多模态区域性脑监测在严重脑静脉窦血栓形成中的组织缺血评估。

Multimodal Regional Brain Monitoring of Tissue Ischemia in Severe Cerebral Venous Sinus Thrombosis.

机构信息

Neurosurgery, Department of Clinical Neurosciences, University Hospital of Lausanne (CHUV), Rue du Bugnon 21, Lausanne, Switzerland.

Department of Intensive Care Medicine, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.

出版信息

Neurocrit Care. 2019 Oct;31(2):297-303. doi: 10.1007/s12028-019-00695-7.

DOI:10.1007/s12028-019-00695-7

PMID:30805844

Abstract

BACKGROUND

Comatose critically ill patients with severe diffuse cerebral venous thrombosis (CVT) are at high risk of secondary hypoxic/ischemic insults, which may considerably worsen neurological recovery. Multimodal brain monitoring (MBM) may therefore improve patient care in this setting, yet no data are available in the literature.

METHODS

We report two patients with coma following severe diffuse CVT who underwent emergent invasive MBM with intracranial pressure (ICP), brain tissue oximetry (PbtO), and cerebral microdialysis (CMD). Therapy of CVT consisted of intravenous unfractionated heparin (UFH), followed by endovascular mechanical thrombectomy (EMT). EMT efficacy was assessed continuously at the bedside using MBM.

RESULTS

Despite effective therapeutic UFH (aPTT two times baseline levels in the two subjects), average CMD levels of lactate and glucose in the 6 h prior to EMT displayed evidence of regional brain ischemia. The EMT procedure was associated with a rapid (within 6 h) improvement in both CMD lactate (6.42 ± 0.61 4.89 ± 0.55 mmol/L, p = 0.02) and glucose (0.49 ± 0.17 vs. 0.96 ± 0.32 mmol/L, p = 0.0005). EMT was also associated with a significant increase in PbtO (22.9 ± 7.5 vs. 30.1 ± 3.6 mmHg, p = 0.0003) and a decrease in CMD glutamate (12.69 ± 1.06 vs. 5.73 ± 1.76 μmol/L, p = 0.017) and intracranial pressure (ICP) (13 ± 4 vs. 11 ± 4 mmHg (p = 004). Patients did not require surgical decompression, regained consciousness, and were discharged from the hospital with a good neurological outcome (modified Rankin score 3 and 4).

CONCLUSIONS

This study illustrates the potential utility of continuous bedside MBM in patients with coma after severe brain injury, irrespective of the primary acute cerebral condition. Despite adequate ICP and PbtO control, the presence of CMD signs of regional brain cell ischemia triggered emergent EMT to treat CVT, which was associated with a significant and clinically relevant improvement of intracerebral physiology.

摘要

背景

患有严重弥漫性脑静脉血栓形成（CVT）的昏迷危重患者存在继发缺氧/缺血损伤的高风险，这可能会极大地恶化神经恢复。因此，多模态脑监测（MBM）可能会改善这种情况下的患者治疗效果，但目前文献中尚无相关数据。

方法

我们报告了两名因严重弥漫性 CVT 导致昏迷的患者，他们接受了紧急有创性 MBM 治疗，包括颅内压（ICP）、脑组织氧饱和度（PbtO）和脑微透析（CMD）。CVT 的治疗包括静脉注射普通肝素（UFH），随后进行血管内机械血栓切除术（EMT）。EMT 效果在床边通过 MBM 进行连续评估。

结果

尽管进行了有效的治疗性 UFH（两名患者的 aPTT 均为基线水平的两倍），但 EMT 前 6 小时的平均 CMD 乳酸和葡萄糖水平显示出局部脑缺血的证据。EMT 过程与 CMD 乳酸（6.42 ± 0.61 与 4.89 ± 0.55 mmol/L，p = 0.02）和葡萄糖（0.49 ± 0.17 与 0.96 ± 0.32 mmol/L，p = 0.0005）的快速（6 小时内）改善相关。EMT 还与 PbtO 的显著增加（22.9 ± 7.5 与 30.1 ± 3.6 mmHg，p = 0.0003）和 CMD 谷氨酸（12.69 ± 1.06 与 5.73 ± 1.76 μmol/L，p = 0.017）和 ICP（13 ± 4 与 11 ± 4 mmHg，p = 0.04）的降低相关。患者无需手术减压，恢复意识，出院时神经功能良好（改良 Rankin 评分为 3 分和 4 分）。