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...     

脑血流储备与蛛网膜下腔出血后迟发性脑缺血相关性的临床分析

目的：探讨脑血流储备（ CVR ）与蛛网膜下腔出血（ SAH ）后迟发性脑缺血（ DCI ）的相关性。方法研究采用双盲法,对SAH患者进行CO2吸入试验,并用TCD测定试验前后的血流速度,根据公式计算CVR值。将患者分为CVR下降的病例组、CVR正常的病例组、CVR下降的对照组及CVR 正常的对照组。结果对4组DCI发生率进行校正的卡方检验,有统计学意义,说明CVR下降可作为DCI发生的预测指标。结论对SAH患者进行CVR的评估可作为临床预测DCI发生的指标之一。     

眼跳潜伏期预测动脉瘤性蛛网膜下腔出血后迟发性脑缺血的研究

目的探讨眼跳潜伏期对动脉瘤性蛛网膜下腔出血(SAH)后迟发性脑缺血(DCI)的预测作用。方法回顾性选择2012年1月~2016年12月来我院接受治疗的SAH患者110例。根据患者入院后30天内有无并发迟发性脑缺血(DCI)分为并发DCI组(n=40)和未并发DCI组(n=70)。应用单因素、多因素非条件Logistic回归分析探讨影响SAH患者DCI发生的危险因素。结果眼跳频率、眼跳总时间、单次眼跳平均时间、眼跳总幅度、眼跳平均幅度、眼跳平均速度、眼跳潜伏期预测SAH后DCI发生的诊断界值分别为2.65次/s、1685.45 ms、39.03 ms、553.25°、8.05°、118.35°/s、375.42 ms。Hunt-Hess分级≥Ⅲ级、Fisher分级≥Ⅲ级、脑积水程度(中度、重度)、眼跳潜伏期≥375.42 ms会增加SAH后DCI发生风险(P0.05)。结论眼跳潜伏期可预测SAH后DCI发生。     

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。     

蛛网膜下腔出血患者迟发性脑血管痉挛相关因素的临床分析

目的 探讨动脉瘤性蛛网膜下腔出血(SAH)患者迟发性脑血管痉挛(DCVs)的临床影响因素. 方法 回顾性分析南方医科大学珠江医院神经外科自2005年1月至2008年12月收治的74例动脉瘤性SAH患者的临床资料,判定DCVS,统计分析其影响因素. 结果年龄、出血次数、吸烟史、Hunt-Hess分级、Fisher分级、白细胞计数峰值与DCVS的发生具有明显相关性,其中年龄、出血次数、Hunt-Hess分级、Fisher分级是DCVS发生的独立影响因素. 结论 低年龄、出血2次以上及Hunt-Hess分级或Fisher分级Ⅲ级以上患者更易发生DCVS,临床上对此类患者应加强监测、及早发现和处理.     

早期低脑血流量和高乳酸血症预测蛛网膜下腔出血后迟发性脑缺血的临床研究

目的 探讨早期低脑血流量和高乳酸血症对蛛网膜下腔出血(SAH)后迟发性脑缺血(DCI)的预测作用。方法 选择2010年1月-2014年12月来本院接受治疗的SAH患者90例; 根据患者有无DCI发生分为DCI发生组(n=35)和DCI未发生组(n=55); 根据病历信息及临床检查详细记录SAH患者的年龄、性别、体质量指数(BMI)、烟酒嗜好,高血压病、糖尿病史和现状、治疗方式,责任动脉瘤位置、血肿形成、脑积水、有无高乳酸血症、Hunt-Hess分级、Fisher分级等; 应用单因素、多因素非条件Cox回归分析预测SAH后DCI发生的危险因素。结果 90例SAH患者中35例(38.89%)发生DCI,55例(61.11%)未发生DCI。2组患者在性别、Fisher分级、Hunt-Hess分级、血肿形成、脑积水、有高乳酸血症、脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT)、达峰时间(TTP)方面差异显著(P<0.05)。其中,DCI发生组在高乳酸血症患者比例方面显著高于DCI未发生组(P<0.05),在CBF方面显著低于DCI未发生组(P<0.05)。CBF、CBV、MTT、TTP的ROC曲线下面积分别为0.88、0.70、0.89、0.73,预测DCI最佳诊断界值分别为15.95 mL·100 g^-1·min^-1、1.77 mL·100 g^-1、9.62 s、11.48 s。 单因素、多因素Cox回归分析显示,有高乳酸血症、Hunt-Hess分级≥Ⅲ级、Fisher分级≥Ⅲ级、CBF<15.95 ml/100 g/min会增加SAH后DCI发生的风险(P<0.05)。结论 早期低脑血流量和高乳酸血症可预测SAH后DCI发生。     

