超选择动脉内灌注及血管成形术治疗脑血管痉挛

目的探讨早期超选择动脉内灌注及血管成形术 (PTA)治疗脑血管痉挛 (CVS)的效果。方法对 6例动脉近端狭窄段进行球囊扩张 ,对 3 8例大脑中动脉M2 段、大脑前动脉A1和A2 段痉挛者 ,灌注 0 .3 %罂粟碱 3 0 0～ 40 0ml,观察全脑血管造影和评价神经功能状态。结果复查全脑血管造影见痉挛血管全部有改善 ,术后 48小时临床状态和神经功能状态均得到改善 ,无死亡。术后 3月随访 ,恢复良好 2 7例 ,中度致残、生活能自理 11例。结论对于近端、局限性CVS宜采用PTA ,而对于远端、弥漫性CVS需采用超选择脑动脉内灌注罂栗碱治疗     

经颅多普勒监测脑外伤后脑血管痉挛

目的探讨经颅多普勒(TCD)监测脑外伤患者脑血管痉挛(CVS)对护理观察的临床意义。方法对95例颅脑外伤患者进行动态TCD检查,并结合患者GCS评分、蛛网膜下腔出血量(t-SAH)量的多少对其结果进行统计评价。结果TCD检查结果与GCS评分、t-SAH量的多少相关,并与脑血管痉挛(CVS)的发展相一致,常在伤后1~3 d开始出现,3~7 d达高峰,2周后渐减轻。大脑中动脉平均血流速度(VMCA)180 cm/s或VMCA45 cm/s者预后差。患者症状、体征改变与CVS变化相一致。结论TCD检查是外伤后CVS动态监测的安全有效的方法,可以指导临床护理观察。     

脑破裂动脉瘤栓塞术后TCD检测脑血管痉挛的 临床价值

目的:分析经颅多普勒(TCD)技术对脑动脉瘤破裂栓塞手术后脑血管痉挛(CVS)的诊断价值。方法:选取颅内动脉瘤患者100例,根据患者术前大脑中动脉(MCA)收缩期峰值流速(PSV)值分为低流速组69例(PSV≤120 cm/s)和高流速组31例(PSV120 cm/s),对比2组于栓塞术后10 d内的MCA血流速度及CVS发生率;所有患者同时以临床是否发生CVS作为标准,评估TCD诊断CVS的临床价值。结果:低流速组和高流速组在术前、术后1 d、术后3 d、术后5 d、术后7 d及术后10 d的MCA血流速度测定值比较差异均具有统计学意义(P0.05);术后10 d内,临床确诊CVS患者32例,TCD检查低流速组诊断CVS 4例、高流速组29例,共计诊断33例,其中正确诊断25例、误诊8例、漏诊7例;TCD诊断CVS的灵敏度为78.12%,特异度为88.24%,漏诊率为21.88%,误诊率为11.76%;术后3月,低流速组预后良好89.86%,高流速组预后良好29.03%,低流速组的预后显著优于高流速组患者(P0.01)。结论:TCD技术在脑动脉瘤破裂栓塞手术后诊断CVS具有较高的灵敏度和特异度,同时术前根据TCD结果可以对患者的预后进行初步评估。     

支架成形术对大脑中动脉狭窄患者短期血液动力学的影响

目的 应用经颅多普勒超声(TCD)观察症状性大脑中动脉(MCA)狭窄患者支架成形术后短期内的血液动力学变化.方法 对标准的抗血小板治疗期间仍有症状发作的29例MCA中重度狭窄患者31条MCA实施支架成形术,应用TCD系统评价术前、术后1 h及3 d内的MCA狭窄段及狭窄下游段的血液动力学变化.结果 血管造影显示支架成形术后MCA的残余狭窄率均＜20%.与术前相比,术后1h及3 d的收缩期峰值血流速度(PSV)明显下降[(162±38)cm/s对(273±77)cm/s,P＜0.01;(168±45)cm/s对(273±77)cm/s,P＜0.01],术后1 h及3 d的PSV差异无统计学意义(P＞0.05).3例患者(3条动脉)术后第3 d TCD发现狭窄段又出现了狭窄样频谱,CT扫描显示2例颅内出血,1例无异常;至少28.6%(8/28)的患者狭窄下游段出现了PSV的成倍增加.对侧MCA支架成形术前后的PSV差异无统计学意义(P＞0.05).结论 支架成形术可明显改善MCA中重度狭窄患者狭窄段及狭窄下游段的血液动力学异常,但存在较高的过度灌注风险.     

