Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria.
Curr Opin Crit Care. 2021 Apr 1;27(2):103-114. doi: 10.1097/MCC.0000000000000798.
Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature.
Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty.
The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
迟发性脑缺血（DCI）使 20%~30%的蛛网膜下腔出血（SAH）患者的临床病程复杂化，并显著恶化预后。在这篇综述中，我们根据 DCI 的潜在机制描述了一种多模式诊断方法，并提供了治疗选择，特别关注最近发表的文献。
症状性血管痉挛是指在存在血管痉挛的情况下出现临床恶化，而 DCI 则构成多种原因。DCI 的病理生理机制不仅包括大血管血管痉挛，还包括神经炎症、微血栓形成、脑自动调节受损、皮质扩散性去极化等。目前 DCI 的定义可能受到这些机制的挑战。我们建议使用临床检查、脑超声、神经影像学方式和多模式神经监测相结合的实用方法，在存在 DCI 的情况下触发治疗干预。除了预防性尼莫地平以及改善氧输送和降低脑代谢需求的管理原则外，其他特定干预措施包括允许性高血压、动脉内应用钙通道阻滞剂以及在选定患者中进行血管成形术。
DCI 潜在的复杂病理生理学需要多模式诊断方法来触发靶向干预。新的治疗概念仍需要在大型试验中得到证实。
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