蛋白(HbO2)、还原氧合血红蛋白(HbDeoxy)和正铁血红蛋白(HbMet)的浓度随时间变化情况及与脑血管痉挛的关系,并观察SAH后脑动脉血流速度与氧合血红蛋白是否相关。 方法 选择发病后24 h内入院的SAH患者共27例。分别于患者发病的第1、3、5、7、10、14天行腰椎穿刺取脑脊液,离心后取上清液,用紫外分光光度仪测量HbO2、HbDeoxy及HbMet的浓度,所得数据经统计学处理后绘趋势图并进行相关分析,并用经颅多普勒(TCD)对大脑中动脉(MCA)血流速度进行监测。 结果 SAH患者HbO2的浓度在发病第3天开始上升,在第7天达到高峰,为1.4×10-2mmol／L,与第1、3、14天相比,P<0.05;HbDeoxy的浓度在第5天开始上升,在第7天达到高峰5.5×10-3mmol／L,与第1、3、5、14天相比,P<0.05:而HbMet的浓度随时间只是轻度上升,在第14天达到高峰7.5×10-3mmol／L,与其他天相比P>0.05。用TCD测得MCA的血流速度从第5天开始升高,到第7天达到高峰111.2 cm／s。对MCA的血流速度变化与HbO2的浓度变化行相关分析,r=0.906,两者呈正相关。 结论 本研究支持HbO2是引起SAH后慢性脑血管痉挛的主要启动因子之一这一假说,并暗示了HbDeoxy也可能是致挛因子。同时证明了SAH后脑动脉血流速度与HbO2有相关性及TCD在     

Hybrid operation for arteriovenous malformations with associated multiple intracranial aneurysms and subarachnoid hemorrhage: Case report

Rationale:The hybrid surgical concept for the treatment of brain arteriovenous malformations (AVMs) with associated intracranial aneurysms (IAs) is still not widely practiced. Concomitant occurrence of AVMs with IAs is common. Subarachnoid hemorrhage (SAH) as a result of AVM or IA rupture is often associated with these dual pathological phenomena. We present a case of concomitant occurrence of AVMs and IAs that was successfully treated using the hybrid operation concept.Patient concerns:A 62-year-old man presented with sudden onset of severe headache, dizziness, nausea, and vomiting for 4 hours.Diagnosis:Computed tomography revealed SAH and a hematoma in the right frontal lobe. A computed tomographic angiogram also revealed a right frontal AVM with 3 IAs.Interventions:We used a hybrid operating room to successfully treat both AVMs and IAs.Outcomes:Two years of follow-up showed that the patients were well and performed their daily duties.Lessons:The hybrid operating room is an innovative, safe, and effective method for the treatment of AVMs with associated IAs, particularly high-grade AVMs and IAs with hemorrhage or SAH. Patients with concomitant AVMs and IAs have the highest chance of hemorrhage compared with those with AVM or IAs alone.     

Modified Glasgow coma scale for predicting outcome after subarachnoid hemorrhage surgery

There are many grading scales that attempt to predict outcome following aneurysmal subarachnoid hemorrhage (aSAH). Most scales used to assess outcome are based on the neurological status of the patient. Here, we propose a new scale for aSAH patients that combines the Glasgow Coma Scale (GCS) and the modified Fisher scale (mFS).Five hundred ninety-seven patients with aSAH who were treated at our institution between January 2008 and December 2017 were retrospectively analyzed. Initial GCS score, Hunt and Hess scale, World Federation of Neurosurgical Societies scale, mFS, and modified Rankin Scale were obtained by reviewing data. Incidence of vasospasm was investigated. Factors found to be significant on a multivariable regression analysis were used to develop a scale that was compared with other grading systems using the area under the curve (AUC) calculated from receiver operating characteristic curve.The GCS score and mFS were related to outcomes in patients with aSAH. A simple score, which we call the GCS-F score, was calculated using these initial data. The GCS-F score had an AUC of 90.5% for unfavorable outcome prediction, and 88.4% for in-hospital mortality prediction. On the receiver operating characteristic curve analysis for vasospasm, the AUC for World Federation of Neurosurgical Societies, mFS and GCS-F scores were 0.912, 0.704, and 0.936, respectively.A simple arithmetic combination of the GCS score and mFS, the GCS-F score, includes the radiographic status as well as the clinical status of the patient, so that the state of the patient can be known in more detail than other single scales. The GCS-F score may be a useful scale for predicting outcome and the occurrence of vasospasm in patients with aSAH.     

Herbal medicines for the prevention and treatment of cerebral vasospasm after subarachnoid hemorrhage: A protocol for systematic review and meta-analysis

Background:Despite the rapid advances in medical technology, including endovascular interventions and medications, cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) is still one of the major threats to the lives of patients with SAH. In East Asian countries, various types of herbal medicines have been used to treat cerebrovascular diseases, including SAH. In this review, we aim to evaluate the efficacy and safety of herbal medicines for the prevention and treatment of CVS after SAH.Methods and analysis:Seven databases will be searched for relevant studies from inception to the present date “June 2020”. Only randomized controlled trials (RCTs) that assess the effect and safety of herbal medicines for the prevention and treatment of CVS after SAH will be included. The methodological quality will be evaluated using the Cochrane risk of bias assessment tool. After selecting the appropriate studies, a meta-analysis of the RCTs will be performed.Results:This study will provide a high-quality synthesis of current evidence of herbal medicines for CVS after SAH.Conclusion:Our systematic review will provide evidence to judge whether herbal medicines are effective interventions for patients with CVS after SAH.Ethics and dissemination:Ethical approval is not required, as this study is based on a review of published research. This review will be published in a peer-reviewed journal and disseminated electronically and in print.Trial registration number:Research registry reviewregistry923.     

