Neurosurgical Clinic, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
Institute for Medical Information Processing, Biometry, and Epidemiology, Chair of Public Health and Health Services Research, Ludwig-Maximilians-University, Munich, Germany.
Neurocrit Care. 2024 Apr;40(2):603-611. doi: 10.1007/s12028-023-01762-w. Epub 2023 Jul 27.
In patients with symptomatic cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage who do not respond to medical therapy, urgent treatment escalation has been suggested to be beneficial for brain tissue at risk. In our routine clinical care setting, we implemented stellate ganglion block (SGB) as a rescue therapy with subsequent escalation to intraarterial spasmolysis (IAS) with milrinone for refractory CV.
In this retrospective analysis from 2012 to 2021, patients with CV following aneurysmal subarachnoid hemorrhage who received an SGB or IAS were identified. Patients were assessed through neurological examination and transcranial Doppler. Rescue therapy was performed in patients with mean cerebral blood flow velocity (CBFV) ≥ 120 cm/s and persistent neurological deterioration/intubation under induced hypertension. Patients were reassessed after therapy and the following day. The Glasgow Outcome Scale was assessed at discharge and 6-month follow-up.
A total of 82 patients (mean age 50.16 years) with 184 areas treated with SGB and/or IAS met the inclusion criteria; 109 nonaffected areas were extracted as controls. The mean CBFV decrease in the middle cerebral artery on the following day was - 30.1 (± 45.2) cm/s with SGB and - 31.5 (± 45.2) cm/s with IAS. Mixed linear regression proved the significance of the treatment categories; other fixed effects (sex, age, aneurysm treatment modality [clipping or coiling], World Federation of Neurological Surgeons score, and Fisher score) were insignificant. In logistic regression, the presence of cerebral infarction on imaging before discharge from the intensive care unit (34/82) was significantly associated with unfavorable outcomes (Glasgow Outcome Scale ≤ 3) at follow-up.
Stellate ganglion block and IAS decreased CBFV the following 24 h in patients with CV. We suggest SGB alone for patients with mild symptomatic CV (CBFV < 180 cm/s), while subsequent escalation to IAS proved to be beneficial in patients with refractory CV and severe CBFV elevation (CBFV ≥ 180 cm/s).
对于症状性脑血管痉挛（CV）患者，在药物治疗无效的情况下，紧急治疗升级被认为对处于危险中的脑组织有益。在我们的常规临床护理环境中，我们实施了星状神经节阻滞（SGB）作为一种救援疗法，随后对难治性 CV 患者进行经动脉痉挛溶解（IAS）治疗，使用米力农。
在这项回顾性分析中，我们纳入了 2012 年至 2021 年期间接受 SGB 或 IAS 治疗的蛛网膜下腔出血后 CV 患者。通过神经学检查和经颅多普勒评估患者。在平均脑血流速度（CBFV）≥120 cm/s 且在诱导性高血压下持续神经功能恶化/插管的患者中进行救援治疗。在治疗后和第二天对患者进行重新评估。出院和 6 个月随访时采用格拉斯哥结局量表进行评估。
共有 82 名患者（平均年龄 50.16 岁）的 184 个部位接受了 SGB 和/或 IAS 治疗，纳入标准；提取了 109 个未受影响的部位作为对照。SGB 治疗后第 2 天大脑中动脉平均 CBFV 下降了-30.1（±45.2）cm/s，IAS 治疗后下降了-31.5（±45.2）cm/s。混合线性回归证明了治疗类别的重要性；其他固定效应（性别、年龄、动脉瘤治疗方式[夹闭或栓塞]、世界神经外科学会评分和 Fisher 评分）并不显著。在逻辑回归中，从重症监护病房出院时存在脑梗死影像学表现（34/82）与随访时预后不良（格拉斯哥结局量表≤3）显著相关。
SGB 和 IAS 均可降低 CV 患者第 24 小时的 CBFV。我们建议对轻度症状性 CV（CBFV<180 cm/s）患者单独使用 SGB，而对难治性 CV 和严重 CBFV 升高（CBFV≥180 cm/s）患者随后升级为 IAS 治疗。
