动脉瘤性蛛网膜下腔出血后脑血管痉挛危险因素的分析

目的 探讨动脉瘤性蛛网膜下腔出血后脑血管痉挛的危险因素.方法 回顾性分析93例动脉瘤性蛛网膜下腔出血患者的临床资料,研究脑血管痉挛的危险因素.结果 93例动脉瘤性蛛网膜下腔出血患者中共有28例患者(30.1％)发生脑血管痉挛.Hunt-Hess分级≥Ⅲ级血管痉挛发生率明显高于Hunt-Hess分级Ⅰ-Ⅱ级,差异有统计学意义(P＜0.01);Fisher分级≥Ⅲ级血管痉挛发生率明显高于Fisher分级Ⅰ-Ⅱ级,差异有统计学意义(P＜0.01);白细胞计数＞ 15×109的患者脑血管痉挛发生率(41.9％,18/43)明显升高(P＜0.05).结论 Hunt-Hess分级≥Ⅲ级、Fisher分级≥Ⅲ级、白细胞计数增高是蛛网膜下腔出血后脑血管痉挛的危险因素.     

Outcome 1 year after aneurysmal subarachnoid hemorrhage: relation between cognitive performance and neuroimaging

OBJECTIVE: To assess the cognitive impairment and the association between neuropsychological measures and neuroimaging 1 year after aneurysmal subarachnoid hemorrhage (SAH). METHOD: Forty-two patients were examined clinically according to Glasgow Outcome Scale (GOS). Computed tomography (CT), single photon emission computed tomography (SPECT) and neuropsychological examination were performed. RESULTS: There were no association between GOS and cognitive impairment index based on the neuropsychological examination. CT showed no sign of cerebral ischemia in 17 (40%) and low attenuating areas indicating cerebral infarction(s) in 25 (60%) patients. A significant correlation (P = 0.01) was observed between the cognitive impairment index and the SPECT index (r = 0.6). SPECT measurement was the only independent predictor for cognitive impairment. CONCLUSION: GOS is a crude outcome measure and patients classified with good recoveries may have significant cognitive deficits. Neuropsychological examination is the preferred method for outcome evaluation as this method specifically addresses the disabilities affecting patients' everyday life.     

Risk factors and outcome of seizures after spontaneous aneurysmal subarachnoid hemorrhage

Background and purpose:  Seizures are important neurologic complications of spontaneous aneurysmal subarachnoid hemorrhage (SAH). A better understanding of the risk factors of seizures following aneurysmal SAH is needed to predict those who will require treatment.
Methods:  A total of 137 adult patients were enrolled in this two-year retrospective study. Baseline prognostic variables were analyzed based on Cox's proportional hazards model after a minimum of one-year follow-up.
Results:  Seizures occurred in 21 patients who had SAH, including acute symptomatic seizures in 11.7% (16/137) and unprovoked seizures in 3.6% (5/137). None progressed to status epilepticus during hospitalization. After a minimum of one-year follow-up, the mean Glasgow Outcome Score was 3.5 ± 1.4 for patients with seizures and 3.1 ± 1.1 for those without.
Conclusions:  Higher mean World Federation of Neurological Societies grade on presentation was predictive of seizure, but seizure itself was not a significant prognostic predictor after a minimum of one-year follow-up. Regarding potential side effects of anti-epileptic drugs, anti-epileptic therapy should be carefully administered to patients with seizures after aneurysmal SAH.     

动脉瘤性蛛网膜下腔出血及相关并发症的诊治

目的探讨动脉瘤性蛛网膜下腔出血（SAH）的血管内治疗及相关并发症处理。方法对动脉瘤性SAH患者早期诊断,采用血管内治疗并对其并发症进行处理。结论本组40例动脉瘤行栓塞治疗,其中栓塞达90%者26例,95%栓塞11例,完全栓塞3例。死亡4例,1例保守治疗后出院。结论动脉瘤性SAH的早期诊治及围手术期治疗极其重要,是降低死亡率及致残率的关键,介入治疗受血管痉挛的影响小。     

CT在诊断动脉瘤性蛛网膜下腔出血中的临床应用研究(附140例报道)