血脂水平与动脉瘤性蛛网膜下腔出血后迟发性脑缺血的相关性

目的 探讨血脂水平与动脉瘤性蛛网膜下腔出血(aSAH)后迟发性脑缺血（DCI）的相关性。方法 回顾性分析2014年1月至2015年12月收治的74例aSAH的临床资料,采用多因素Logistic回归分析检验性别、年龄、动脉瘤位置、动脉瘤大小、世界神经外科医师联盟（WFNS）分级、改良Fisher分级、Hunt-Hess分级、治疗方式、总甘油三脂、总胆固醇、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、脂蛋白(a)、载脂蛋白A、载脂蛋白B等因素与DCI的关系。结果 74例中,65例入院后检测血脂,20例出现DCI,45例未出现DCI,aSAH后DCI的发生率为30.8%。多因素Logistic回归分析显示高甘油三酯及改良Fisher分级是aSAH后DCI发生的独立危险因素。结论 及时检测aSAH患者的血脂水平和对患者进行改良Fisher分级对DCI的诊断治疗均有参考价值。     

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。     

血清ET-1水平与动脉瘤性蛛网膜下腔出血后迟发性脑缺血的关系

目的 探讨血清内皮素-1(ET-1)水平对动脉瘤性蛛网膜下腔出血（aSAH）后迟发性脑缺血（DCI）的预测效能。方法回顾性分析2019年9月至2023年1月收治的104例aSAH的临床资料。DCI定义为在排除手术相关脑缺血后,第3～14天出现CT低密度或相应的MRI表现。采用ELISA法检测入院时血清ET-1水平。结果 104例中,39例（37.50%）发生DCI。多因素logistics回归分析显示血清ET-1水平增高为DCI的独立危险因素（OR=9.784;95%CI 3.458～27.688;P<0.001）。ROC曲线分析显示,血清ET-1水平预测DCI的曲线下面积为0.840(95%CI 0.764～0.917),最佳截断值为33.25 pg/ml,灵敏度及特异度分别为79.5%、76.9%。结论 aSAH后血清ET-1水平升高,监测血清ET-1水平变化,可预测DCI的发生风险。     

早期脑血流量检测在预测蛛网膜下腔出血迟发性脑缺血患者预后的作用研究

目的探讨早期脑血流量检测对蛛网膜下腔出血(SAH)迟发性脑缺血(DCI)患者预后的预测作用。方法选择2008年1月～2012年11月来我院接受治疗的SAH后DCI患者150例。根据5年后患者临床结局分为存活组(n=96)和死亡组(n=54)。比较两组患者在临床特征方面的差异。绘制ROC曲线,计算曲线下面积评估各参数的预测效力。应用单因素、多因素非条件Cox回归分析预测SAH后DCI患者预后的危险因素。采用Kaplan-Meier法绘制累积生存曲线,采用Log-Rank法比较生存率差异。结果 150例患者术后5年96例(64%)存活,54例(36%)死亡。单因素、多因素Cox回归分析结果显示,脑血流量(CBF)15.82ml/100g/min、PAASH分级≥4级、Fisher分级≥III级不利于患者预后(P0.05)。随访5年后,CBF15.82 ml/100 g/min的患者累积生存率为18%(9/50),显著低于CBF≥15.82 ml/100 g/min患者的累积生存率45%(45/100)(P0.05)。结论入院时CBF可作为预测SAH后DCI患者预后的重要指标。     

Quantitative continuous EEG for detecting delayed cerebral ischemia in patients with poor-grade subarachnoid hemorrhage

OBJECTIVE: Delayed cerebral ischemia (DCI) due to vasospasm is often undetected by clinical exam in patients with poor-grade subarachnoid hemorrhage (SAH). The purpose of this study was to identify quantitative EEG (qEEG) parameters that are most sensitive and specific for the detection of DCI in stuporous or comatose SAH patients. METHODS: Of 78 consecutive Hunt-Hess grade 4 or 5 SAH patients admitted to our Neuro-ICU over a 2-year period, 48 were eligible for participation and 34 were enrolled. Continuous EEG monitoring was performed from post-operative day 2 to post-SAH day 14. In each patient, 20 artifact-free, 1 min EEG-clips following an alerting stimulus were analyzed: 10 clips were obtained on monitoring day 1 (baseline), and 10 on days 4-6 (follow-up). In DCI patients, follow-up clips were obtained after the onset of deterioration and before infarction had occurred. Twelve qEEG parameters were calculated using fast Fourier transformation; generalized estimating equations were used to compare ratios of change in qEEG parameters in patients with and without DCI. RESULTS: Nine of 34 patients (26%) developed DCI. The alpha/delta ratio (alpha power/delta power; ADR) demonstrated the strongest association with DCI. The median decrease of ADR for patients with DCI was 24%, compared to an increase of 3% for patients without DCI (Z=4.0, P<0.0001). Clinically useful cut-offs included 6 consecutive recordings with a >10% decrease in ADR from baseline (sensitivity 100%, specificity 76%) and any single measurement with a >50% decrease (sensitivity 89%, specificity 84%). CONCLUSIONS: A decrease in the ADR may be a sensitive method of detecting DCI, with reasonable specificity. This post-stimulation qEEG parameter may supplement the clinical exam in poor-grade SAH patients and may prove useful for the detection of DCI. SIGNIFICANCE: Following ADRs may allow earlier detection of DCI and initiation of interventions at a reversible stage, thus preventing infarction and neurological morbidity.     

