Welty T E, Horner T G
Department of Pharmaceutical Support Services, Methodist Hospital of Indiana, Inc., Indianapolis 46202.
Clin Pharm. 1990 Jan;9(1):35-9.
The pathophysiology and treatment of acute subarachnoid hemorrhage (SAH) are reviewed. SAH occurs when blood is released into the subarachnoid space, which surrounds the brain and spinal cord. Symptoms of SAH include severe headache, nausea, vomiting, neck pain, nuchal rigidity, and photophobia. The initial hemorrhage is fatal in 20-30% of patients. Complications of SAH include rebleeding, hydrocephalus, delayed cerebral ischemia associated with cerebral vasospasm, and seizures. The likelihood of rebleeding is increased by measures that rapidly lower intracranial pressure. The risk of developing hydrocephalus is associated with the volume of blood within the subarachnoid space and ventricular system. Cerebral vasospasm develops in 20-40% of patients, and up to 50% of affected patients die or suffer permanent neurological damage. Seizures occur in 5-15% of patients with SAH. Radiologic procedures form the foundation for the diagnosis of SAH. The most commonly used rating scale classifies the severity of SAH based on the clinical presentation of the patient. Surgery is the definitive treatment for the prevention of rebleeding. Hydrocephalus can only be treated surgically, most commonly by insertion of a drain. The only measures proved to be effective for treatment of delayed cerebral ischemia are volume expansion and the induction of hypertension. The calcium-channel blocker nimodipine was recently approved for treatment of arterial spasm in SAH. Intravenous nicardipine is also being studied for the same indication. These agents may improve clinical outcome substantially by limiting fixed neurological deficits. To prevent seizures, prophylactic antiepileptic therapy with phenytoin sodium is generally accepted. The SAH complications of rebleeding, hydrocephalus, delayed cerebral ischemia, and seizures are managed by surgical, drug, and fluid therapy.
本文综述了急性蛛网膜下腔出血（SAH）的病理生理学及治疗方法。当血液进入围绕脑和脊髓的蛛网膜下腔时，即发生SAH。SAH的症状包括严重头痛、恶心、呕吐、颈部疼痛、颈项强直和畏光。初始出血在20% - 30%的患者中是致命的。SAH的并发症包括再出血、脑积水、与脑血管痉挛相关的迟发性脑缺血和癫痫发作。迅速降低颅内压的措施会增加再出血的可能性。发生脑积水的风险与蛛网膜下腔和脑室系统内的血量有关。20% - 40%的患者会发生脑血管痉挛，高达50%的受影响患者死亡或遭受永久性神经损伤。5% - 15%的SAH患者会发生癫痫发作。放射学检查是SAH诊断的基础。最常用的评分量表根据患者的临床表现对SAH的严重程度进行分类。手术是预防再出血的确定性治疗方法。脑积水只能通过手术治疗，最常见的是插入引流管。已证明对治疗迟发性脑缺血有效的唯一措施是扩容和诱导高血压。钙通道阻滞剂尼莫地平最近被批准用于治疗SAH中的动脉痉挛。静脉注射尼卡地平也正在针对相同适应症进行研究。这些药物可能通过限制固定的神经功能缺损而显著改善临床结局。为预防癫痫发作，通常接受苯妥英钠的预防性抗癫痫治疗。SAH的再出血、脑积水、迟发性脑缺血和癫痫发作等并发症通过手术、药物和液体疗法进行处理。
