动脉瘤性蛛网膜下腔出血患者脑脊液中内皮素浓度的动态变化

目的 研究动脉瘤性蛛网膜下腔出血后患者脑脊液中内皮素的动态变化及其与血管痉挛的关系。方法 采集40例破裂动脉瘤患者脑脊液标本,采集时间为入院后即刻、出血后第3、5、7、10、14天,采用放免法检测脑脊液中ET－1浓度。结论 出血后第3天脑脊液中ET－1浓度即有明显升高,在出血后第7天达到高峰,而后逐渐下降。血管痉挛患者ET－1浓度明显高于未痉挛者。结论 脑脊液中ET－1浓度的升高参与蛛网膜下腔出血后脑血管痉挛的发生。     

蛛网膜下腔出血患者不同时期脑脊液中一氧化氮浓度的变化

目的：研究动脉瘤性蛛网膜下腔出血后患者不同时期脑脊液中一氧化氮（NO）浓度的动态变化及其与脑血管痉挛的关系。方法：采集52例破裂动脉瘤患者脑脊液标本，采集时间为入院后即刻，出血后第3，5，7，10，14天，采用镉粒还原法检测脑脊液中NO浓度，结果：出血后第3天脑脊液中NO浓度即有明显降低，在出血后第7天达到最低，而后逐渐升高，症状性脑血管痉挛患者NO浓度明显低于未痉挛者及无症状的血管痉挛患者，结论：症状性脑血管痉挛的发生与脑脊液中NO浓度降低有关。     

Cerebrovascular dynamics with head-of-bed elevation in patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage.

BACKGROUND: In patients with aneurysmal subarachnoid hemorrhage, elevation of the head of the bed during vasospasm has been limited in an attempt to minimize vasospasm or its sequelae or both. Consequently, some patients have remained on bed rest for weeks. OBJECTIVES: To determine how elevations of the head of the bed of 20 degrees and 45 degrees affect cerebrovascular dynamics in adult patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage and to describe the response of mild or moderate vasospasm to head-of-bed elevations of 20 degrees and 45 degrees with respect to variables such as grade of subarachnoid hemorrhage and degree of vasospasm. METHODS: A within-patient repeated-measures design was used. The head of the bed was positioned in the sequence of 0 degrees -20 degrees -45 degrees -0 degrees in 20 patients with mild or moderate vasospasm between days 3 and 14 after aneurysmal subarachnoid hemorrhage. Continuous transcranial Doppler recordings were obtained for 2 to 5 minutes after allowing approximately 2 minutes for stabilization in each position. RESULTS: No patterns or trends indicated that having the head of the bed elevated increases vasospasm. As a group, there were no significant differences within patients at the different positions of the head of the bed. Utilizing repeated-measures analysis of variance, P values ranged from .34 to .97, well beyond .05. No neurological deterioration occurred. CONCLUSIONS: In general, elevation of the head of the bed did not cause harmful changes in cerebral blood flow related to vasospasm.     

法舒地尔防治动脉瘤介入栓塞术后脑血管痉挛的疗效观察

【目的】探讨盐酸法舒地尔防治颅内动脉瘤破裂蛛网膜下腔出血（SAH）介入栓塞术后脑血管痉挛（CVS）的效果。【方法】将60例脑动脉瘤破裂SAH介入栓塞术后患者随机分为治疗组和对照组各30例,治疗组术后给予法舒地尔30mg静脉滴注q8h,疗程14d,每次静脉滴注时间为30min;对照组30例,术后采用尼莫地平,1mg／h,静脉泵入,疗程14d,比较两组的Glasgow评分,头部CT及经颅多普勒（TCD）观察大脑中动脉（MCA）血流速度的变化。【结果】法舒地尔与尼莫地平均可迅速促进疾病的好转;对CT检查所见脑内低密度灶,法舒地尔与尼莫地平均可使其改善;法舒地尔与尼莫地平扩张痉挛脑动脉的作用较好,两者无显著性差异（P〉0．05）。【结论】法舒地尔与尼莫地平均是预防和治疗动脉瘤破裂SAH介入栓塞术后CVS安全有效的药物。     