目的 探讨CT在诊断动脉瘤性蛛网膜下腔出血(ASAH)中的应用价值。方法 回顾性分析了140例CT。表现为SAH并拟诊为颅内动脉瘤(AN)的临床病例资料，从中找出AN破裂在CT。上的出血规律。结果 经CT诊断为ASAH140例，其中133例经脑血管造影(DSA)、核磁共振血管造影(MRA)和直接手术证实为AN，7例没有发现AN，CT诊断AN的阳性率为95％。发现不同部位的AN破裂所引起的SAH在CT上的表现不同，其出血有一定规律。结 论通过CT检查，可以初步对AN进行定位和定性诊断，对AN的进一步检查和治疗有重要的临床意义。     

脑灌注压对动脉瘤性蛛网膜下腔出血后迟发性脑缺血的预测价值

目的探讨脑灌注压(CPP)对动脉瘤性蛛网膜下腔出血(aSAH)后迟发性脑缺血(DCI)发生的预测价值。方法纳入2016年1月至12月在我院就诊并进行CPP检测的50例aSAH患者,其中19例发生DCI。统计所有患者低于各CPP阈值的时间总比例,通过ROC曲线及二元logisctic回归分析比较CPP与DCI的相关性。结果 CPP低于50 mmHg、55 mmHg、60 mmHg、65 mmHg的时间比例对DCI的预测阈值分别为0.28%(AUC=0.778)、3.0%(AUC=0.756)、10.8%(AUC=0.749)、16.1%(AUC=0.718),经二元logistic回归分析显示均与DCI的发生相关(P0.05)。而CPP低于70 mmHg、75 mmHg、80 mmHg的时间比例对DCI的预测阈值分别为24.8%(AUC=0.697)、49.6%(AUC=0.686)、55.9%(AUC=0.672),经二元logistic回归分析显示均与DCI无相关性(P0.05)。结论 aSAH患者发生DCI的风险与CPP降低有关,而维持CPP在70 mmHg以上可能有助于预防DCI发生。     

脑灌注压对动脉瘤性蛛网膜下腔出血后迟发性脑缺血的预测价值

目的 探讨脑灌注压（CPP）对动脉瘤性蛛网膜下腔出血（aSAH）后迟发性脑缺血（DCI）发生的预测价值。方法 纳入2016年1月至12月在我院就诊并进行CPP检测的50例aSAH患者,其中19例发生DCI。统计所有患者低于各CPP阈值的时间总比例,通过ROC曲线及二元logisctic回归分析比较CPP与DCI的相关性。结果 CPP低于50 mmHg、55 mmHg、60 mmHg、65 mmHg的时间比例对DCI的预测阈值分别为0.28%（AUC=0.778）、3.0%（AUC=0.756）、10.8%（AUC=0.749）、16.1%（AUC=0.718）,经二元logistic回归分析显示均与DCI的发生相关（P<0.05）。而CPP低于70 mmHg、75 mmHg、80 mmHg的时间比例对DCI的预测阈值分别为24.8%（AUC=0.697）、49.6%（AUC=0.686）、55.9%（AUC=0.672）,经二元logistic回归分析显示均与DCI无相关性（P>0.05）。结论 aSAH患者发生DCI的风险与CPP降低有关,而维持CPP在70 mmHg以上可能有助于预防DCI发生。     

107例动脉瘤性蛛网膜下腔出血患者预后的多因素分析

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)患者的临床特点及其与预后的相关因素。方法回顾性分析大连医科大学附属第二医院神经外科2012年1月至2015年10月收治的107例SAH患者,根据GOS评分将病例分为预后良好组及不良组,采用单因素分析及对多因素Logistic回归分析,探讨上述各因素对预后的影响。结果全部107例患者经单因素分析显示,诱因、动脉瘤大小、Hunt-Hess评分、脑血管痉挛与患者预后明显相关(均P0.05)。多因素Logistic回归分析显示,诱因(P=0.026)、动脉瘤大小(P=0.002)、Hunt-Hess评分(P=0.016)及脑血管痉挛(P=0.003)为影响a SAH患者预后的独立危险因素。结论 a SAH患者的发病诱因、动脉瘤大小、Hunt-Hess分级和脑血管痉挛是影响患者预后的危险因素。     

