Department of Neurosurgery, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
Department of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Tuebingen, Germany.
Neurosurg Rev. 2021 Dec;44(6):3479-3486. doi: 10.1007/s10143-021-01522-4. Epub 2021 Mar 29.
To determine the area most at risk of delayed cerebral ischemia (DCI) in relation to the location of the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH) and, therefore, help to choose the site for focal multimodal neuromonitoring.
We retrospectively analyzed angiographic findings, CCT scans, and patient charts of patients who were admitted with aSAH to our neurosurgical intensive care unit between 2009 and 2017. DCI was defined as infarction on CCT 2-6 weeks after aSAH.
DCI occurred in 17.9% out of 357 included patients. A DCI occurring in the vascular territory of the artery carrying the ruptured aneurysm was found in 81.0% of patients with anterior circulation aneurysms but only in 16.7% with posterior circulation aneurysms (Fisher's exact, p=0.003). The vascular territory most frequently showing a DCI was the ipsilateral MCA territory (86.7%) in ICA aneurysms, the contra- (71.4%) and the ipsilateral (64.3%) ACA territory in ACA aneurysms, the right (93.8%) and the left (81.3%) ACA territory in AcomA aneurysms, and the ipsilateral MCA territory in MCA aneurysms (69.2%) as well as in VA/PICA/SCA aneurysms (100.0%). DCI after the rupture of a BA aneurysm occurred with 33.3% in 6 out of 8 vascular territories, respectively. DCI of multiple vascular territories occurred in 100.0% of BA aneurysms, 87.5% of AcomA aneurysms, 71.4% of ACA aneurysms, 40.0% of ICA aneurysms, 38.5% of MCA aneurysms, and 33.3% of VA/PICA/SCA aneurysms.
Few studies exist that could determine the area most at risk of a DCI after an aSAH. Our data could identify the territory most at risk for DCI with a probability of > 60% except for BA aneurysms, which showed DCI in various areas and patients suffering from multiple DCIs. Either the ipsilateral ACA or MCA were affected by the DCI in about 80% of ACA and more than 90% of AcomA, ICA, MCA, and VA/PICA/SCA aneurysms. Therefore, local intraparenchymal neuromonitoring in the ACA/MCA watershed area might detect the vast majority of DCIs for all aneurysm locations, except for BA aneurysms. In ACA and AcomA aneurysms, bilateral DCI of the ACA territory was common, and bilateral probe positioning might be considered for monitoring high-risk patients. Non-focal monitoring methods might be preferably used after BA aneurysm rupture.
确定与破裂的动脉瘤位置相关的迟发性脑缺血（DCI）的最危险区域，从而有助于选择局灶性多模态神经监测的部位。
我们回顾性分析了 2009 年至 2017 年间我院神经外科重症监护病房收治的蛛网膜下腔出血（SAH）患者的血管造影发现、CCT 扫描和患者病历。DCI 定义为 SAH 后 2-6 周 CCT 上的梗死。
357 例纳入患者中有 17.9%发生 DCI。前循环动脉瘤患者中有 81.0%出现了破裂动脉瘤供血动脉区域的 DCI，而后循环动脉瘤患者中只有 16.7%（Fisher 确切检验，p=0.003）。最常发生 DCI 的血管区域是 ICA 动脉瘤中同侧 MCA 区域（86.7%），ACA 动脉瘤中对侧（71.4%）和同侧（64.3%）ACA 区域，AcomA 动脉瘤中右侧（93.8%）和左侧（81.3%）ACA 区域，MCA 动脉瘤中同侧 MCA 区域（69.2%）以及 VA/PICA/SCA 动脉瘤中（100.0%）。8 个 BA 动脉瘤中，有 6 个分别出现了 33.3%的 DCI。BA 动脉瘤中 100.0%、AcomA 动脉瘤中 87.5%、ACA 动脉瘤中 71.4%、ICA 动脉瘤中 40.0%、MCA 动脉瘤中 38.5%和 VA/PICA/SCA 动脉瘤中发生了多血管区域的 DCI。
很少有研究能够确定蛛网膜下腔出血后 DCI 的最危险区域。除了 BA 动脉瘤，我们的数据可以确定 DCI 最危险的区域，其概率>60%，BA 动脉瘤则显示出各种区域和多个 DCI 的情况。大约 80%的 ACA 和超过 90%的 AcomA、ICA、MCA 和 VA/PICA/SCA 动脉瘤中，同侧的 ACA 或 MCA 受到 DCI 的影响。因此，除了 BA 动脉瘤外，在 ACA/MCA 分水岭区域进行局部脑实质内神经监测可能会检测到所有动脉瘤位置的绝大多数 DCI。在 ACA 和 AcomA 动脉瘤中，ACA 区域的双侧 DCI 很常见，双侧探头定位可能需要考虑用于监测高危患者。BA 动脉瘤破裂后可能最好使用非局灶性监测方法。
