Seule Martin A, Muroi Carl, Mink Susanne, Yonekawa Yasuhiro, Keller Emanuela
Neurointensive Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.
Neurosurgery. 2009 Jan;64(1):86-92; discussion 92-3. doi: 10.1227/01.NEU.0000336312.32773.A0.
To evaluate the feasibility and safety of mild hypothermia treatment in patients with aneurysmal subarachnoid hemorrhage (SAH) who are experiencing intracranial hypertension and/or cerebral vasospasm (CVS).
Of 441 consecutive patients with SAH, 100 developed elevated intracranial pressure and/or symptomatic CVS refractory to conventional treatment. Hypothermia (33-34 degrees C) was induced and maintained until intracranial pressure normalized, CVS resolved, or severe side effects occurred.
Thirteen patients were treated with hypothermia alone, and 87 were treated with hypothermia in combination with barbiturate coma. Sixty-six patients experienced poor-grade SAH (Hunt and Hess Grades IV and V) and 92 had Fisher Grade 3 and 4 bleedings. The mean duration of hypothermia was 169 +/- 104 hours, with a maximum of 16.4 days. The outcome after 1 year was evaluated in 90 of 100 patients. Thirty-two patients (35.6%) survived with good functional outcome (Glasgow Outcome Scale [GOS] score, 4 and 5), 14 (15.5%) were severely disabled (GOS score, 3), 1 (1.1%) was in a vegetative state (GOS score, 2), and 43 (47.8%) died (GOS score, 1). The most frequent side effects were electrolyte disorders (77%), pneumonia (52%), thrombocytopenia (47%), and septic shock syndrome (40%). Of 93 patients with severe side effects, 6 (6.5%) died as a result of respiratory or multi-organ failure.
Prolonged systemic hypothermia may be considered as a last-resort option for a carefully selected group of SAH patients with intracranial hypertension or CVS resistant to conventional treatment. However, complications associated with hypothermia require elaborate protocols in general intensive care unit management.
评估亚低温治疗对颅内压升高和/或出现脑血管痉挛（CVS）的动脉瘤性蛛网膜下腔出血（SAH）患者的可行性及安全性。
在441例连续性SAH患者中，100例出现颅内压升高和/或对传统治疗无效的症状性CVS。诱导并维持体温在33 - 34摄氏度，直至颅内压恢复正常、CVS缓解或出现严重副作用。
13例患者仅接受亚低温治疗，87例患者接受亚低温联合巴比妥类药物昏迷治疗。66例患者为Hunt和Hess分级IV级和V级的严重SAH，92例患者为Fisher分级3级和4级出血。亚低温的平均持续时间为169±104小时，最长为16.4天。100例患者中的90例在1年后进行了预后评估。32例患者（35.6%）存活且功能预后良好（格拉斯哥预后评分[GOS]为4分和5分），14例（15.5%）严重残疾（GOS评分3分），1例（1.1%）处于植物状态（GOS评分2分），43例（47.8%）死亡（GOS评分1分）。最常见的副作用为电解质紊乱（77%）、肺炎（52%）、血小板减少（47%）和感染性休克综合征（40%）。93例出现严重副作用的患者中，6例（6.5%）因呼吸或多器官衰竭死亡。
对于精心挑选的、颅内压升高或对传统治疗耐药的CVS的SAH患者，延长全身亚低温治疗可被视为一种最后的选择。然而，在综合重症监护病房管理中，与亚低温相关的并发症需要精心制定方案。