高分级动脉瘤性蛛网膜下腔出血合并呼吸抑制患者的手术治疗

目的 评价高分级动脉瘤性蛛网膜下腔出血合并呼吸抑制患者显微手术治疗的疗效.方法 同顾性分析7例动脉瘤性蛛网膜下腔出血合并呼吸抑制患者的资料,患者均在进行呼吸功能复苏抢救后急行显微外科手术治疗,以GOS评分量表对患者神经功能评分.结果 7例患者的7个动脉瘤均显微手术夹闭,术后6个月时的GOS评分:恢复良好2例,中度病残但生活自理3例,重度病残、生活不能自理1例,死亡1例.结论 对即使已经合并呼吸抑制的高分级动脉瘤患者急性期手术治疗是可行的,结合及时的气管插管控制呼吸,脑室外引流以及去骨板减压等处理可以帮助改善其预后.     

蛛网膜下腔出血诱导小鼠长期认知功能损害

目的了解蛛网膜下腔出血（SAH）小鼠模型是否存在认知功能损害及探讨造成认知功能损害的可能机制。方法经枕大池注射自身动脉血建立SAH小鼠模型;14d时测量大脑主要动脉直径;通过8一臂迷宫实验评估SAH30d后动物空间学习和记忆功能;加高效液相色谱分析海码组织谷氨酸和天门冬氨酸水平。结果SAH后2周,大脑主要动脉无明显痉挛;SAH30d后,小鼠工作记忆能力和参考记忆能力明显低于对照组和假手术组（P〈0．05）;SAH后24h、48h和72h,海马区谷氨酸和天门冬氨酸含量明显增高（P〈0．01）,30d后,这两种氨基酸的浓度明显下降（P〈0．05）。结论SAH不引起迟发性脑血管痉挛,但可引起小鼠长时间认知功能损害。SAH引起急性脑血流量降低,海马区兴奋性氨基酸大量释放,可能引起海马区神经细胞损害,迟发性海马区兴奋性氨基酸（EAA）降低和认知功能损害是海马损害后的结果。     

Long-term domain-specific improvement following poor grade aneurysmal subarachnoid hemorrhage

Background While efforts have been made to document short-term outcomes following poor grade aneurysmal subarachnoid hemorrhage (aSAH), no data exist concerning the degree of delayed improvement in neurological function. Here we assess cognitive function, level of independence, and quality of life (QoL) over 12 months following poor grade aSAH. Methods Data on definitively treated poor grade patients (Hunt and Hess grade IV or V) surviving 12 months post-aSAH were obtained through a prospectively maintained SAH database. Demographic information, medical history, and clinical course were analyzed. Health outcomes assessments completed by surviving patients at discharge (DC), three months (3 M) and 12 months (12 M) follow-up, including the Telephone Interview for Cognitive Status (TICS), Barthel Index (BI), and Sickness Impact Profile (SIP), were used to evaluate cognitive function, level of independence, and QoL. Findings Fifty-six poor grade patients underwent aneurysm-securing intervention and survived at least 12 months post-aSAH. Thirty-five (63%) surviving patients underwent health outcomes assessments at DC, 3 M and 12 M post-aSAH. A majority of patients had improved scores on the TICS (DC to 3 M: 91%; 3 M to 12 M: 82%), BI (DC to 3 M: 96%; 3 M to 12 M: 92%), and SIP (3 M to 12 M: 80%) following aSAH. Using paired-sample analyses, significant improvement on each test was observed. Conclusion A substantial portion of patients experience cognitive recovery, increased independence, and improved QoL following poor grade aSAH. Delayed follow-up assessments are necessary when evaluating functional recovery in this population. These findings have the potential to impact poor grade aSAH management and prognosis. Received in revised form: 24 July 2005     

