Kobata Hitoshi, Sugie Akira, Yoritsune Erina, Miyata Tomo, Toho Taichiro
Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan ; 11-1 Minamiakutagawacho, Takatsuki, Osaka, 569-1124 Japan.
Springerplus. 2013 Aug 28;2(1):413. doi: 10.1186/2193-1801-2-413. eCollection 2013.
Three-dimensional CT angiography (3D-CTA) is increasingly used in the initial evaluation of subarachnoid hemorrhage (SAH). However, there is a risk of aneurysm re-rupture in the hyperacute phase. We sought to clarify the incidence of re-rupture and characterize the subgroup in which extravasation of contrast media was seen on 3D-CTA.
We examined the records of 356 consecutive patients presenting to our institution with non-traumatic SAH between October 2003 and December 2011. After resuscitation, patients with poor grade SAH underwent CT then 3D-CTA while sedated, mechanically ventilated and with a target systolic blood pressure of 120 mmHg.
336 patients underwent 3D-CTA; 20 died without return of spontaneous circulation. Extravasated contrast medium was seen in 16 (4.8%), 15 (4.5%) at the initial evaluation. Their World Federation of Neurosurgical Societies Grade was V; one patient was resuscitated from cardiac arrest. The mean times from onset to arrival and to CTA were 43.7 minutes and 71.8 minutes, respectively. Ten patients (62.5%) had episodes suggestive of aneurysm re-rupture before 3D-CTA. Surgical clipping, evacuation of hematoma and wide decompressive craniectomy was completed in six patients and one underwent coil embolization. Two of 16 patients survived: one with moderate disability and one made a good recovery.
Contrast extravasation was detected by 3D-CTA in 4.5% of cases despite intensive resuscitation, suggesting that continuous or intermittent rebleeding may occur frequently in the hyperacute phase. The consequences of rebleeding are devastating; however, favorable results can be obtained with immediate aneurysm repair with decompression and intensive neurocritical care.
三维CT血管造影（3D - CTA）在蛛网膜下腔出血（SAH）的初始评估中应用越来越广泛。然而，在超急性期存在动脉瘤再次破裂的风险。我们旨在明确再次破裂的发生率，并对在3D - CTA上可见造影剂外渗的亚组进行特征描述。
我们检查了2003年10月至2011年12月期间连续356例因非创伤性SAH就诊于我院的患者记录。复苏后，病情分级较差的SAH患者在镇静、机械通气且目标收缩压为120 mmHg的情况下接受CT检查，随后进行3D - CTA检查。
336例患者接受了3D - CTA检查；20例患者未恢复自主循环而死亡。在初始评估时，16例（4.8%）可见造影剂外渗，其中15例（4.5%）。他们的世界神经外科协会分级为V级；1例患者心脏骤停后复苏成功。从发病到入院以及到CTA检查的平均时间分别为43.7分钟和71.8分钟。10例患者（62.5%）在3D - CTA检查前有提示动脉瘤再次破裂的发作。6例患者完成了手术夹闭、血肿清除和广泛减压颅骨切除术，1例接受了弹簧圈栓塞。16例患者中有2例存活：1例有中度残疾，1例恢复良好。
尽管进行了强化复苏，但3D - CTA仍在4.5%的病例中检测到造影剂外渗，这表明在超急性期可能频繁发生持续性或间歇性再出血。再出血的后果是毁灭性的；然而，通过立即进行动脉瘤修复、减压和强化神经重症监护可获得良好结果。