自发性蛛网膜下腔出血全脑血管造影分析

目的探讨数字减影全脑血管造影(digital subtraction angiography,DSA)对蛛网膜下腔出血(subarachnoidhemorrhage,SAH)病因诊断的价值。方法选择行DSA检查的SAH患者276例,根据发病时间分为<24 h组(A组)32例,1～3 d组(B组)111例,4～14 d组(C组)93例,>14 d组(D组)40例。又按年龄分为≤60岁患者248例,>60岁患者28例。对其病因、造影时间、并发症等进行分析比较。结果 276例SAH患者DSA病因诊断阳性率为71.4%。所有患者动脉瘤为主要病因,而动静脉畸形、烟雾病在年龄≤60岁患者中则更为常见。B组、C组、D组不同时间DSA的异常检出率明显高于A组,差异有统计学意义(P<0.05)。A组再出血、脑积水、消化道出血、低钠血症、癫痢发作的发生率高于其他组。结论 DSA对SAH病因诊断阳性率高,SAH患者病因诊断应常规行DSA检查,时间以发病1～3 d为宜。     

中脑周围蛛网膜下腔出血的静脉引流方式

目的探讨脑内不同深静脉引流方式与中脑周围蛛网膜下腔出血(PMSAH)的关系方法回顾性分析2014年1月至2017年1月安徽医科大学第二附属医院诊治的90例蛛网膜下腔出血(SAH)患者的临床资料。其中PMSAH 30例为PMSAH组,动脉瘤性SAH 60例为对照组。单侧大脑半球静脉引流分为A型(正常的连续):基底静脉有大脑深中静脉引流,引流入Galen大脑大静脉;B型(正常的不连续):基底静脉与前方的钩静脉、后方的Galen静脉有不连续静脉引流;C型(原始的变异):未向Galen大脑大静脉引流,中脑周围静脉向岩上窦引流,或基底静脉直接引流入横窦、直窦。双侧大脑半球静脉引流的不同组合分为:正常型引流(Ⅰ型:AA),不连续型引流(Ⅱ型:AB、BB),原始型引流(Ⅲ型:AC、BC、CC),比较两组静脉引流方式的差异。结果 PMSAH组中,Ⅰ、Ⅱ型引流均占26.7%(各8例),Ⅲ型引流占46.7%(14例)。对照组中Ⅰ型引流占48.3%(29例),Ⅱ型引流占28.3%(17例),Ⅲ型引流占23.3%(14例)。3种静脉引流方式在两组中分布比较,差异无统计学意义(χ~2=5.804,P=0.055),但Ⅲ型静脉引流(46.7%比23.3%)在两组间差异有统计学意义(χ~2=5.081,P=0.024)。结论 PMSAH患者的深静脉引流多表现为基底静脉引流入硬脑膜静脉窦,而并非向大脑大静脉引流。提示原始引流入硬膜窦的方式较引流入大脑大静脉的方式更容易破裂。     

动脉瘤性蛛网膜下腔出血后迟发性脑缺血的早期凝血及纤溶生物标志物变化

目的通过对动脉瘤性蛛网膜下腔出血(aSAH)后早期血液凝血和纤溶相关标志物进行动态分析,探讨其与迟发性脑缺血(DCI)之间的关系,尝试从临床角度阐述微血栓形成机制在DCI发生发展中可能的潜在影响。方法前瞻性连续纳入2016年12月至2018年6月北京天坛医院发病3 d内的aSAH住院患者165例。入院后按照统一标准化方案分别采集患者入院时、发病后(4±1)、(7±1)、(10±1)、(13±1)d的血液样本,记录DCI患者及非DCI患者各时间点的部分血液凝血[包括凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、血小板计数、血管性血友病因子(vWF)抗原定量和vWF活性]及纤溶相关标志物参数(D-二聚体、纤维蛋白原)。PT、APTT、纤维蛋白原水平通过凝血酶测定,D-二聚体含量通过乳胶光度法测定,vWF抗原定量和vWF活性检测分别采用vWF抗原检测试剂盒和vWF活性检测试剂盒,并对两组间不同时间点各参数进行重复测量方差分析。结果DCI发生率为31.5%(52/165)。凝血及纤溶标志物相关结果显示,DCI患者在aSAH后早期即出现血管性血友病因子(vWF)抗原含量和活性升高,并在发病后(7±1)d达到高峰,DCI患者vWF抗原及活性水平较非DCI患者更高,两组间差异具有统计学意义(F值分别为6.873、5.784,P值分别为0.017、0.021),同时vWF抗原及活性水平与时间相关(F值分别为105.448、89.141,均P<0.01),且存在组别与采样时间之间的交互效应(F值分别为9.525、10.114,P值分别为0.022、0.016)。此外,DCI与不同采样时间对PT、APTT、血小板计数、D-二聚体、纤维蛋白原等水平无明显影响(均P>0.05),并且两组别与时间不存在交互作用(均P>0.05)。结论DCI患者vWF抗原含量及活性明显高于非DCI患者,提示可能存在微血栓形成,动态监测vWF抗原含量及活性有助于早期发现DCI。