Wendel Christopher, Scheibe Ricardo, Wagner Sören, Tangemann Wiebke, Henkes Hans, Ganslandt Oliver, Schiff Jan-Henrik
1Neurosurgical Clinic and.
2Department of Anesthesiology and Intensive Care Medicine, Klinikum Stuttgart, Germany.
J Neurosurg. 2019 Aug 9;133(3):773-779. doi: 10.3171/2019.5.JNS182890. Print 2020 Sep 1.
Cerebral vasospasm (CV) is a delayed, sustained contraction of the cerebral arteries that tends to occur 3-14 days after aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured aneurysm. Vasospasm potentially leads to delayed cerebral ischemia, and despite medical treatment, 1 of 3 patients suffer a persistent neurological deficit. Bedside transcranial Doppler (TCD) ultrasonography is used to indirectly detect CV through recognition of an increase in cerebral blood flow velocity (CBFV). The present study aimed to use TCD ultrasonography to monitor how CBFV changes on both the ipsi- and contralateral sides of the brain in the first 24 hours after patients have received a stellate ganglion block (SGB) to treat CV that persists despite maximum standard therapy.
The data were culled from records of patients treated between 2013 and 2017. Patients were included if an SGB was administered following aSAH, whose CBFV was ≥ 120 cm/sec and who had either a focal neurological deficit or reduced consciousness despite having received medical treatment and blood pressure management. The SGB was performed on the side where the highest CBFV had been recorded with 8-10 ml ropivacaine 0.2%. The patient's CBFV was reassessed after 2 and 24 hours.
Thirty-seven patients (male/female ratio 18:19), age 17-70 years (mean age 49.9 ± 11.1), who harbored 13 clipped and 22 coiled aneurysms (1 patient received both a coil and a clip, and 3 patients had 3 untreated aneurysms) had at least one SGB. Patients received up to 4 SGBs, and thus the study comprised a total of 76 SGBs.After the first SGB, CBFV decreased in 80.5% of patients after 2 hours, from a mean of 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001), and it further decreased in 63.4% after 24 hours to 137.2 ± 38.2 cm/sec (p = 0.007). A similar significant effect was found for the subsequent SGB. Adding clonidine showed no significant effect on either the onset or the duration of the SGB. Contralateral middle cerebral artery (MCA) blood flow was not reduced by the SGB.
To the authors' knowledge, this is the largest study on the effects of administering an SGB to aSAH patients after aneurysm rupture. The data showed a significant reduction in ipsilateral CBFV (MCA 20.5%) after SGB, lasting in about two-thirds of cases for over 24 hours with no major complications resulting from the SGB.
脑血管痉挛（CV）是一种脑动脉的延迟性、持续性收缩，往往发生在破裂动脉瘤导致的动脉瘤性蛛网膜下腔出血（aSAH）后3 - 14天。血管痉挛可能导致迟发性脑缺血，尽管进行了药物治疗，但仍有三分之一的患者会出现持续性神经功能缺损。床旁经颅多普勒（TCD）超声检查通过识别脑血流速度（CBFV）的增加来间接检测CV。本研究旨在使用TCD超声检查来监测在患者接受星状神经节阻滞（SGB）以治疗尽管接受了最大标准治疗仍持续存在的CV后的最初24小时内，大脑同侧和对侧的CBFV如何变化。
数据来自2013年至2017年期间接受治疗的患者记录。如果患者在aSAH后接受了SGB，其CBFV≥120 cm/秒，并且尽管接受了药物治疗和血压管理仍有局灶性神经功能缺损或意识减退，则纳入研究。使用8 - 10 ml 0.2%的罗哌卡因在记录到最高CBFV的一侧进行SGB。在2小时和24小时后重新评估患者的CBFV。
37例患者（男女比例为18:19），年龄17 - 70岁（平均年龄49.9±11.1），其中13例动脉瘤夹闭，22例动脉瘤栓塞（1例患者同时接受了栓塞和夹闭，3例患者有3个未治疗的动脉瘤），至少接受了一次SGB。患者最多接受4次SGB，因此该研究总共包括76次SGB。第一次SGB后，80.5%的患者在2小时后CBFV下降，从平均160.3±28.2 cm/秒降至127.5±34.3 cm/秒（p < 0.001），24小时后63.4%的患者CBFV进一步下降至137.2±38.2 cm/秒（p = 0.007）。后续的SGB也发现了类似的显著效果。添加可乐定对SGB的起效或持续时间均无显著影响。SGB未降低对侧大脑中动脉（MCA）血流。
据作者所知，这是关于动脉瘤破裂后对aSAH患者进行SGB效果的最大规模研究。数据显示SGB后同侧CBFV显著降低（MCA降低20.5%），约三分之二的病例持续超过24小时，且SGB未导致重大并发症。
