McLaughlin Nancy, Bojanowski Michel W
Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montreal, Hôpital Notre-Dame, Montreal, Quebec, Canada.
Can J Neurol Sci. 2006 May;33(2):181-8.
The timing of aneurysmal surgery for patients presenting within the period at risk for vasospasm (VS) is controversial. The goal of this study is to review our experience of surgically treated patients in the presence of angiographic VS.
From 1990-2004, 894 consecutive patients presented with an aneurysmal subarachnoid hemorrhage (SAH) and were treated with a policy of early surgery. We retrospectively analyzed the patients that had pre-operative angiographic VS. In this study, symptomatic VS was diagnosed when a decreased level of consciousness and/or focal deficit occurred after SAH in the presence of angiographic VS without confounding factors. Functional outcome was assessed three months after SAH using the Glasgow Outcome Scale.
Of the 40 patients studied, 62.5% were in good clinical grade Hunt & Hess (H&H 1-2) on admission; 25%, intermediate grade (H&H 3); 12.5%, poor grade (H&H 4-5). Surgery was performed 24 hours or less after initial angiography in 87.5% of patients and less than 48 hours in 97.5%. Pre-operative symptomatic VS was diagnosed in 25%. Post-operatively, angiographic VS was documented in 87.2%. Of the 30% of patients that presented post-operative symptomatic VS, 66.7% also demonstrated pre-operative symptomatic VS. The functional outcome was favorable in 92.5% of the studied patients. Two deaths occurred in patients presenting pre-operative early radiological and symptomatic VS.
Aneurysmal surgery, especially between 3-12 days following SAH, in the presence of asymptomatic pre-operative angiographic VS can be associated with a good outcome. Early surgery is not contra-indicated and might enable optimal treatment of VS.
对于在血管痉挛（VS）风险期内就诊的动脉瘤患者，动脉瘤手术的时机存在争议。本研究的目的是回顾我们在存在血管造影证实的VS情况下手术治疗患者的经验。
1990年至2004年，894例连续的动脉瘤性蛛网膜下腔出血（SAH）患者接受了早期手术治疗。我们回顾性分析了术前血管造影显示VS的患者。在本研究中，当SAH后在存在血管造影VS且无混杂因素的情况下出现意识水平下降和/或局灶性神经功能缺损时，诊断为症状性VS。使用格拉斯哥预后量表在SAH后三个月评估功能结局。
在研究的40例患者中，62.5%入院时临床分级良好（Hunt & Hess 1 - 2级）；25%为中度分级（Hunt & Hess 3级）；12.5%为重度分级（Hunt & Hess 4 - 5级）。87.5%的患者在首次血管造影后24小时或更短时间内进行了手术，97.5%的患者在48小时内进行了手术。术前症状性VS的诊断率为25%。术后，血管造影显示VS的记录率为87.2%。在出现术后症状性VS的患者中，66.7%术前也有症状性VS。92.5%的研究患者功能结局良好。术前出现早期影像学和症状性VS的患者中有2例死亡。
在存在术前无症状性血管造影VS的情况下，动脉瘤手术，尤其是在SAH后3 - 12天之间进行，可能会有良好的结局。早期手术并非禁忌，可能有助于对VS进行最佳治疗。
