Mäder Lisa, Ganai Ajaz, Aroyo Ilia, Schill Josef, Tröscher-Weber Regina, Huppert Peter, Kotterer Otto, Geletneky Karsten, Kollmar Rainer
Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany.
Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany.
Ther Hypothermia Temp Manag. 2019 Sep;9(3):216-221. doi: 10.1089/ther.2018.0049. Epub 2019 Mar 26.
Targeted temperature management (TTM) might improve outcome of patients with severe subarachnoid hemorrhage (SAH) in which vasospasm, delayed cerebral ischemia (DCI), and increased intracranial pressure (ICP) are frequent and severe complications. A series of patients ( = 3) with severe aneurysmatic SAH were treated by TTM if they developed ICP crisis and/or severe vasospasm diagnosed by angiography. Once these complications were detected, body core temperature (BCT) was rapidly decreased to 35°C or 33°C, if necessary. BCT induced and maintained by surface cooling remained at the desired level for at least 72 hours. Rewarming was performed by 1°C, only if the target parameters ICP and velocities in the serial Doppler sonography indicating macrovascular vasospasm improved to regular levels. In case of increase of ICP or middle cerebral arteries velocities BCT was decreased again to the last effective level. The patients developed vasospasm between days 6 and 12 after SAH. All aneurysms were treated by coiling. BCT was reduced between days 6 and 12 after SAH. Total duration of BCT <36.5°C was between 5.5 and 8 days. It remained <35°C for 4-6 days, and at 33°C for 3 days on average. ICP could be sufficiently controlled in all patients, because no ICP crisis was observed during TTM and after rewarming. Two patients developed minor DCI. Side effects of prolonged ventilation of 7-18 days included pneumonia for two patients that could be treated sufficiently. Other complications were one case of ventriculitis and two temporary deliriums. Outcome of the patients was good because no focal neurological symptoms could be detected after rehabilitation. TTM represents a promising treatment approach for severe SAH in which standard treatment is often limited and experimental. It deserves further clinical investigation in a larger cohort.
目标温度管理（TTM）可能会改善重症蛛网膜下腔出血（SAH）患者的预后，在这类患者中，血管痉挛、迟发性脑缺血（DCI）和颅内压（ICP）升高是常见且严重的并发症。一系列（n = 3）重症动脉瘤性SAH患者，如果出现ICP危机和/或经血管造影诊断为严重血管痉挛，就采用TTM治疗。一旦发现这些并发症，必要时将核心体温（BCT）迅速降至35°C或33°C。通过体表降温诱导并维持的BCT在至少72小时内保持在所需水平。仅当连续多普勒超声检查中指示大血管痉挛的目标参数ICP和血流速度改善至正常水平时，才以1°C的速度进行复温。如果ICP或大脑中动脉血流速度增加，则将BCT再次降至最后一个有效水平。患者在SAH后第6至12天出现血管痉挛。所有动脉瘤均采用弹簧圈栓塞治疗。SAH后第6至12天降低BCT。BCT<36.5°C的总持续时间在5.5至8天之间。平均而言，BCT保持<35°C 4至6天，保持在33°C 3天。所有患者的ICP都能得到充分控制，因为在TTM期间和复温后均未观察到ICP危机。两名患者出现轻度DCI。7至18天的长时间通气的副作用包括两名患者发生肺炎，均可得到充分治疗。其他并发症包括1例脑室炎和2例短暂性谵妄。患者的预后良好，因为康复后未发现局灶性神经症状。对于重症SAH，TTM是一种有前景的治疗方法，而重症SAH的标准治疗往往有限且处于试验阶段。它值得在更大的队列中进行进一步的临床研究。
