蛛网膜下腔出血后迟发性脑缺血的病理生理机制探讨

蛛网膜下腔出血(subarachnoid hemorrhage,SAH)是一种十分凶险的脑血管病,具有高死亡率、高致残率及高治疗难度的特点.迟发性脑缺血(delayed cerebral ischemia,DCI)是SAH后一种常见的并发症,一旦发生将严重影响患者预后.因此,明确DCI的病理生理机制对其预防和治疗具有至...     

经颅多普勒预测高改良Fisher分级蛛网膜下腔出血后迟发性脑缺血研究

目的 观察在高改良Fisher分级的蛛网膜下腔出血患者中双侧大脑中动脉血流速度比值（mean blood flow velocity ratio of the ipsilateral to contralateral middle cerebral arteries,I/C mBFV）对于迟发性脑 缺血（delayed cerebral ischemia,DCI）的预测价值是否高于大脑中动脉平均血流速度（mean blood flow velocity,mBFV）≥120 cm/s。 方法 回顾性连续收集2011年11月-2013年11月首都医科大学附属北京天坛医院NICU住院的改良 Fisher分级≥3级的蛛网膜下腔出血患者,所有患者均接受经颅多普勒（transcranial doppler sonography, TCD）检查。记录大脑中动脉mBFV及双侧I/C mBFV。终点事件为DCI。计算I/C mBFV和大脑中动脉 mBFV≥120 cm/s预测DCI的敏感性、特异性、阳性预测值及阴性预测值。 结果 共44例患者纳入研究,共18例患者发生了迟发性脑缺血,发生率为41%。以大脑中动脉 mBFV≥120 cm/s为标准时,TCD诊断的敏感性是77.8%,特异性是50%,阳性预测值53.8%,阴性预测 值为75%。以I/C mBFV≥1.5为标准时,TCD的敏感性是71.8%,特异性是41.7%,阳性预测值50%,阴 性预测值为71.4%。 结论 对于高Fisher分级的蛛网膜下腔出血的患者,TCD仍是预测迟发性脑缺血的有利工具。与I/C mBFV≥1.5为标准相比,mBFV≥120 cm/s的预测价值更高。     

动脉瘤性SAH迟发性脑血管痉挛的多元因素分析

目的 探讨动脉瘤性蛛网膜下腔出血（SAH）继发脑血管痉挛的相关因素。方法 回顾性分析本院收治的54例动脉瘤性SAH病人的临床资料，判定脑血管痉挛程度，统计分析其相关因素。结果Fisher分级Ⅲ-Ⅳ级患者脑血管痉挛发生率（7014％，19／27）明显高于Fisher分级Ⅰ-Ⅱ级者（4414％，12／27）（P〈0．01）；Hunt—Hess分级Ⅲ-Ⅴ级患者脑血管痉挛发生率（75．0％，21／28）明显高于Hunt—Hess分级Ⅰ-Ⅱ级者（38．5％，10／26）（P〈0．05）；3d后手术患者的脑血管痉挛发生率（70．0％，21／30）明显高于3d内手术患者（41．7％，10／24）（P〈0．05）。结论SAH的Fisher分级〉Ⅱ级和Hunt—Hess分级〉Ⅱ级是颅内动脉瘤继发脑血管痉挛的危险因素。早期手术能降低脑血管痉挛的发生率。     

蛛网膜下腔出血后迟发性脑血管痉挛的发病机制和治疗进展

脑血管痉挛（cerebral vasospasm,CVS）是蛛网膜下腔出血（subarochnoid hemorrhage,SAH）最 严重的并发症,尤其是迟发性脑血管痉挛（delayed cerebral vasospasm,DCV）,一旦发生可能会出现 脑缺血甚至死亡等严重并发症。目前其发病机制尚不明确,多种因素如红细胞分解产物、一氧化氮 （nitric oxide,NO）、内皮素、自由基和脂质过氧化物等均是导致DCV的重要因素,而对于治疗DCV的方 法也在持续探索中,SAH后DCV仍是目前面临的一大难题。本文主要对SAH后CVS的发病机制及治疗进 展进行综述。     

