Weiss Miriam, Conzen Catharina, Mueller Marguerite, Wiesmann Martin, Clusmann Hans, Albanna Walid, Schubert Gerrit Alexander
Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany.
Front Neurol. 2019 Feb 21;10:136. doi: 10.3389/fneur.2019.00136. eCollection 2019.
The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is also unclear. The present study evaluates the safety and efficacy of endovascular rescue treatment (ERT, continuous intraarterial nimodipine; IAN, transcutaneous balloon angioplasty, TBA). In this prospective observational study, we assessed periprocedural complications and side effects in context of ERT. We evaluated neurological status, multimodal neuromonitoring (pO, lactate/pyruvate ratio, transcranial doppler), and cranial imaging (CTP, DSA). All parameters were included into multivariate analysis to determine predictors for the need of retreatment. We included 33 consecutive patients with 54 ERT (IAN = 35; TBA = 13; TBA + IAN = 6). We recorded no serious complications and initial improvement in all parameters (neurostatus 72.3% of patients; pO 15.0 ± 11.7 to 25.8 ± 15.5 mmHg, < 0.0001; lactate/pyruvate ratio 46.3 ± 27.5 to 31.0 ± 9.7, <0.05; transcranial doppler 139.0 ± 46.3 to 98.9 ± 29.6 cm/s, < 0.05; CTP 81.6% of patients; DSA 93.1% of patients). Retreatment ( = 16, 48.5%) was independently associated with preinterventional pO < 5 mmHg ( <0.01) and early (<72 h) discontinuation of IAN treatment ( = 0.08). DCI related cerebral infarction was noted in = 8 patients (24.2%). At 3 months after discharge, favorable outcome was noted for = 11 (35.5%) patients. Provided a detailed decision tree, timely ERT can provide a relatively safe and effective treatment option in those highly-selected patients undergoing multimodality monitoring where conservative treatment options are exhausted. Continuous treatment in particular may be suitable to surpass sustained DCI and was associated with a low rate of DCI related infarction and comparably high percentage of good outcome.
由于缺乏支持证据，动脉瘤性蛛网膜下腔出血后迟发性脑缺血的抢救措施在很大程度上仍基于经验，而且相关的风险状况也不清楚。本研究评估血管内抢救治疗（ERT，持续动脉内尼莫地平；IAN，经皮球囊血管成形术，TBA）的安全性和有效性。在这项前瞻性观察研究中，我们评估了ERT过程中的围手术期并发症和副作用。我们评估了神经状态、多模态神经监测（pO、乳酸/丙酮酸比值、经颅多普勒）和头颅成像（CTP、DSA）。所有参数都纳入多变量分析以确定再次治疗需求的预测因素。我们纳入了33例连续患者，共进行了54次ERT（IAN = 35；TBA = 13；TBA + IAN = 6）。我们未记录到严重并发症，所有参数均有初始改善（神经状态改善的患者占72.3%；pO从15.0±11.7 mmHg升至25.8±15.5 mmHg，P<0.0001；乳酸/丙酮酸比值从46.3±27.5降至31.0±9.7，P<0.05；经颅多普勒从139.0±46.3 cm/s降至98.9±29.6 cm/s，P<0.05；CTP改善的患者占81.6%；DSA改善的患者占93.1%）。再次治疗（n = 16，48.5%）与介入前pO<5 mmHg（P<0.01）和IAN治疗早期（<72小时）中断独立相关（P = 0.08）。8例患者（24.2%）出现与DCI相关的脑梗死。出院后3个月时，11例（35.5%）患者预后良好。提供详细的决策树，在那些经过多模态监测且保守治疗方案已用尽的高度选择的患者中，及时进行ERT可提供相对安全有效的治疗选择。特别是持续治疗可能适合于克服持续性DCI，并且与DCI相关梗死的发生率低以及良好预后的比例相对较高相关。
