Grossen Audrey A, Ernst Griffin L, Bauer Andrew M
Neurosurg Focus. 2022 Mar;52(3):E10. doi: 10.3171/2021.12.FOCUS21629.
Aneurysmal subarachnoid hemorrhage (aSAH) accounts for a relatively small portion of strokes but has the potential to cause permanent neurological deficits. Vasospasm with delayed ischemic neurological deficit is thought to be responsible for much of the morbidity associated with aSAH. This has illuminated some treatment options that have the potential to target specific components of the vasospasm cascade. Intrathecal management via lumbar drain (LD) or external ventricular drain (EVD) offers unique advantages in this patient population. The aim of this review was to provide an update on intrathecal vasospasm treatments, emphasizing the need for larger-scale trials and updated protocols using data-driven evidence.
A search of PubMed, Ovid MEDLINE, and Cochrane databases included the search terms (subarachnoid hemorrhage) AND (vasospasm OR delayed cerebral ischemia) AND (intrathecal OR intraventricular OR lumbar drain OR lumbar catheter) for 2010 to the present. Next, a meta-analysis was performed of select therapeutic regimens. The primary endpoints of analysis were vasospasm, delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome.
Twenty-nine studies were included in the analysis. There were 10 studies in which CSF drainage was the primary experimental group. Calcium channel antagonists were the focus of 7 studies. Fibrinolytics and other vasodilators were each examined in 6 studies. The meta-analysis included studies examining CSF drainage via LD (n = 4), tissue plasminogen activator in addition to EVD (n = 3), intraventricular nimodipine (n = 2), and cisternal magnesium (n = 2). Results showed that intraventricular nimodipine decreased vasospasm (OR 0.59, 95% CI 0.37-0.94; p = 0.03). Therapies that significantly reduced DCI were CSF drainage via LD (OR 0.47, 95% CI 0.25-0.88; p = 0.02) and cisternal magnesium (OR 0.27, 95% CI 0.07-1.02; p = 0.05). CSF drainage via LD was also found to significantly reduce the incidence of cerebral infarction (OR 0.35, 95% 0.24-0.51; p < 0.001). Lastly, functional outcome was significantly better in patients who received CSF drainage via LD (OR 2.42, 95% CI 1.39-4.21; p = 0.002).
The authors' results showed that intrathecal therapy is a safe and feasible option following aSAH. It has been shown to attenuate cerebral vasospasm, reduce the incidence of DCI, and improve clinical outcome. The authors support the use of intrathecal management in the prevention and rescue management of cerebral vasospasm. More randomized controlled trials are warranted to determine the best combination of pharmaceutical agents and administration route in order to formulate a standardized treatment approach.
动脉瘤性蛛网膜下腔出血（aSAH）在中风中所占比例相对较小，但有可能导致永久性神经功能缺损。血管痉挛伴延迟性缺血性神经功能缺损被认为是与aSAH相关的许多发病率的原因。这揭示了一些有可能针对血管痉挛级联反应特定成分的治疗选择。通过腰大池引流（LD）或脑室外引流（EVD）进行鞘内管理在该患者群体中具有独特优势。本综述的目的是提供鞘内血管痉挛治疗的最新情况，强调需要进行更大规模的试验并使用数据驱动的证据更新方案。
对PubMed、Ovid MEDLINE和Cochrane数据库进行检索，检索词为（蛛网膜下腔出血） AND （血管痉挛或延迟性脑缺血） AND （鞘内或脑室内或腰大池引流或腰大池导管），检索时间为2010年至今。接下来，对选定的治疗方案进行荟萃分析。分析的主要终点是血管痉挛、延迟性脑缺血（DCI）、脑梗死和功能结局。
分析纳入了29项研究。有10项研究将脑脊液引流作为主要实验组。7项研究聚焦于钙通道拮抗剂。6项研究分别对纤溶剂和其他血管扩张剂进行了研究。荟萃分析纳入了通过LD进行脑脊液引流的研究（n = 4）、除EVD外使用组织纤溶酶原激活剂的研究（n = 3）、脑室内使用尼莫地平的研究（n = 2）以及脑池内使用镁的研究（n = 2）。结果显示，脑室内使用尼莫地平可降低血管痉挛（比值比0.59，95%置信区间0.37 - 0.94；p = 0.03）。显著降低DCI的治疗方法包括通过LD进行脑脊液引流（比值比0.47，95%置信区间0.25 - 0.88；p = 0.02）和脑池内使用镁（比值比0.27，95%置信区间0.07 - 1.02；p = 0.05）。还发现通过LD进行脑脊液引流可显著降低脑梗死的发生率（比值比0.35，95% 0.24 - 0.51；p < 0.001）。最后，通过LD进行脑脊液引流的患者功能结局明显更好（比值比2.42，95%置信区间1.39 - 4.21；p = 0.002）。
作者的结果表明，鞘内治疗是aSAH后一种安全可行的选择。已证明其可减轻脑血管痉挛，降低DCI的发生率，并改善临床结局。作者支持在脑血管痉挛的预防和抢救管理中使用鞘内管理。需要更多的随机对照试验来确定药物和给药途径的最佳组合，以制定标准化的治疗方法。