血糖波动对动脉瘤性蛛网膜下腔出血后迟发性脑缺血及30天死亡的影响

目的 探讨血糖波动与动脉瘤性蛛网膜下腔出血（aneurysmal subarachnoid hemorrhage,aSAH）患者发生迟发性脑缺血（delayed cerebral ischemic,DCI）及30?d死亡的关系。 方法 回顾性收集并分析aSAH患者的临床资料。连续收集患者14?d空腹血糖水平并按其特征分为4组：稳定组（第1天＜7?mmol/L,2～14?d均＜10mmol/L）、不稳定组（第1天＜7?mmol/L,2～14?d至少1次≥10?mmol/L）、控制良好组（第1天≥7?mmol/L,2～14?d均＜10?mmol/L）和控制不良组（第1天≥7 mmol/L,2～14?d至少1次≥10?mmol/L）,采用单因素和多因素分析探索血糖波动对患者发生DCI和30?d全因死亡的影响。 结果 研究共纳入341例患者,其中血糖稳定组212例,不稳定组23例,控制良好组62例,控制不良组44例。单因素分析显示,4组的DCI发生率差异有统计学意义（P=0.043）,其中不稳定组DCI发生率最高（39.13%）,其次是控制不良组（29.55%）、稳定组（17.92%）和控制良好组（17.74%）;30?d全因死亡率差异也有统计学意义（P<0.001）,其中控制不良组死亡率最高（15.91%）,其次是不稳定组（13.04%）、控制良好组（6.45%）和稳定组（1.42%）。多因素logistic回归分析显示,血糖控制不稳定（OR?6.032,95%CI?1.941～18.747,P=0.002）和控制不良（OR?2.889,95%CI?1.247～6.691,P=0.013）是aSAH患者发生DCI的危险因素,同时,血糖控制不稳定（OR?14.033,95%CI?1.971～99.921,P=0.008）和控制不良（OR?19.723,95%CI?3.597～108.143,P=0.001）也是aSAH患者30?d全因死亡的危险因素。 结论 aSAH患者血糖控制不稳定或控制不良与DCI和30?d死亡相关。     

不同浓度氧合血红蛋白对大鼠蛛网膜下腔出血后迟发性脑血管痉挛的影响

目的 观察不同浓度氧合血红蛋白对大鼠蛛网膜下腔出血(subarachnoid hemorrhage,SAH)后迟发性脑血管痉挛(delayed cerebral vasospasm,DCV)的影响.方法 将24只大鼠分为三组,对照组(8例)、动脉血SAH组(8例)、静脉血SAH组(8例),分别用枕大池二次注血法将0.3...     

Fluid Balance and Blood Volume Measurement after Aneurysmal Subarachnoid Hemorrhage

Background  Patients with aneurysmal subarachnoid hemorrhage (SAH) are at risk for circulatory volume depletion, which is a risk factor for delayed cerebral ischemia (DCI). In a prospective observational study we assessed the effectiveness of fluid administration based on regular evaluation of the fluid balance in maintaining normovolemia. Methods  A total of 50 patients with aneurysmal SAH were included and were treated according to a standard protocol aimed at maintaining normovolemia. Fluid intake was adjusted on the basis of the fluid balance, which was calculated at 6-h intervals. Circulating blood volume (CBV) was measured by means of pulse dye densitometry (PDD) on alternating days during the first 2 weeks after SAH. Results  Of the 265 CBV measurements, 138 (52%) were in the normovolemic range of 60–80 ml/kg; 76 (29%) indicated hypovolemia with CBV < 60 ml/kg; and 51 (19%) indicated hypervolemia with CBV > 80 ml/kg. There was no association between CBV and daily fluid balance (regression coefficient β = −0.32; 95% CI: −1.81 to 1.17) or between CBV and a cumulative fluid balance, adjusted for insensible loss through perspiration and respiration (β = 0.20; 95% CI: −0.31 to 0.72). Conclusion  Calculations of fluid balance do not provide adequate information on actual CBV after SAH, as measured by PDD. This raises doubt whether fluid management guided by fluid balances is effective in maintaining normovolemia.     

