1例动脉瘤性蛛网膜下腔出血患者的循证治疗

目的结合1例典型动脉瘤性蛛网膜下腔出血(aSAH)患者的循证治疗经过,总结评价治疗aSAH的最佳证据,为临床实践提供参考。方法根据所提出的如何预防并发症及处理破裂动脉瘤的问题,全面检索Cochrane图书馆(2006年第4期)、OVID ACP Journal Club(1991～2006)、OVID MEDLINE (1966～2006)、美国国家指南交换中心(1998～2006)及中国生物医学文献数据库(1978～2006),获取并评价相关的系统评价、随机对照试验、临床对照试验证据及治疗指南。结果共纳入7篇系统评价、3篇RCT、1篇CCT和5篇临床指南。当前证据表明,口服尼莫地平可有效预防脑血管痉挛相关的不良结局,而替拉扎特对分级较好的女性患者无效,其他预防措施效果尚不明确；是否应用抗纤溶剂预防再出血,各证据间存在异议；破裂动脉瘤若同时适合手术夹闭或介入治疗,选择后者临床结局更佳。参照证据和指南,并结合患者情况和意愿,我们对该例患者实施尼莫地平和抗纤溶剂治疗,并对动脉瘤行早期介入栓塞。住院期间患者未发生脑血管痉挛缺血和早期再出血,短期随访示临床转归良好,介入治疗的远期效益尚待后续随访证实。结论为有效预防并发症发生和改善预后,应基于最佳临床证据和指南对aSAH患者实施治疗。

Evidence-Based Treatment for a Patient with Aneurysmal Subarachnoid Hemorrhage

Objective To identify an evidence- based treatment for a patient with aneurysmal subarachnoid hemorrhage (aSAH).Methods We first put forward clinical problems about how to prevent complications and how to treat ruptured aneurysm of aSAH,then searched The Cochrane Library (Issue 4,2006),Ovid ACP Journal Club (1991 to 2006),Ovid MEDLINE (1966 to 2006),NGC (1998 to 2006) and CBM (1978 to 2006) to identify systematic reviews, randomized controlled trials,controlled clinical trials and treatment guidelines.Results Eleven studies and five guidelines were included.Current evidence indicated that nimodipine was effective for prophylaxis of poor outcome after vasospasm,while tirilazad was not effective in female patients with good grades.The effectiveness of other preventive treatments was not clear.Evidence on the use of antifibrinolytics for the prevention of re-bleeding was inconsistent.If a ruptured aneurysm was considered suitable for both surgical clipping and endovascular treatment,coiling was associated with a better outcome.According to the available evidence and guidelines,we administered considering the patient's conditions and preferences,nimodipine and antifibrinolytics to prevent complications and her aneurysm was treated by early endovascular embolization.Vasospasm and re-bleeding did not happen during her hospital stay.Short-term follow- up showed a good outcome.Long-term prognostic benefits after endovascular therapy need to be confirmed by subsequent follow-ups.Conclusions Therapies based on the best clinical evidence and guidelines should be given to effectively prevent complications and improve outcome of aSAH.