经颅多普勒对蛛网膜下腔出血脑血管痉挛状况的评价作用

目的探讨经颅多普勒(TCD)对蛛网膜下腔出血(SAH)后脑血管痉挛(CVS)的评估作用。方法建立兔SAH模型,应用TCD动态观察方法,测定基底动脉峰值变化。结果治疗组第3天峰值(51±8)cm/s,高于治疗前(40±6)cm/s(t=2.463,P<0.05),第5天开始下降犤(46±6)cm/s,第10天接近正常犤(41±9)cm/s犦。对照组第3,14天犤(54±8),(46±6)cm/s犦均高于治疗前(41±8)cm/s,也高于治疗组(t=2.275～2.495,P<0.05)。结论CVS程度与脑损伤相关,TCD对CVS有诊断和判定预后的价值。     

大脑中动脉狭窄血管内支架成形术前后经颅多普勒超声的评价作用

目的探讨大脑中动脉(MCA)狭窄血管内支架成形术前后经颅多普勒超声(TCD)血流动力学的变化。方法通过对26例确诊为MCA狭窄的患者,经药物抗栓治疗期间仍有反复短暂性缺血发作及患者自愿做支架治疗的患者,行MCA血管内支架成形术治疗。应用TCD观察对比术前及术后血流动力学变化。结果26例MCA狭窄患者均成功行血管内支架成形术。术前MCA平均血流速度为(184·4±15·57)cm/s,血管内支架成形术后MCA的平均血流速度明显下降为(77·6±7·86)cm/s,差异有统计学意义(P<0·001)。结论TCD显示,血管内支架成形术后可缓解MCA狭窄程度,改善其血流动力学的变化,进而改善脑组织的功能,有利于肢体功能的恢复,从而预防脑卒中的发生。MCA血管内支架成形术后不宜MRA及DSA检查,TCD对诊断颅内血管狭窄及血流动力学变化有较高的特异性。     

28例蛛网膜下腔出血患者经颅多普勒超声检查

目的:应用经颅多普勒超声(TCD)动态观察蛛网膜下腔出血(SAH)后血流变化情况,预测血管痉挛(VSP)的发生.方法:本文应用TCD动态观察28例SAH患者病后4周内大脑中动脉血流速度(FV)变化,与脑CT显示出血量进行比较,同时观察临床体征的变化.结果:SAH后FV异常率为75%(21/28),VSP的发生率为35.7%(10/28),其中60%(6/10)发生于病后8-12天,持续6～18天;两侧FV明显高于对侧(P<0.01);3例出现症状性VSP患者均为出血量较大者,并于症状出现前1～2天FV每天增加30cm/s以上,平均FV为200cm/s.结论:通过TCD检查可以预测SAH后VSP的发生,其发生率为35.7%,多于病后1～2周内发生; 出血量越多,VSP发生可能性越大;FV大于200cm/s或每大增加超过30cm/s.有发生症状性VSP的倾向.     

经颅多普勒监测下过度通气治疗重型颅脑损伤患者的临床研究

目的探讨经颅多普勒（TCD）监测下调整过度通气治疗策略对重症颅脑损伤（sTBI）患者的疗效。 方法将59例sTBI患者分为对照组（30例）和实验组（29例）,对照组采用过度通气治疗,实验组在对照组基础上,根据TCD监测的脑血管痉挛（CVS）程度调整通气治疗策略。监测两组患者治疗前后大脑中动脉（MCA）的平均血流速度（Vm）,并计算治疗前后的平均血流速度变化值（ΔVm）。同时,将两组sTBI患者分为无CVS组（Vm<120 cm/s）、轻度CVS组（120 ≤ Vm<140 cm/s）、中重度CVS组（Vm ≥ 140 cm/s）,对各亚组间的ΔVm进行比较。采用格拉斯哥结局量表（GOS）对两组患者治疗6个月后的疗效进行评估。 结果实验组患者ΔVm显著高于对照组患者[22.0（13.0,39.5）cm/s vs. 10.0（7.0,26.3）cm/s,H = 2.527,P = 0.012]。对照组和实验组不同CVS程度患者间ΔVm比较,差异有统计学意义（H = 20.276,P = 0.001）;实验组中,轻度CVS组及中重度CVS组均显著高于无CVS组[23.0（21.5,41.0）、40.0（22.5,52.0）、13.0（9.8,18.0）cm/s],且中重度CVS组更高（P均<0.05）;且对于中重度CVS患者,实验组的ΔVm明显较对照组增加[40.0（22.5,52.0）cm/s vs. 9.0（8.0,31.0）cm/s,P<0.05]。治疗6个月后实验组GOS评分整体优于对照组（u = 2.059,P = 0.045）。 结论根据TCD监测结果调整过度通气治疗策略有利于缓解CVS,改善sTBI患者的疗效。     