床旁TCD监测对蛛网膜下腔出血后迟发性脑缺血价值研究

目的 探讨床旁经颅多普勒超声（transcranial Doppler,TCD）监测在蛛网膜下腔出血（subarachnoid hemorrhage,SAH）后预测和发现脑血管痉挛,减少迟发性脑缺血（delayed cerebral ischemia,DCI）发生 的价值。 方法 连续纳入2011年10月至2013年10月首都医科大学附属北京天坛医院神内重症监护病房 （intensive care unit,ICU）住院的完成床旁TCD监测的222例SAH患者。记录患者的临床及影像资料、治 疗及并发症。入院24小时内完成TCD基线监测,根据结果分成正常组85例、流速增快组14例、血 管痉挛组123例,比较患者抗血管痉挛强化治疗的使用率、DCI及不良预后［3个月后改良Rankin量表 （modified Rankin Scale,mRS）评分4～6分］的发生率和治疗改善率的差异。 结果 3组患者比较,血管痉挛组和血流增快组的GCS评分低、Hunt-Hess分级Ⅰ～Ⅲ级比例少、世界 神经外科医师联盟（World Federation of Neurosurgical Society,WFNS）分级Ⅰ～Ⅲ级比例少、改良Fisher 分级3～4级所占比例多、颅内血肿发生率多,差异均具有显著性（P <0.05）。血管痉挛组和流速增快 组患者DCI 发生率高于正常组（68.2%、35.7%、3.2%,P＜0.01）。TCD流速增快组和血管痉挛组患者给 予的抗血管痉挛加强治疗（70.6%、100%、4.1%）及脑脊液置换治疗（21.2%、7.1%、5.7%）多,临床缓 解率（56.5%、28.6%、10.6%）高（P＜0.01）。90天随访血管痉挛组和流速增快组预后不良高于正常组 （30.6%、21.4%、15.4%,P =0.031）。 结论 TCD结果异常的患者（血管痉挛组和血流增快组）发病后的病情重,出血量大,尽管给予加强 治疗,DCI的发生率及预后不良率仍高于正常组。床旁TCD监测能够筛查出DCI高危患者并评价治疗效 果,是防治DCI所需的有效检测工具。     

Recurrent Subarachnoid Hemorrhage after Complete Obliteration of Intracranial Aneurysm

The authors report a case of recurrent subarachnoid hemorrhage (SAH) after complete occlusion of an intracranial aneurysm. It is known that regrowth of an aneurysm after the complete clipping is a rare event. For detection of recurrence, however, it may be necessary to follow up with the patient regularly after the initial operation for intracranial aneurysms, because re-rupture of an aneurysm can cause a fatal result, and the cumulative risk of a recurrent SAH is thought to be not low over time.     