动脉瘤性蛛网膜下腔出血患者迟发性缺血性神经功能障碍的临床特点及护理

总结42例动脉瘤性蛛网膜下腔出血后迟发性缺血性神经功能障碍（DIND）的临床特点及护理对策。认为动脉瘤性蛛网膜下腔出血患者延迟性缺血性神经功能障碍的主要临床特点为紧张焦虑等心理障碍、颅内压增高、血液黏稠度增高、脑血管痉挛、动脉瘤再破裂,以及中枢性高热、水电解质平衡失调、肺部感染等并发症。应采取有针对性的护理措施,护理重点包括：加强心理护理;避免诱发脑血管痉挛及动脉瘤再破裂的诱因,并警惕两者先兆症状的观察及变化,控制患者血压;注重动态分析患者颅内压监护仪、红细胞压积、经颅多普勒、颅脑CT等检查结果,着重观察监测指标异常的患者,发现异常情况及时报告医生处理;并发症预防与护理。全组治疗结果根据Glasgow预后评分：Ⅰ级17例,Ⅱ级11例,Ⅲ级4例,Ⅳ级2例,Ⅴ级8例;病死率19%。     

Cerebral vasospasm: current concepts of pathogenesis and treatment

It is believed that most patients with subarachnoid hemorrhage secondary to aneurysmal rupture experience some degree of cerebral vasospasm, although not all develop specific neurologic deficits. Management is complicated, and at present the outcome is often less than optimal. This article reviews the symptoms, predictors and pathophysiology of vasospasm, highlighting current theories of pathogenesis as well as their relationship to treatment. This information is essential for the neuroscience nurse to care adequately for these patients. A plan of care for the patient with cerebral vasospasm is included.     

Controversies in the management of aneurysmal subarachnoid hemorrhage

BACKGROUND: The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management. OBJECTIVE: To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation. DATA SOURCE: Search of MEDLINE and Cochrane databases and manual review of article bibliographies. DATA SYNTHESIS AND CONCLUSIONS: Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.     

The accuracy of transcranial Doppler to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVES. To examine the accuracy of transcranial Doppler to detect cerebral vasospasm in a patient population with aneurysmal subarachnoid hemorrhage. DESIGN. Prospective blind comparison of transcranial Doppler with cerebral angiography. Diagnostic accuracy of transcranial Doppler was assessed using receiver operating characteristic (ROC) analysis and likelihood ratios. Sensitivity and specificity were calculated using directly measured middle cerebral artery diameter as reference standard. SETTING. Intensive Care Unit of a large university teaching hospital. PATIENTS AND PARTICIPANTS. Twenty-two patients with subarachnoid hemorrhage were included. Patients underwent angiography on admission and after 8 days to diagnose vasospasm and were defined as having clinical vasospasm, angiographic vasospasm, or no vasospasm. MEASUREMENTS AND RESULTS. Sensitivity and specificity were 1.00 and 0.75 for angiographic vasospasm and both equal to 1.00 for clinical vasospasm diagnosis. A transcranial Doppler mean velocity threshold value of 100 cm/s for angiographic vasospasm and 160 cm/s for clinical vasospasm detection were chosen by ROC analysis. CONCLUSIONS. A Transcranial Doppler mean velocity threshold of 160 cm/s, calculated by the ROC analysis, accurately detects clinical vasospasm. A daily transcranial Doppler examination performed by a trained operator should be routinely used to provide early identification of patients at high risk and to orient therapeutic decisions.     

