Mikeladze K G, Okishev D N, Belousova O B, Konovalov An N, Pilipenko Yu V, Kheireddin A S, Ageev I S, Shekhtman O D, Kurdyumova N V, Tabasaranskiy T F, Okisheva E A, Eliava Sh Sh, Yakovlev S B
Burdenko Neurosurgical Institute, Moscow, Russia.
Burdenko Neurosurgical Institute, Moscow, Russia, Sechenov First Moscow State Medical University, Moscow, Russia.
Zh Vopr Neirokhir Im N N Burdenko. 2018;82(4):23-31. doi: 10.17116/neiro201882423.
The study purpose was to analyze the efficacy of intra-arterial administration of verapamil (IAV) in the treatment of angiospasm in SAH patients and to determine optimal parameters of the procedure. A number of studies demonstrated the efficacy of intra-arterial administration of vasodilators, in particular verapamil, in the treatment of angiospasm after aneurysmal SAH, which served the basis for inclusion of this method in the recommended protocol for treatment of SAH patients [1-7].
We analyzed the efficacy of IAV in 35 patients in the acute period of SAH, with 77.2% of the patients having a Hunt-Hess score of III-V. The inclusion criteria were as follows: IAV within two weeks after SAH; excluded aneurysm; verapamil dose per administration of at least 15 mg; follow-up for at least three months. Efficacy endpoints were as follows: changes in spasm according to angiography and transcranial dopplerography (TCDG); development of ischemic lesions; clinical outcome according to the modified Rankin scale.
A total of 76 IAV procedures were performed. The verapamil dose per procedure was 36.7±9.7 mg, on average; the number of procedures varied from 1 to 5. One arterial territory was treated in 12 cases, two arterial territories were treated in 48 cases, and three arterial territories were treated in 15 cases. Typical adverse reactions included decreased blood pressure, a reduced heart rate, and elevated ICP. In all cases, TCDG revealed signs of reduced angiospasm - a 20-40% decrease in the LBFV in the M1 MCA. Four (11.4%) patients died; of these, only one died due to angiospasm progression. On examination at 3 months or more after discharge, favorable outcomes were observed in 74.3% of cases.
IAV is associated with a low risk of significant complications. IAV should be performed under control of systemic hemodynamics and ICP. The indications for IAV include signs of moderate worsening or severe angiospasm according to TCDG and/or angiography. The IAV procedure may be performed every day. Further clarification of the IAV procedure and evaluation of clinical outcomes under prospective study conditions are required.
本研究旨在分析维拉帕米动脉内给药（IAV）治疗蛛网膜下腔出血（SAH）患者血管痉挛的疗效，并确定该治疗方法的最佳参数。多项研究表明，血管扩张剂尤其是维拉帕米动脉内给药在治疗动脉瘤性SAH后血管痉挛方面具有疗效，这为将该方法纳入SAH患者推荐治疗方案奠定了基础[1 - 7]。
我们分析了35例SAH急性期患者IAV的疗效，其中77.2%的患者Hunt - Hess分级为III - V级。纳入标准如下：SAH后两周内进行IAV；排除动脉瘤；每次维拉帕米给药剂量至少15 mg；随访至少三个月。疗效终点如下：根据血管造影和经颅多普勒超声（TCDG）评估痉挛变化；缺血性病变的发生；根据改良Rankin量表评估临床结局。
共进行了76次IAV治疗。每次治疗维拉帕米平均剂量为36.7±9.7 mg；治疗次数从1次到5次不等。12例患者治疗一个动脉区域，48例患者治疗两个动脉区域，15例患者治疗三个动脉区域。典型不良反应包括血压下降、心率降低和颅内压升高。所有病例中，TCDG均显示血管痉挛减轻迹象——大脑中动脉M1段局部脑血流速度（LBFV）下降20% - 40%。4例（11.4%）患者死亡；其中仅1例死于血管痉挛进展。出院后3个月或更长时间检查时，74.3%的病例观察到良好结局。
IAV发生严重并发症的风险较低。IAV应在全身血流动力学和颅内压监测下进行。IAV的适应证包括根据TCDG和/或血管造影显示的中度病情恶化或严重血管痉挛迹象。IAV治疗可每天进行。需要在前瞻性研究条件下进一步明确IAV治疗方法并评估临床结局。