远隔缺血适应干预对动脉瘤性蛛网膜下腔出血患者凝血功能的影响

目的 探讨远隔缺血适应（remote ischemic conditioning,RIC）对动脉瘤性蛛网膜下腔出血患者凝血功能的影响。      

马来酸桂哌齐特与尼莫地平治疗兔蛛网膜下腔出血后迟发性脑血管痉挛的比较

目的比较马来酸桂哌齐特与尼莫地平治疗兔蛛网模下腔出血(subarachnoid hemorrhage,SAH)后迟发性脑血管痉挛(delayed cerebral vasospasm,DCVS)的效果。方法将48只新西兰兔分为3组:DCVS组、马来酸桂哌齐特组与尼莫地平组。各组行枕大池二次注血法制作DCVS模型后,依次分别静推5%葡萄糖溶液、马来酸桂哌齐特稀释液、尼莫地平稀释液进行治疗。各组分别在造模后3 d、7 d行神经症状评分与脑血管造影,观察神经功能与基底动脉直径变化;并取基底动脉,观察病理变化。结果造模后3 d,DCVS组与马来酸桂哌齐特组、尼莫地平组之间神经症状评分、基底动脉直径、管壁平滑肌厚度差异均有统计学意义[神经症状:掊2=16.726,P<0.05;直径:(492.86±48.58)μm,(551.43±45.55)μm,(568±34.21)μm,F=2.149,P<0.05);厚度:(27.48±3.63)μm,(22.92±3.26)μm,(22.47±8.49)μm,F=17.794,P<0.05)],其中马来酸桂哌齐特组与尼莫地平组间无统计学意义(P>0.05),但均较DCVS组均有统计学意义(P<0.05);造模后7 d,DCVS组与马来酸桂哌齐特组、尼莫地平组之间神经症状评分、基底动脉直径、管壁平滑肌厚度差异均有统计学意义[神经症状:x2=9.906,P<0.05;直径:(577.14±32.00)μm,(630±25.82)μm,(674±45.04)μm,F=10.531,P<0.05);厚度:(30.42±9.24)μm,(24.89±3.48)μm,(22.65±4.56)μm,F=5.864,P<0.05)],其中马来酸桂哌齐特组与尼莫地平组间神经症状评分无统计学意义(P>0.05),但均较DCVS组均有统计学意义(P<0.05)。结论17.5 mg/(kg.d)马来酸桂哌齐特在治疗DCVS 3 d时解痉效果与0.5 mg/(kg.d)尼莫地平相似,但7d时马来酸桂哌齐特疗效不如尼莫地平。     

Spontaneous Anterior Cerebral Artery Dissection Presenting with Simultaneous Subarachnoid Hemorrhage and Cerebral Infarction in a Patient with Multiple Extracranial Arterial Dissections

Simultaneous subarachnoid hemorrhage and infarction is a quite rare presentation in a patient with a spontaneous dissecting aneurysm of the anterior cerebral artery. Identifying relevant radiographic features and serial angiographic surveillance as well as mode of clinical manifestation, either hemorrhage or infarction, could sufficiently determine appropriate treatment. Enlargement of ruptured aneurysm and progressing arterial stenosis around the aneurysm indicates impending risk of subsequent stroke. In this setting, prompt treatment with stent-assisted endovascular embolization can be a reliable alternative to direct surgery. When multiple arterial dissections are coexistent, management strategy often became complicated. However, satisfactory clinical results can be obtained by acknowledging responsible arterial site with careful radiographic inspection and antiplatelet medication.     

Efficacy of Cilostazol in Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis

Objectives

Cilostazol, a selective inhibitor of phosphodiesterase 3, may reduce symptomatic vasospasm and improve outcome in patients with aneurysmal subarachnoid hemorrhage considering its anti-platelet and vasodilatory effects. We aimed to analyze the effects of cilostazol on symptomatic vasospasm and clinical outcome among patients with aneurysmal subarachnoid hemorrhage (aSAH).

颅内动脉瘤性蛛网膜下腔出血患者预后的多因素分析

目的探讨影响颅内动脉瘤性蛛网膜下腔出血患者预后的相关因素。方法回顾性分析本院2007年1月至12月收治的119例动脉瘤性蛛网膜下腔出血患者的临床资料,井进行Logistic多元回归分析。结果动脉瘤性蛛网膜下腔出血患者的年龄、Fisher分级和Hunt—Hess分级与预后具有显著相关性（P〈0．01）,其OR值分别是0．921、0．153和0．228,其95％可信区间分别是（0．864-0．981）、（0．063-0．374）和（0．116-0．449）。结论动脉瘤性蛛网膜下腔出血患者的年龄、Fisher分级和Hunt—Hess分级是影响患者预后的危险因素,且随着年龄的增长,Fisher分级和Hunt—Hess分级的增加,患者的预后明显愈差。     