经颅多普勒对蛛网膜下腔出血脑血管痉挛状况的评价作用

目的 探讨经颅多普勒(TCD)对蛛网膜下腔出血(SAH)后脑血管痉挛(CVS)的评估作用。方法 建立兔SAH模型。应用TCD动态观察方法。测定基底动脉峰值变化。结果 治疗组第3天峰值(51&;#177;8)cm／s，高于治疗前(40&;#177;6)cm／s(t=2．463，P&;lt;0．05)。第5天开始下降[(46&;#177;6)cm／s，第10天接近正常[(41&;#177;9)cm／s]。对照组第3，14天[(54&;#177;8)，(46&;#177;6)cm／s]均高于治疗前(41&;#177;8)cm／s，也高于治疗组(t=2．275～2．495，P&;lt;0．05)。结论 CVS程度与脑损伤相关。TCD对CVS有诊断和判定预后的价值。     

经颅多普勒超声在大脑中动脉狭窄血管成形术前后及随诊中的应用

目的:探讨经颅多普勒超声(TCD)在观察症状性大脑中动脉(MCA)狭窄支架成形术和介入治疗后的血流动力学改变。方法:回顾性分析接受颅内动脉支架成形术的MCA狭窄病例22例,所有病例治疗前后均行TCD检查,平均随访4.6个月。结果:①术前TCD改变:病变侧大脑中动脉流速显著增高,频谱异常。14例患者病侧大脑前动脉(ACA)流速代偿性增快,6例患者病侧大脑后动脉(PCA)流速代偿性增快。②术后TCD改变:多数患者术后当天及3~14月后TCD示病侧MCA流速出现不同程度的下降,1例术后2天出现血管痉挛。③平均随诊4.6个月,1例术后11月出现支架内再狭窄,TCD与复查的血管造影结果相符。结论:TCD是观察MCA狭窄及介入治疗随访的敏感方法,能准确的评价治疗效果并可用于长期随访。     

Possible overlap between reversible cerebral vasoconstriction syndrome and symptomatic vasospasm after aneurysmal subarachnoid hemorrhage

A 34-year-old woman with a previous history of severe headache (“thunderclap”) was admitted with a diagnosis of aneurysmal subarachnoid hemorrhage (SAH). The patient developed symptomatic vasospasm on day 5 that resolved rapidly after having increased arterial blood pressure. She experienced also short-lasting excruciating headache. On day 12, while velocities had normalised, as revealed by transcranial Doppler (TCD), for more than 48 h, she developed aphasia and right hemiplegia associated with diffuse segmental vasospasm on the left middle cerebral artery. Intra-arterial infusion of vasodilatory agents was required. Recurrence of symptomatic vasospasm was noted on day 25, with a great number of territories involved as shown in the cerebral angiogram. A second intra-arterial treatment was needed. The patient complained of multiple episodes of extremely severe headache (“thunderclap”), with also transient dysarthria and hemiparesia on day 30. She was discharged on day 38 after full recovery. The clinical and TCD/radiological findings were consistent with a reversible cerebral vasoconstriction syndrome overlapping SAH related symptomatic vasospasm.     

颅内动脉瘤破裂的介入治疗时机及继发脑血管痉挛的防治

目的 探讨颅内动脉瘤破裂介入治疗的时机及脑血管痉挛（CVS）的防治方法。方法 采用早期介入栓塞治疗，术中动脉灌注、术后静脉滴注罂粟碱，应用白蛋白、低分子右旋糖酐、小剂量多巴胺以及腰椎穿刺放血性脑脊液等综合措施。结果 CVS的发病率为24．4％。预后良好72．1％，病死率1、2％。结论 早期介入治疗有利于预防颅内动脉瘤再次破裂，综合运用上述措施能较好地防治继发CVS，改善预后。     

Coil herniation following intra-arterial verapamil infusion for the treatment of cerebral vasospasm: Case report and literature review

Complications associated with intra-arterial infusion of vasodilator agents for the treatment of vasospasm associated with a ruptured cerebral aneurysm are extremely rare. We present the case of a patient who developed left lower extremity monoplegia following intra-arterial infusion of verapamil for treatment of diffuse cerebral vasospasm, 6 days after initially undergoing treatment of a ruptured right A1-2 junction aneurysm. A repeat angiogram following this intra-arterial vasodilator treatment demonstrated a coil loop which had herniated into the right A2 artery. Herein, we describe a previously unreported complication which occurred following intra-arterial pharmacologic vasospasm treatment, review the existing literature, and suggest potential causes and treatment options.     

脑底池连续泵输注罂粟碱防治动脉瘤术后血管痉挛

目的探索脑底池连续泵输注罂粟碱对腑动脉瘤破裂早期手术后的血管痉挛的防治作用,以提高手术治疗效果及患者生存质量。方法对13例经头颅CT三维血管成像和全脑血管造影检查诊断为脑动脉瘤破裂伴SAH患者,行早期急诊手术开颅脑动脉瘤颈夹闭,用PCA泵脑底池连续输注罂粟碱,经腰大池引流脑脊液,直至罂粟碱输注治疗结束同时观察脑血管痉挛临床五项指征。结果13例患者输注罂粟碱8d的11例,10d的2例。患者全部存活,术后无脑血管痉挛和不良反应。结论脑底池连续输注罂粟碱防治脑动脉瘤破裂、蛛网膜下腔出血术后血管痉挛,效果确切,安全可行。     

Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage

Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.     

