高渗氯化钠羟乙基淀粉溶液对脑动脉瘤出血介入术后脑血管痉挛的影响及机制

目的 探讨术中及术后输注高渗氯化钠羟乙基淀粉溶液(hypertonic sodium chloride hydroxyethyl starch solution,HSH)对脑动脉瘤破裂出血介入术后脑血管痉挛(cerebral vasospasm,CVS)的影响及其机制. 方法 发病后3d内拟行颅内动脉瘤介入栓塞术的动脉瘤破裂蛛网膜下腔出血(aneurysm subarachnoid hemorrhage,aSAH)患者30例.ASA分级Ⅱ、Ⅲ级,Hunt和Hess(原发性蛛网膜下腔出血的临床状态)分级Ⅱ、Ⅲ级,改良Fisher分级1、2级,格拉斯哥昏迷评分(Glasgow ComaScale,GCS) 13～15分,年龄18～80岁.按随机数字表法分为两组(每组15例):实验组(H组),输注4.2％ HSH 4 ml/kg;对照组(N组),输注等量生理盐水.两组均于术前(T0),输注HSH或生理盐水结束时(T1),手术结束时(T9及术后第1天(T3)、第2天(T4)、第3天(T5)、第4天(T6)、第5天(T7)的上午8点,分别记录MAP、CVP、血浆渗透压(plasma osmotic pressure,POP)、HR、Na+、K+、C1-等数值;采用经颅多普勒超声(transcranial doppler,TCD)监测T0及T3～T7时右侧大脑中动脉血流速度,ELISA检测上述时间点血浆中IL-6、TNF-α、内皮素-1(endothelin-1,ET-1)及一氧化氮(nitric oxide,NO)等因子浓度,同时记录患者GCS得分、神经功能缺损评分(china stroke scale,CSS)及24 h出入量. 结果 H组CVP在T1～T7时分别高于N组(P＜0.05);POP在T2～T7时高于N组(P＜0.05).两组患者大脑中动脉血流速度术后呈上升趋势,H组患者在T5～T7时低于N组(P＜0.05);H组患者在T7时血浆IL-6、TNF-α浓度低于N组(P＜0.05);T5～T7时,H组ET-1浓度低于N组(P＜0.05);T4～T7时,H组NO浓度高于N组(P＜0.05);上述指标其他时间点及两组间GCS得分、CSS评分、24h出入量比较,差异无统计学意义(P＞0.05). 结论 脑动脉瘤破裂出血患者围手术期小量输注HSH能有效减轻脑血管介入手术后CVS发生程度,其机制可能与抑制炎症介质及血管舒缩因子平衡紊乱有关.

Effects of hypertonic sodium chloride hydroxyethyl starch solution on cerebral vasospasm in patients with ruptured aneurysm undergoing interventional embolization surgery

Objective To investigate the protective effect and potential mechanisms of hypertonic sodium chloride hydroxyethyl starch solution (HSH) on cerebral vasospasm (CVS) in patients with ruptured aneurysm undergoing interventional embolization surgery.Methods Thirty aSAH patients with Ⅱ or Ⅲ level of ASA and Hunt/Hess,1 or 2 grade of improvement Fisher,13-15 score of GCS,18-80 years of age and undergoing interventional embolization surgery were randomly divided into 2 groups(n=15):group H and group N.For group H,patients received 4.2％ HSH(4 ml/kg).For group N,patients received normal saline (4 ml/kg).Than,the MAP,CVP,plasma osmotic pressure (POP),HR,Na+,K+,Cl-were recorded at 8 AM of different day time points:preoperative induction (To),the end of intravenous infusion of HSH or normal saline(T1),the end of surgery(T2),1st day after operation (T3),2nd day after operation (T4),3rd day after operation (T5),4th day after operation (T6),5th day after operation (T7).Right middle cerebral artery blood flow velocity was monitored with transcranial doppler (TCD) at T3-T7.The plasma IL-6,TNF-α,endothelin-1 (ET-1) and nitric oxide(NO) productions were measured by ELlSA,and glasgow coma scale(GCS),china stroke scale(CSS) and 24 h of fluid therapy were recorded at T3-T7.Results Compared with group N,CVP in group H was significantly higher than that in group N at T1-T7(P＜0.05).POP in group H were significantly higher than that in group N at T2-T7(P＜0.05).The middle cerebral artery blood velocity in two groups were on the rise,but it in group H was significantly lower than that in group N at T5-T7 (P＜0.05).Plasma IL-6 and TNF-α levels in group H were significantly higher than those in group N (P＜0.05) at T7,and plasma ET-1 level in group H was significantly higher than that in group N (P＜0.05) at T5-T7,however,plasma NO level in group H was significantly lower than that in group N at T4-T7 (P＜0.05).There was no significant difference in GCS,CSS and 24 h of fluid therapy (P＞0.05).Conclusions Intravenous infusion of HSH could effectively attenuate cerebral vasospasm in patients with aSAH undergoing interventional embolization surgery,which may be through inhibiting inflammation and breaking the imbalance of ET-1 and NO.