Andereggen L, Beck J, Z'Graggen W J, Schroth G, Andres R H, Murek M, Haenggi M, Reinert M, Raabe A, Gralla J
From the Department of Neurosurgery (L.A., J.B., W.J.Z., R.H.A., M.M., M.R., A.R.).
Institute for Diagnostic and Interventional Neuroradiology (L.A., G.S., J.G.).
AJNR Am J Neuroradiol. 2017 Mar;38(3):561-567. doi: 10.3174/ajnr.A5024. Epub 2016 Dec 15.
For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions.
This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions.
During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions ( = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; = .004).
Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.
对于药物治疗和血流动力学治疗无效的脑血管痉挛患者，血管内治疗往往是最后的手段。关于多种即时血管内干预的疗效和安全性的大型队列研究数据稀少。我们的目的是评估在药物、血流动力学和初始血管内干预均无效的脑血管痉挛患者中进行多次重复即时血管内干预的可行性和安全性。
这是一项单中心回顾性研究，前瞻性收集了动脉瘤性蛛网膜下腔出血患者在治疗过程中需要≥3次血管内干预的难治性脑血管痉挛患者的数据。主要终点是最后一次随访时的功能结局（改良Rankin量表评分≤2分）。次要终点是血管内治疗的血管造影反应和脑梗死的出现。
在4年期间，我院共治疗了365例动脉瘤性蛛网膜下腔出血患者。31例（8.5%）符合纳入标准。52例（14%）患者接受了≤2次血管内干预作为难治性脑血管痉挛的挽救治疗。最后一次随访时，≥3次干预的患者中有18例（58%）预后良好，而≤2次干预的患者中有31例（61%）预后良好（P = 0.82）。初始Hunt和Hess评分≤2分是预后良好的显著独立预测因素（比值比，4.7；95%置信区间，1.2 - 18.5；P = 0.03），而功能区脑梗死与预后不良显著相关（改良Rankin量表评分3 - 6分；比值比，13.5；95%置信区间，2.3 - 81.2；P = 0.004）。
重复即时血管内干预是一种积极但可行的最后治疗策略，对于三分之二难治性脑血管痉挛且已开始血管内治疗的患者具有良好的预后。