经颅多普勒诊断颅内动脉瘤术后脑血管痉挛

目的探讨经颅多普勒检查在颅内动脉瘤术后脑血管痉挛诊断中的价值。方法采用临床病例分析统计方法,归纳、分析颅内动脉瘤术后患者的经颅多普勒检查资料。结果33例患者中,有15例在术后出现不同程度的脑血管痉挛症状,比较有、无症状患者MCA和eICA流速变化,发现有症状性血管痉挛的患者,MCA血流速度增加值明显大于无症状组。结论经颅多普勒可以在患者出现临床症状以前,早期发现颅内动脉的血流速度增高,指导临床医生及时调整治疗方案,避免造成严重并发症。     

破裂颅内动脉瘤夹闭术后迟发症状性脑血管痉挛危险因素分析

【目的】探讨破裂颅内动脉瘤术后迟发症状性脑血管痉挛的危险因素。【方法】回顾性分析本院2012年9月至2013年10月51例前循环破裂颅内动脉瘤开颅夹闭术患者的临床资料,采用非条件多因素Logistic回归分析夹闭术后迟发症状性脑血管痉挛的危险因素。【结果】患者年龄,Hunt-Hess分级,术中动脉瘤破裂,脑肿胀,慢性贫血,手术时间是其可能的危险因素,术中发现责任血管痉挛是独立危险因素。【结论】提高手术技巧,术中积极降低脑血管痉挛因素,是减少症状性脑血管痉挛的重要措施。     

Accuracy of transcranial Doppler sonography for predicting cerebral infarction in aneurysmal subarachnoid hemorrhage

PURPOSE: To evaluate the accuracy of transcranial Doppler (TCD) sonography using different criteria for predicting cerebral infarction due to symptomatic vasospasm. METHODS: We retrospectively evaluated the clinical and radiologic data of consecutive patients admitted with acute aneurysmal subarachnoid hemorrhage (SAH) in the anterior cerebral circulation between January 2001 and June 2002. TCD sonographic examinations were performed on alternate days up to 20 days after admission. Cerebral infarction was defined on CT as a new hypodensity in the vascular distribution with corresponding clinical symptoms. Vasospasm was diagnosed as mild or severe when TCD sonography revealed a mean blood flow velocity (MBFV) greater than 120 and 180 cm/s in the middle or anterior cerebral artery and in the intracranial part of the internal carotid artery, respectively. RESULTS: A total of 93 patients with aneurysmal SAH in the anterior cerebral circulation were included. Vasospasm was demonstrated by TCD sonography in 60 patients (64.5%) and was shown via multivariable logistic regression analysis to be predictive of cerebral infarction (OR 3.11, 95% CI 1.46-6.59), with an 82.6% and 69.6% sensitivity, a 41.4% and 77.1% specificity, a 31.7% and 50.0% positive predictive value, and an 87.9% and 88.5% negative predictive value when the MBFV was greater than 120 and 180 cm/s, respectively. CONCLUSIONS: Vasospasm on TCD was found to be predictive of symptomatic cerebral infarction on CT, but its positive predictive value remained low despite the adoption of restrictive TCD criteria for vasospasm.     

法舒地尔联合尼莫地平治疗脑动脉瘤栓塞术后脑血管痉挛疗效观察

目的:探讨脑动脉瘤栓塞术后脑血管痉挛临床治疗中联合应用法舒地尔、尼莫地平的效果。方法:以2018年4月至2019年4月本院接收的58例脑动脉瘤栓塞术后发生脑血管痉挛的患者为研究对象,以随机双盲法为参考进行分组,即观察组(29例)、对照组(29例);对照组行尼莫地平治疗,观察组行尼莫地平+法舒地尔治疗,比对两组患者治疗前后的意识状态(GCS)评分、日常生活质量(Barthel)指数、神经功能缺损(NFI)评分以及大脑中动脉平均血流速度(MCA)。结果:两组患者治疗前的观察指标基本一致,即对应数据组间差异统计学意义不成立(P>0.05);治疗后,观察组患者的GCS评分、Barthel指数高于对照组,NFI评分低于对照组,MCA高于对照组,即组间差异有明显的统计学意义存在(P<0.05)。结论:脑动脉瘤栓塞术后脑血管痉挛临床治疗中联合应用法舒地尔、尼莫地平效果较为显著,可以改善患者的临床症状与神经功能,对患者康复有积极作用。