Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
Neurosurg Rev. 2023 Sep 7;46(1):231. doi: 10.1007/s10143-023-02138-6.
The study aimed to investigate the indication and functional outcome after barbiturates and decompressive craniectomy (DC) as last-tier treatments for elevated intracranial pressure (ICP) in aneurysmal subarachnoid hemorrhage (aSAH). This observational study included 891 aSAH patients treated at a single center between 2008 and 2018. Data on demography, admission status, radiology, ICP, clinical course, and outcome 1-year post-ictus were collected. Patients treated with thiopental (barbiturate) and DC were the main target group.Thirty-nine patients (4%) were treated with thiopental alone and 52 (6%) with DC. These patients were younger and had a worse neurological status than those who did not require these treatments. Before thiopental, the median midline shift was 0 mm, whereas basal cisterns were compressed/obliterated in 66%. The median percentage of monitoring time with ICP > 20 mmHg immediately before treatment was 38%, which did not improve after 6 h of infusion. Before DC, the median midline shift was 10 mm, and the median percentage of monitoring time with ICP > 20 mmHg before DC was 56%, which both significantly improved postoperatively. At follow-up, 52% of the patients not given thiopental or operated with DC reached favorable outcome, whereas this occurred in 10% of the thiopental and DC patients.In summary, 10% of the aSAH cohort required thiopental, DC, or both. Thiopental and DC are important integrated last-tier treatment options, but careful patient selection is needed due to the risk of saving many patients into a state of suffering.
本研究旨在探讨巴比妥类药物和去骨瓣减压术（DC）作为颅内压（ICP）升高的最后治疗手段，在颅内动脉瘤性蛛网膜下腔出血（aSAH）中的适应证和功能预后。本观察性研究纳入了 2008 年至 2018 年期间在一家中心治疗的 891 例 aSAH 患者。收集了人口统计学、入院状态、影像学、ICP、临床病程和发病后 1 年的预后数据。接受硫喷妥钠（巴比妥类药物）和 DC 治疗的患者是主要的目标人群。39 例（4%）患者单独接受硫喷妥钠治疗，52 例（6%）患者接受 DC 治疗。这些患者比不需要这些治疗的患者更年轻，神经功能状态更差。在使用硫喷妥钠之前，中线移位的中位数为 0 毫米，而基底池受压/闭塞的比例为 66%。治疗前即刻 ICP＞20mmHg 的监测时间中位数百分比为 38%，输注 6 小时后无改善。在进行 DC 之前，中线移位的中位数为 10 毫米，在进行 DC 之前 ICP＞20mmHg 的监测时间中位数百分比为 56%，这两个指标在手术后均显著改善。在随访时，未接受硫喷妥钠或未行 DC 手术的患者中，52%达到了良好的结局，而硫喷妥钠和 DC 组的这一比例为 10%。总之，10%的 aSAH 患者需要接受硫喷妥钠、DC 或两者联合治疗。硫喷妥钠和 DC 是重要的综合最后治疗选择，但由于有使许多患者陷入痛苦状态的风险，需要谨慎选择患者。
