Inamasu Joji, Ganaha Tsukasa, Nakae Shunsuke, Ohmi Tatsuo, Wakako Akira, Tanaka Riki, Kuwahara Kiyonori, Kogame Hirotaka, Kawazoe Yushi, Kumai Tadashi, Hayakawa Motoharu, Hirose Yuichi
Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake, 470-1192, Japan.
Acta Neurochir (Wien). 2016 May;158(5):885-93. doi: 10.1007/s00701-016-2768-6. Epub 2016 Mar 10.
There are no guidelines regarding the optimal treatment of subarachnoid hemorrhage (SAH) patients complicated by Takotsubo cardiomyopathy (TCM). Although coiling has been favored as the first-line treatment, clipping may also be indicated in patients with ruptured middle cerebral artery aneurysms or in those with massive intracerebral hemorrhage. The study objective is (1) to report the feasibility/safety of clipping/coiling and (2) to identify possible prognosticators in that population.
Between January 2008 and December 2014, 371 consecutive patients with aneurysmal SAH underwent transthoracic echocardiography after admission, and 30 with TCM (7.7 %) were identified. We reviewed the incidence and type of perioperative complications among clipped (n = 11) and coiled (n = 19) patients. The 30 patients were dichotomized based on their 90-day modified Rankin scale (mRS) scores into favorable (mRS: 0-2) and unfavorable (mRS: 3-6) groups, and their demographic, laboratory and echocardiographic variables were compared.
Neither clipped nor coiled patients developed serious perioperative cardiopulmonary complications, but coiled patients had a higher incidence of fatal procedure-related complications. Among the 30 patients, 13 (43 %) had favorable 90-day outcomes, and the favorable group was significantly younger. Age, but not the degree of cardiac dysfunction, correlated with outcomes by multivariate regression analysis.
Clipping was shown to be a safe treatment modality in our cohort, and treatment selection may better be made on a case-by-case basis in most patients with SAH-induced TCM. The lack of correlation between the degree of cardiac dysfunction and outcomes indicates that aggressive intervention is justified in patients with severely impaired cardiac function.
对于合并应激性心肌病（TCM）的蛛网膜下腔出血（SAH）患者，尚无关于最佳治疗的指南。尽管血管内栓塞术一直被视为一线治疗方法，但对于大脑中动脉动脉瘤破裂患者或大量脑出血患者，也可能需要进行开颅夹闭术。本研究的目的是：（1）报告开颅夹闭术/血管内栓塞术的可行性/安全性；（2）确定该人群中可能的预后因素。
2008年1月至2014年12月期间，371例连续的动脉瘤性SAH患者在入院后接受了经胸超声心动图检查，其中30例（7.7%）被诊断为TCM。我们回顾了接受开颅夹闭术（n = 11）和血管内栓塞术（n = 19）患者围手术期并发症的发生率和类型。根据90天改良Rankin量表（mRS）评分，将30例患者分为预后良好组（mRS：0 - 2）和预后不良组（mRS：3 - 6），并比较两组患者的人口统计学、实验室检查和超声心动图变量。
接受开颅夹闭术和血管内栓塞术的患者均未发生严重的围手术期心肺并发症，但血管内栓塞术患者发生致命性手术相关并发症的发生率更高。在30例患者中，13例（43%）90天预后良好，预后良好组患者明显更年轻。多因素回归分析显示，年龄与预后相关，而心脏功能障碍程度与预后无关。
在我们的队列研究中，开颅夹闭术是一种安全的治疗方式，对于大多数SAH合并TCM的患者，治疗选择最好根据具体情况进行。心脏功能障碍程度与预后缺乏相关性，这表明对于心脏功能严重受损的患者，积极干预是合理的。