Progressive Manifestations of Reversible Cerebral Vasoconstriction Syndrome Presenting with Subarachnoid Hemorrhage,Intracerebral Hemorrhage,and Cerebral Infarction

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset headache with focal neurologic deficit and prolonged but reversible multifocal narrowing of the distal cerebral arteries. Stroke, either hemorrhagic or ischemic, is a relatively frequent presentation in RCVS, but progressive manifestations of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction in a patient is seldom described. We report a rare case of a 56-year-old woman with reversible cerebral vasoconstriction syndrome consecutively presenting as cortical subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction. When she complained of severe headache with subtle cortical subarachnoid hemorrhage, her angiography was non-specific. But, computed tomographic angiography showed typical angiographic features of this syndrome after four days. Day 12, she suffered mental deterioration and hemiplegia due to contralateral intracerebral hematoma, and she was surgically treated. For recurrent attacks of headache, medical management with calcium channel blockers has been instituted. Normalized angiographic features were documented after 8 weeks. Reversible cerebral vasoconstriction syndrome should be considered as differential diagnosis of non-aneurysmal subarachnoid hemorrhage, and repeated angiography is recommended for the diagnosis of this under-recognized syndrome.     

蛛网膜下腔出血患者继发症状性脑血管痉挛的相关危险因素分析

目的 研究探讨动脉瘤性蛛网膜下腔出血（subarachnoid hemorrhage,SAH）继发症状性脑血管痉挛 （symptomatic cerebral vasospasm,SCVS）的相关危险因素,为SCVS的防治提供参考。 方法 回顾性分析96例SAH患者临床资料,对性别、年龄、高血压史、糖尿病史、Fisher分级等影响因 素进行统计学分析。 结果 96例患者中发生SCVS的患者共39例,单因素分析结果显示SCVS组与非SCVS组在年龄、高血 压、吸烟、脑室内积血、Hunt-Hess分级、Fisher分级、数字减影血管造影（digital subtraction angiography, DSA）显示血管痉挛程度、尼莫地平使用等方面差异有显著性;多因素Logistic回归分析结果显示：低 龄、高血压史、Fisher分级是发生SCVS的危险因素,其比值比（odds ratio,OR）分别为0.567、1.982和 2.713;而尼莫地平的使用是SCVS发生的保护因素,OR为0.799。 结论 SAH后SCVS是多种因素共同作用的结果,其中低年龄、高血压史、Fisher分级是SCVS的独立危 险因素,尼莫地平使用为保护因素。     

罂粟碱明胶微球治疗脑血管痉挛的实验研究

目的 研制罂粟碱明胶微球，探索微球药物控释系统治疗脑血管痉挛的可行性。方法 采用改良的双相乳化冷凝聚合法制备明胶微球。并将其与盐酸罂粟碱复合。观察微球分散度、粒径及外观形态；计算微球包封率、载药率及体外释药特性。将自体动脉血分二次注入枕大池制备兔蛛网膜下腔出血（SAH）模型，随后将罂粟碱明胶微球注入该模型兔的枕大池；第7天时，观察并计算基底动脉血管横截面积。结果 微球大小均匀，平均直径（18．36±3．56）μm，载药量为28．0％，包封率为93-3％，体外14d内药物缓释91．0％。兔的基底动脉横截面积：正常组为（0．91±0．19）mm^2，SAH模型组为（0.3l±0．44）mm^2，明胶微球（不含罂粟碱）组为（0．21±0．05）mm^2，罂粟碱明胶微球组为（0．71±0．11）mm^2；罂粟碱明胶微球与SAH模型组和明胶微球组间有明显差异（P〈0．05）。结论 在蛛网膜下腔早期注入罂粟碱缓释明胶微球对实验性脑血管痉挛有防治作用。