CT灌注成像预测及诊断蛛网膜下腔出血后迟发性脑缺血的Meta分析

目的 系统评价CT灌注成像（CTP）对蛛网膜下腔出血（SAH）后迟发性脑缺血（DCI）的诊断及预测价值。方法 计算机检索PubMed、Cochrane Database、Embase、CNKI及中国生物医学文献库中有关CTP与DCI关系的研究。使用Rev Man 5.3软件进行Meta分析。结果 共纳入10篇文献,包括519例SAH。Meta分析结果显示,SAH早期CTP的CBF、CBV、MTT、TTP与DCI无明显相关性（P>0.05）。高发时间窗内CTP的CBF降低、MTT增高与DCI有关（P<0.05）,而CBV、TTP与DCI无显著相关性（P>0.05）。对DCI的诊断界值,CBF在25~36.3 ml/100g/min范围内变化,而MTT则在5.0~6.5 s范围内变化。结论 CTP可用于诊断而不能用于早期预测SAH后DCI,但仍需标准化CTP测量方法及确定DCI的最佳诊断界值。     

Epileptiform abnormalities predict delayed cerebral ischemia in subarachnoid hemorrhage

Objective

To identify whether abnormal neural activity, in the form of epileptiform discharges and rhythmic or periodic activity, which we term here ictal-interictal continuum abnormalities (IICAs), are associated with delayed cerebral ischemia (DCI).

Amount of blood during the subacute phase and clot clearance rate as prognostic factors for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) is a poorly predictable complication occurring after aneurysmal subarachnoid hemorrhage (SAH) that can have dramatic functional consequences. Identifying the patients with the highest risk of DCI may help to institute more suitable monitoring and therapy. Early brain injuries and aneurysm-securing procedure complications could be regarded as confounding factors leading to severity misjudgment. After an early resuscitation phase, a subacute assessment may be more relevant to integrate the intrinsic SAH severity.A retrospective analysis was performed upon patients prospectively included in the registry of SAH patients between July 2015 to April 2020. The amount of cisternal and intraventricular blood were assessed semi-quantitatively on acute and subacute CT scans performed after early resuscitation. A clot clearance rate was calculated from their comparison. The primary endpoint was the occurrence of a DCI.A total of 349 patients were included in the study; 80 (22.9%) experienced DCI. In those patients, higher Fisher grades were observed on acute (p = 0.026) and subacute (p = 0.003) CT scans. On the subacute CT scan, patients who experienced DCI had a higher amount of blood, either at the cisternal (median Hijdra sum score: 11 vs 5, p < 0.001) or intraventricular (median Graeb score: 4 vs 2, p < 0.001) level. There was a negative linear relationship between the cisternal clot clearance rate and the risk of DCI.The assessment of the amount of subarachnoid blood and clot clearance following resuscitation after aneurysmal SAH can be useful for the prediction of neurological outcome.     

Temporal profile of plasma adiponectin level and delayed cerebral ischemia in patients with subarachnoid hemorrhage

Adiponectin affects nitric oxide production, and low plasma adiponectin levels are associated with impaired endothelium-dependent vasorelaxation. However, adiponectin pathophysiology in the acute phase after stroke, especially subarachnoid hemorrhage, is not well understood. The present study evaluated the changes in plasma adiponectin concentrations in patients with subarachnoid hemorrhage and investigated the relationship between plasma adiponectin and delayed cerebral ischemia. Serial plasma samples from 27 patients with subarachnoid hemorrhage were obtained on day 0 or 1 after hemorrhage, and days 3, 7, 10, 14, and 21. As a control, plasma samples were obtained from 26 healthy volunteers. Differences between patients with and without delayed cerebral ischemia were assessed to investigate the relationship between plasma adiponectin concentrations and the occurrence of delayed cerebral ischemia. There were no significant differences in the clinical characteristics of patients with and without delayed cerebral ischemia. The plasma adiponectin concentrations were significantly lower in patients on days 3 and 7 compared with controls. Plasma adiponectin concentrations in patients with delayed cerebral ischemia were significantly lower than in those without delayed cerebral ischemia on days 3, 7, 10, and 14. The present results indicate that low plasma adiponectin concentrations from day 3 to day 14 might be associated with the development of delayed cerebral ischemia.     

钙拮抗剂防治蛛网膜下腔出血后的迟发性脑血管痉挛的观察

目的 :观察钙拮抗剂对蛛网膜下腔出血后迟发性脑血管痉挛 (DCVS)的疗效。方法 :对 66例蛛网膜下腔出血 (SAH)患者将其分为钙拮抗剂治疗组 ( 32例 )和常规治疗对照组 ( 34例 )。结果 :32例治疗组中发生DCVS的 5例 ,34例对照组中发生DCVS2 1例 (P <0 0 5) ;死亡人数治疗组 4例 ,对照组 7例 ,无显著差异 (P >0 0 5)。结论 :钙拮抗剂在DCVS的防治中有显著疗效。