阿托伐他汀钙对动脉瘤性蛛网膜下腔出血后脑血管痉挛的作用及机制

目的研究阿托伐他汀钙对动脉瘤性蛛网膜下腔出血(a SAH)后血管痉挛(CVS)的影响及机制。方法连续收集2013年03月至2015年11月收治的动脉瘤性蛛网膜下腔出血患者共62例,随机分为研究组(33例)与对照组(29例)。对照组给予常规治疗,研究组在对照组治疗基础上加服阿托伐他汀钙(20 mg/qn,连服14 d)。于发病后第1天、第3天、第7天和第14天检测分析两组患者大脑中动脉平均血流速度(VMCA)及血清中内皮素血管肽-1(ET-1)、一氧化氮(NO)水平。同时,比较两组患者脑血管痉挛(CVS)的发生率、迟发型脑梗死和复发出血的发生率以及Modified Rankin Scale score量表(mRS)评分。结果在第7天、第14天研究组的VMCA、ET-1均低于对照组,差异有统计学意义(P0.05)。在第3天、第7天、第14天,研究组NO含量高于对照组,差异有统计学意义(P0.05)。研究组脑血管痉挛的发生率较对照组低(36.36%vs.65.52%),差异有统计学意义(P0.05)。研究组mRS评分≤2分所占比例较对照组高(75.76%vs.44.83%),差异有统计学意义(P0.05)。迟发型脑梗死和再发出血的发生率两组差异无统计学意义(P0.05)。结论阿托伐他汀钙能够减少蛛网膜下腔出血后脑血管痉挛的发生,并促进神经功能恢复,其机制可能与改善血管内皮舒缩功能有关。     

动脉瘤性蛛网膜下腔出血后慢性脑积水形成相关危险因素分析

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)后慢性脑积水形成的危险因素。方法回顾分析170例aSAH患者临床资料,应用出血后3周的CT评价aSAH后慢性脑积水;先将可能的危险因素与脑积水之间行显著性检验,再用多元回归加以明确,得到回归方程。结果 aSAH后慢性脑积水易患因素依次为入院时较高Hunt-Hess分级(P=0.006)、反复多次出血(P=0.007)、高龄(P=0.010)。结论 aSAH后慢性脑积水形成为多因素共同作用的结果。     

动脉瘤性蛛网膜下腔出血患者认知功能研究

目的通过对动脉瘤性蛛网膜下腔出血患者认知功能的动态评估,探讨认知功能变化的临床意义。方法选择颅内前循环动脉瘤100例,并经血管内治疗或开颅夹闭处理。在入院时、出院时和出院后2月以简易智能量表等评估患者的认知功能。结果100例动脉瘤性蛛网膜下腔出血患者认知功能损害率入院时37.0%,出院时60.0%,出院后2月38.0%;出院时认知功能损害率高于入院时（P〈0.01）和出院后2月（P〈0.01）;认知功能损害主要反应在注意力和计算力、短程记忆和反应速度等方面;血管内治疗组和开颅夹闭组出院时和出院2月时认知功能损害率均差异显著（P〈0.05）。结论动脉瘤性蛛网膜下腔出血患者在不同时间段存在不同程度的认知功能损害,前瞻性预防和外科处理措施的改进能提高该类患者的生活质量。     

动脉瘤性蛛网膜下腔出血致Terson综合征行玻璃体切割术治疗的临床分析

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)所致Terson综合症的临床治疗效果。方法对我院确诊13例颅内破裂动脉瘤致Terson综合症的患者,13例(21只眼)均行玻璃体切割术的疗效进行回顾性分析。结果 13例病例中,前交通动脉瘤4例,后交通动脉瘤3例,小脑后下动脉瘤3例,基底动脉顶端动脉瘤1例,椎-基底动脉夹层动脉瘤1例,椎动脉-小脑后下动脉夹层动脉瘤1例。21眼行玻璃体切割术,术后随访3~12个月,平均随访6.1月,21只眼视力均有所提高,平均视力恢复至0.45,其中视力≥0.3者16眼,占76.2%。结论对aSAH患者应常规进行眼科筛查有无Terson综合症;玻璃体切割术是治疗Terson综合症安全有效的,可以提高患者的生活质量。     

Fatigue after aneurysmal subarachnoid hemorrhage evaluated by pituitary function and 3D-CBF

