Muraoka Shinsuke, Izumi Takashi, Nishihori Masahiro, Goto Shunsaku, Takeuchi Issei, Saito Ryuta
Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan.
J Clin Med. 2025 May 13;14(10):3403. doi: 10.3390/jcm14103403.
Aneurysmal subarachnoid hemorrhage (aSAH) remains a life-threatening cerebrovascular event with high rates of mortality and long-term morbidity. Among its complications, delayed cerebral ischemia (DCI) is a major contributor to poor clinical outcomes. Although cerebral vasospasm has traditionally been considered the primary mechanism underlying DCI, recent studies have revealed the multifactorial nature of this condition. This review aims to provide a comprehensive overview of the pathophysiology, preventive strategies, and current treatment options for DCI following aSAH. A narrative literature review was conducted using the PubMed database to identify peer-reviewed articles relevant to the prevention and treatment of DCI following aSAH. The search strategy employed the following terms: ("Subarachnoid Hemorrhage" [MeSH]) AND "Delayed Cerebral Ischemia" AND ("Prevention and Control" [Subheading] OR "Secondary Prevention" [MeSH]). This search strategy was designed to capture studies addressing both pharmacological and non-pharmacological preventive measures for DCI. A comprehensive PubMed search identified a total of 113 relevant articles. Among these, 40 publications primarily addressed pharmacological interventions, while 22 focused on neuromonitoring techniques. An additional 20 articles explored the pathophysiological mechanisms underlying DCI, and 15 involved preclinical studies utilizing animal models. The remaining 16 articles encompassed diverse topics, including prophylactic endovascular therapies, newly proposed definitions of DCI, treatment algorithm development, functional outcome analyses, and entries in clinical trial registries. Emerging evidence highlights that vasospasm alone does not account for all cases of DCI. Pharmacological approaches such as nimodipine, clazosentan, and fasudil have shown varying degrees of efficacy. Circulatory management and removal of subarachnoid hematoma via CSF drainage or thrombolytics may reduce DCI risk, although their impact on long-term neurological outcomes remains controversial. Endovascular therapy and adjunctive agents such as cilostazol or anticoagulants have demonstrated potential but require further validation through large-scale trials. Effective DCI prevention and treatment require a multimodal approach targeting diverse pathological mechanisms beyond vasospasm. Improved risk stratification, early detection, and individualized therapy are essential for advancing the management of patients with aSAH.
动脉瘤性蛛网膜下腔出血（aSAH）仍然是一种危及生命的脑血管事件，死亡率高且长期存在致残率。在其并发症中，迟发性脑缺血（DCI）是导致临床预后不良的主要因素。尽管传统上认为脑血管痉挛是DCI的主要潜在机制，但最近的研究揭示了这种情况的多因素性质。本综述旨在全面概述aSAH后DCI的病理生理学、预防策略和当前的治疗选择。使用PubMed数据库进行了叙述性文献综述，以识别与aSAH后DCI的预防和治疗相关的同行评审文章。搜索策略使用了以下术语：（“蛛网膜下腔出血”[医学主题词]）AND“迟发性脑缺血”AND（“预防与控制”[副标题]或“二级预防”[医学主题词]）。该搜索策略旨在获取涉及DCI的药理学和非药理学预防措施的研究。全面的PubMed搜索共识别出113篇相关文章。其中，40篇出版物主要涉及药理学干预，22篇关注神经监测技术。另外20篇文章探讨了DCI的病理生理机制，15篇涉及利用动物模型的临床前研究。其余16篇文章涵盖了各种主题，包括预防性血管内治疗、DCI的新提出定义、治疗算法开发、功能结局分析以及临床试验注册条目。新出现的证据突出表明，仅血管痉挛并不能解释所有DCI病例。诸如尼莫地平、氯沙坦和法舒地尔等药理学方法已显示出不同程度的疗效。通过脑脊液引流或溶栓剂进行循环管理和清除蛛网膜下腔血肿可能会降低DCI风险，尽管它们对长期神经结局的影响仍存在争议。血管内治疗以及诸如西洛他唑或抗凝剂等辅助药物已显示出潜力，但需要通过大规模试验进一步验证。有效的DCI预防和治疗需要一种针对血管痉挛以外多种病理机制的多模式方法。改进风险分层、早期检测和个体化治疗对于推进aSAH患者的管理至关重要。
