Institute of Neurological Sciences, Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK.
Institute of Neurological Sciences, Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK.
World Neurosurg. 2019 May;125:469-474. doi: 10.1016/j.wneu.2019.02.041. Epub 2019 Feb 27.
Management of hypertension in subarachnoid hemorrhage patients within the preaneurysmal treatment period remains ambiguous, in part due to the lack of high-level, evidence-based guidelines. Despite this, current recommendations offer guidance regarding certain parameters (e.g., mean arterial pressure, systolic blood pressure). However, managing hypertension within this critical period is difficult because a fine balance must be achieved between lowering blood pressure enough to minimize the risk of rebleeding and preventing reduced cerebral perfusion and subsequent ischemic damage. Furthermore, the different causes of hypertension within the preaneurysmal treatment period are polyfactorial and include pathophysiologic responses, sympathetic nervous system activation, and iatrogenic from hyperdynamic therapy and vasopressors, which requires consideration for these patients to receive optimal management. Other factors including loss of autoregulation and concomitant conditions must also be considered when deciding whether to start antihypertensive therapy.
We review the literature and provide a comprehensive update on management of hypertension within the preaneurysmal treatment period, which we hope stresses the need for better evidence-based guidelines that will in turn help manage this cohort.
Thorough review revealed no high-grade, evidence-based guidelines to manage these patients, which results in variation in clinical practice among different clinicians and institutions. Despite this, current recommendations seem reasonable until such guidelines are established.
It is clear that further, larger studies are warranted in order to clarify the effect of antihypertensive therapy on patient outcome and what the BP thresholds are, along with establishing the best treatment, for commencing antihypertensive therapy.
在蛛网膜下腔出血患者的治疗前期，高血压的管理仍存在争议，部分原因是缺乏高级别的循证指南。尽管如此，目前的建议仍为某些参数（如平均动脉压、收缩压）提供了指导。然而，在这个关键时期管理高血压是困难的，因为必须在降低血压以尽量减少再出血风险和防止脑灌注降低及随后的缺血性损伤之间取得平衡。此外，治疗前期高血压的不同原因是多因素的，包括病理生理反应、交感神经系统激活和源于过度治疗的高动力疗法和升压药，这需要考虑这些患者接受最佳管理。在决定是否开始降压治疗时，还需要考虑其他因素，包括自动调节的丧失和伴随的情况。
我们回顾了文献，并对治疗前期高血压的管理进行了全面更新，我们希望这将强调需要更好的循证指南，从而有助于管理这一人群。
彻底的审查没有发现管理这些患者的高级别循证指南，这导致了不同临床医生和机构之间的临床实践存在差异。尽管如此，在制定这些指南之前，目前的建议似乎是合理的。
显然，需要进一步进行更大规模的研究，以阐明降压治疗对患者预后的影响，以及确定降压阈值，同时确定开始降压治疗的最佳治疗方法。