OBJECTIVE: The reason for longstanding fatigue following aneurysmal subarachnoidal hemorrhage (SAH) is still not clarified. The bleed from supratentorial aneurysms is often in the vicinity of the hypothalamus and pituitary gland making an endocrine dysfunction plausible. METHODS: Ten patients with post-SAH fatigue were investigated with 3D-CBF (SPECT) and underwent an evaluation of the pituitary function. RESULTS: Five had normal pituitary function. Disturbances in the gonadotropin function was detected in three patients and suspected in two. The mean insulin-like growth factor I (IGF-I) value of the patients was in the lower part of the reference range. In the patients with endocrine dysfunction, the 3D-CBF was pathologic in the central structures of the basal region. CONCLUSIONS: The present results indicate that an aneurysmal SAH may result in partially impaired pituitary capacity. This deficit may contribute to fatigue after aneurysmal SAH, but cannot solely explain this disorder. SPECT identified regional tissue damage in the patients with pituitary dysfunction after SAH.     

动脉瘤性蛛网膜下腔出血患者开颅夹闭术与介入栓塞术后认知功能的对比研究

目的探讨开颅夹闭术与介入栓塞术对动脉瘤性蛛网膜下腔出血(SAH)患者认知功能的影响。方法分析2015年7月—2017年12月,行开颅夹闭术或介入栓塞术治疗的122例动脉瘤性蛛网膜下腔出血患者的临床资料。采用简易精神状态检查(MMSE)量表对所有患者的认知功能进行评定;每例患者共进行4次MMSE评分:入院时(治疗前)、术后近期(术后2周)、中期(术后2个月)、远期(术后1年)。将患者按照手术治疗方式分为开颅夹闭组(42例)和介入栓塞组(80例),分别对比两组患者术前、近期、中期和远期的MMSE评分;并对不同时期认知功能障碍发生率进行比较。结果两组患者术前MMSE评分的差异无统计学意义(P>0.05);介入栓塞组在术后早期、中期及远期的MMSE评分均明显高于开颅夹闭组(均P<0.05)。开颅夹闭组患者在术后近期及中期的认知功能障碍发生率均明显高于介入栓塞组(均P<0.05);但在术后远期,两组患者认知功能障碍发生率的差异无统计学意义(P>0.05)。结论行开颅夹闭术的动脉瘤性蛛网膜下腔出血患者,术后近期及中期的认知功能障碍发生率明显高于介入栓塞术患者。介入栓塞治疗动脉瘤有助于减轻认知功能的损害。     

Cerebrospinal fluid ferritin in chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

Objectives Subarachnoid hemorrhage (SAH) is a common cause of chronic hydrocephalus. Blood in the subarachnoid space is intracranially metabolized to bilirubin and iron, and free iron is thereafter detoxified by ferritin. However, no studies have reported the relationship between intracranial heme metabolism and chronic hydrocephalus after SAH. The goal of this prospective study was to clarify the relationship between intracranial heme metabolism and chronic hydrocephalus after SAH. Methods The authors measured the levels of bilirubin, iron and ferritin in the cerebrospinal fluid (CSF) of 70 consecutive patients with aneurysmal SAH of Fisher computed tomography Group III, and determined the relationship between these substances’ levels and hydrocephalus requiring ventriculoperitoneal shunting. Results The CSF concentrations of ferritin and inflammatory cells were significantly higher in shunted patients (n = 27) than in non-shunted patients (n = 43) on Days 3 and 4 (p<0.05 in ferritin and p<0.01 in inflammatory cells) and 11 to 14 (p<0.005 in ferritin) post-SAH. These results were independent of other clinical factors. The occurrence of chronic hydrocephalus was not affected by the extent of the intracranial heme metabolism in terms of the bilirubin and iron levels. Conclusions This is the first study to show that patients who subsequently had chronic hydrocephalus requiring CSF shunting were associated with higher CSF levels of ferritin in the acute stage of SAH. Higher CSF ferritin levels may not reflect the amount of blood in the subarachnoid space that was intracranially metabolized, but rather more intense subarachnoid inflammatory reactions which may cause chronic hydrocephalus after SAH. Received in revised form: 19 January 2006