Symptomatic vasospasm diagnosis after subarachnoid hemorrhage: evaluation of transcranial Doppler ultrasound and cerebral angiography as related to compromised vascular distribution

OBJECTIVE: To evaluate the reliability of transcranial Doppler ultrasound in detecting symptomatic vasospasm in patients after aneurysmal subarachnoid hemorrhage and monitoring response after hypertensive and endovascular treatments. DESIGN: Retrospective chart review. SETTING: Neurosciences critical care unit in a tertiary-care university hospital. PATIENTS: All patients admitted to a neurosciences critical care unit with the diagnosis of subarachnoid hemorrhage between January 1990 and June 1997. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: We reviewed transcranial Doppler ultrasound data of 199 patients; 55 had symptomatic vasospasm. Clinical symptoms and corresponding vascular distributions were identified, as was angiographic vasospasm (n = 35). The sensitivity and specificity of transcranial Doppler ultrasound for anterior circulation vessels were calculated by using a mean cerebral blood flow velocity criterion of >120 cm/sec. Clinical diagnosis of symptomatic vasospasm was used as the standard to determine sensitivity and specificity of transcranial Doppler ultrasound and cerebral angiography. The sensitivity of transcranial Doppler ultrasound for anterior circulation in patients with symptomatic vasospasm was 73% with a specificity of 80%. The sensitivity of cerebral angiography was 80%. For individual vessels, the sensitivity and specificity of transcranial Doppler ultrasound were middle cerebral artery, 64% and 78%; anterior cerebral artery, 45% and 84%; and internal carotid artery, 80% and 77%, respectively. The mean times for symptomatic and transcranial Doppler ultrasound signs of vasospasm presentation were 6.4 +/- 2 and 6.1 +/- 3 days, respectively. In patients without symptomatic vasospasm, the mean time for mean cerebral blood flow velocities >120 cm/sec was 7.0 +/- 3 days (p <.05). Symptomatic vasospasm also was associated with thickness of clot on head computed tomography scan and rapidly increasing mean cerebral blood flow velocities. Transcranial Doppler ultrasound signs of vasospasm improved after endovascular treatment in 30 patients. CONCLUSIONS: The reliability of transcranial Doppler ultrasound was better at detecting high mean cerebral blood flow velocities in patients with symptomatic vasospasm related to middle cerebral and internal carotid artery distributions than for anterior cerebral artery distribution. Transcranial Doppler ultrasound was as sensitive as cerebral angiography at detecting symptomatic vasospasm. High mean cerebral blood flow velocities can be apparent before the presence of symptomatic vasospasm. Daily transcranial Doppler ultrasound monitoring could provide early identification of patients with aneurysmal subarachnoid hemorrhage who are at high risk for symptomatic vasospasm and may be helpful at following success of endovascular treatment.     

Endovascular coiling for cerebral aneurysms

Aneurysmal subarachnoid hemorrhage is an increasing problem in the United States, affecting approximately 30,000 people every year. Despite advances in the neurosurgical field, approximately 50% of patients die within the first month after hemorrhage. Traditionally, craniotomy with aneurysmal clipping has been employed to manage these patients, but endovascular embolization is moving to the forefront of treatment, particularly for high grade (IV to V) aneurysms. Patient selection is often based on age, aneurysm size, location, characteristics and presentation, and patient hemodynamics. Postprocedure management relies on skilled observers to determine those potential complications that may occur, including vasospasm, rupture, bleeding, or vessel occlusion. Advanced practice nurses have an obligation to be aware not only of the procedure and its management, but also of the potential complications and ongoing care of the patients and families as well.     

Aneurysmal subarachnoid hemorrhage: neurosurgical frontiers and nursing challenges

Despite increases in survival beyond the initial hemorrhage, the devastating consequences of subarachnoid hemorrhage persist. Ruptured intracranial aneurysms are the most likely cause of subarachnoid hemorrhage, with morbidity and mortality rates approaching 75%. Complications arising from aneurysmal subarachnoid hemorrhage include rebleeding, delayed cerebral ischemia, hydrocephalus, hypothalamic dysfunction, and seizure activity. In order to positively influence outcome after subarachnoid hemorrhage, preservation of an adequate cerebral blood flow and prevention of secondary aneurysmal rupture is essential. This article reviews aneurysmal subarachnoid hemorrhage, relating the management of complications to currently accepted treatment strategies.     

