吸入麻醉与静脉麻醉预处理对蛛网膜下腔出血后迟发性脑缺血的影响。
Inhalational Versus Intravenous Anesthetic Conditioning for Subarachnoid Hemorrhage-Induced Delayed Cerebral Ischemia.
机构信息
Department of Anesthesiology (U.A., M.K., R.K., R.S.), Washington University, St. Louis, MO.
Neurocritical Care Service, Harborview Medical Center (A.V.L.).
出版信息
Stroke. 2022 Mar;53(3):904-912. doi: 10.1161/STROKEAHA.121.035075. Epub 2021 Nov 4.
BACKGROUND
Inhalational anesthetics were associated with reduced incidence of angiographic vasospasm and delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (SAH). Whether intravenous anesthetics provide similar level of protection is not known.
METHODS
Anesthetic data were collected retrospectively for patients with SAH who received general anesthesia for aneurysm repair between January 1, 2014 and May 31, 2018, at 2 academic centers in the United States (one employing primarily inhalational and the other primarily intravenous anesthesia with propofol). We compared the outcomes of angiographic vasospasm, DCI, and neurological outcome (measured by disposition at hospital discharge), between the 2 sites, adjusting for potential confounders.
RESULTS
We compared 179 patients with SAH receiving inhalational anesthetics at one institution to 206 patients with SAH receiving intravenous anesthetics at the second institution. The rates of angiographic vasospasm between inhalational versus intravenous anesthetic groups were 32% versus 52% (odds ratio, 0.49 [CI, 0.32-0.75]; =0.001) and DCI were 21% versus 40% (odds ratio, 0.47 [CI, 0.29-0.74]; =0.001), adjusting for imbalances between sites/groups, Hunt-Hess and Fisher grades, type of aneurysm treatment, and American Society of Anesthesiology status. No impact of anesthetics on neurological outcome at time of discharge was noted with rates of good discharge outcome between inhalational versus intravenous anesthetic groups at (78% versus 72%, =0.23).
CONCLUSIONS
Our data suggest that those who received inhalational versus intravenous anesthetic for ruptured aneurysm repair had significant protection against SAH-induced angiographic vasospasm and DCI. Although we cannot fully disentangle site-specific versus anesthetic effects in this comparative study, these results, when coupled with preclinical data demonstrating a similar protective effect of inhalational anesthetics on vasospasm and DCI, suggest that inhalational anesthetics may be preferable for patients with SAH undergoing aneurysm repair. Additional investigations examining the effect of inhalational anesthetics on other SAH outcomes such as early brain injury and long-term neurological outcomes are warranted.
背景
吸入性麻醉药可降低蛛网膜下腔出血（SAH）患者的血管痉挛发生率和迟发性脑缺血（DCI）。但静脉麻醉药是否具有相同的保护作用尚不清楚。
方法
对 2014 年 1 月 1 日至 2018 年 5 月 31 日期间，在美国 2 个学术中心接受全身麻醉治疗的动脉瘤性 SAH 患者的麻醉数据进行回顾性收集。我们比较了这 2 个中心的血管痉挛、DCI 和神经结局（以出院时的处置方式衡量），并对潜在混杂因素进行了调整。
结果
我们比较了 179 例在 1 家机构接受吸入性麻醉的 SAH 患者与 206 例在第 2 家机构接受静脉麻醉的 SAH 患者。与静脉麻醉组相比，吸入性麻醉组的血管痉挛发生率分别为 32%和 52%（比值比，0.49[95%CI，0.32-0.75]；=0.001），DCI 发生率分别为 21%和 40%（比值比，0.47[95%CI，0.29-0.74]；=0.001）。调整中心/组之间、Hunt-Hess 和 Fisher 分级、动脉瘤治疗类型和美国麻醉医师协会状态的不平衡后，发现麻醉对出院时的神经结局没有影响，吸入性麻醉组与静脉麻醉组的良好出院结局率分别为 78%和 72%（比值比，0.23）。
结论
我们的数据表明，与接受静脉麻醉的患者相比，接受吸入麻醉的破裂性动脉瘤修复患者发生 SAH 引起的血管痉挛和 DCI 的风险显著降低。尽管在这项比较研究中，我们无法完全区分特定于站点的效果与麻醉效果，但这些结果与临床前数据表明吸入麻醉对血管痉挛和 DCI 具有相似的保护作用相结合，表明吸入麻醉可能更适合接受动脉瘤修复的 SAH 患者。需要进一步研究来检查吸入性麻醉对其他 SAH 结果（如早期脑损伤和长期神经结局）的影响。
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