Copeptin in aneurysmal subarachnoid hemorrhage

Copeptin is a peptide derived from pre-provasospression along with arginine vasospressin. In the setting of aneurysmal subarachnoid hemorrhage (SAH), elevated serum copeptin levels correlate with vasospasm, inpatient mortality, mortality at 1 year, and poor functional outcome at 1 year. The potential role of serum copeptin levels in the management of patients with aneurysmal SAH is promising and should be explored further.     

Cerebral vasospasm following intracranial aneurysm rupture: a protocol for detection

Cerebral vasospasm is currently recognized as a major cause of morbidity and mortality in patients surviving subarachnoid hemorrhage due to intracranial aneurysmal rupture. Effective management and possible prevention of the ischemic sequelae of vasospasm can occur if the clinical syndrome of vasospasm is detected in its earliest stages. This article acquaints the reader with the significant risk factors associated with development of vasospasm, the temporal profile of occurrence and the signs and symptoms of the clinical syndrome. A brief overview of some popular theories of vasospasm etiology and pathogenesis is presented. Additionally, a protocol for detection is provided incorporating the knowledge of population at risk, temporal profile and signs and symptoms of cerebral vasospasm.     

Hypertension may be the most important component of hyperdynamic therapy in cerebral vasospasm

Although hyperdynamic therapy is an accepted method of treatment of patients with symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage, it remains unproven in large scale trials and controlled studies. Furthermore, methods of hyperdynamic therapy and specific endpoints vary widely. A systematic review of clinical trials of the various techniques of hyperdynamic therapy and their effects on cerebral blood flow found only 11 studies suitable for analysis. Although controlled trials are lacking, there is some evidence to suggest that hypertension is the most promising component of hyperdynamic therapy. These findings support a future randomized trial of induced hypertension in patients with symptomatic cerebral vasospasm.     

Cerebral angioplasty: a new treatment for vasospasm secondary to subarachnoid hemorrhage

The potential benefit of cerebral angioplasty for patients with delayed cerebral ischemia secondary to vasospasm is promising. Cerebral angioplasty has the potential for positively affecting patient outcome and quality of life. Further, cerebral angioplasty may lead to a reduction in long-term care needs for patients who experience severe cerebral vasospasm from an aneurysmal subarachnoid hemorrhage. The challenge to the neuroscience nurse begins with the early detection of neurological changes signaling the onset of progressive delayed cerebral ischemia despite conventional therapies for vasospasm. The nurse's sagacious management of neurologic, hemodynamic and pulmonary status and the ongoing support of the patient and family throughout the angioplasty procedure is crucial to a positive outcome.     

蛛网膜下腔出血患者预后的Logistic危险因素分析

目的探讨蛛网膜下腔出血患者预后的Logistic危险因素。方法选取蛛网膜下腔出血患者98例,分析2组年龄、血压、手术时期等基本资料,并进行Logistic分析。结果 98例蛛网膜下腔出血患者中预后良好60例,预后不良38例。预后良好组患者年龄≥50岁、血压等级、Hunt-Hess分级、APACHEⅡ评分、再次出血及脑血管痉挛所占比例均显著高于预后不良组(P0.05)。Logistic分析显示,急性生理及慢性健康状况(APACHEⅡ)评分、脑血管痉挛、Hunt-Hess分级、再次出血及年龄是影响蛛网膜下腔出血的独立危险因素。结论 APACHEⅡ评分、脑血管痉挛、Hunt-Hess分级、再次出血及年龄是影响蛛网膜下腔出血患者预后危险因素。     

Management of 350 aneurysmal subarachnoid hemorrhages in 22 Italian neurosurgical centers

OBJECTIVE: To collect information on clinical practice and current management strategies in 22 Italian neurosurgical hospitals for patients with aneurysmal subarachnoid hemorrhage. DESIGN AND SETTING: Observational 6-month study for prospective data collection. PATIENTS: 350 cases of aneurysmal subarachnoid hemorrhage. MEASUREMENTS AND RESULTS: Each center enrolled from 4-36 patients. Neurological deterioration (24%) was more frequent in patients with higher Fisher classification, and with pretreatment rebleeding and it was associated with an unfavorable outcome (46%, 36/78, vs. 33%, 83/251). Aneurysms were mainly secured by clipping (55%, 191/350). An endovascular approach was utilized in 35% (121/350). The more frequent medical complications were fever, recorded in one-half of cases, pneumonia (18%), sodium disturbances (hyponatremia 22%, hypernatremia 17%), cardiopulmonary events as neurogenic pulmonary edema (4%) and myocardial ischemia (5%). Intracranial hypertension was experienced in one-third of the patients, followed by hydrocephalus (29%) and vasospasm (30%). Cerebral ischemia was found in an about one-quarter of the cohort. To identify the independent predictors of outcome we developed a model in which the dichotomized Glasgow Outcome Scale was tested as function of extracranial and intracranial complications. Only high intracranial pressure and deterioration in neurological status were independent factors related to unfavorable outcome. CONCLUSIONS: Our data confirm that in every step of care there is extreme heterogeneity among centers. These patients are complex, with comorbidities, immediate risk of rebleeding, and delayed risk of intracranial and medical complications. Following SAH early treatment and careful intensive care management requires the careful coordination of the various clinical specialties.     

动脉瘤性蛛网膜下腔出血患者脑脊液IL-1β、IL-6及TNFα检测及意义

【目的】探讨动脉瘤性蛛网膜下腔出血（SAH）患者脑脊液白介素-1β（IL-1β）、白介素-6（IL-6）和肿瘤坏死因子d（TNFa）水平及其与脑血管痉挛的关系。【方法】选用双抗体夹心酶联免疫吸附试验（ELISA）检测动脉瘤性SAH患者脑脊液IL-1β、IL-6和TNFa浓度,并将其结果与经颅多普勒（TCD）检查判别的脑血管痉挛与否进行相关分析。【结果】动脉瘤性SAH患者脑脊液中IL-1β、IL-6和TNFa水平均明显升高（P〈0．05）,IL-1β、IL-6水平与脑血管痉挛显著相关（P〈0．05）,TNFa水平与脑血管痉挛无统计学相关（P〉O．05）。【结论】动脉瘤性SAH患者脑脊液IL-1β和IL-6水平增高可能与脑血管痉挛发病有关,检测其患者脑脊液中IL-1β和IL-6有助于脑血管痉挛的预测及治疗。     

Using CT in the Diagnosis and Management of Patients with Cerebral Vasospasm

Cerebral vasospasm remains a serious complication of aneurysmal subarachnoid hemorrhage. Efforts in improving its clinical outcome have been focused on early diagnosis and applying effective treatment regimens. Standard diagnostic modalities currently used do not fully address this complex disease. The use of CT angiography and CT perfusion are discussed, with emphasis on its potential role in not only detecting vasospasm, but also in guiding management decisions and assessing clinical outcome.     

Unresolved issues in the management of aneurysmal subarachnoid hemorrhage

A cerebral aneurysm is an outpouching of a weakened arterial wall, usually at a bifurcation of one of the larger vessels of the Circle of Willis. When the outpouching ruptures, arterial pressure forces blood into the subarachnoid space. The annual incidence of aneurysmal subarachnoid hemorrhage is 8 to 10 per 100 000 in the United States. The outcome varies for this patient population. New management strategies have emerged; some practices are evidence based, whereas others are based on anecdotal experiences. This variation has resulted in a number of unresolved issues in caring for patients with an aneurysmal subarachnoid hemorrhage. This article discusses some of these unresolved issues, including the use of medications such as nimodipine, antifibrinolytics, statins, and magnesium; coiling or clipping for aneurysm securement; and the prevention and treatment of potential complications. Critical care nurses must conduct detailed assessments and provide complex care to optimize patient outcomes.