King W A, Martin N A
Neurovascular Section, University of California, Los Angeles School of Medicine.
Neurosurg Clin N Am. 1994 Oct;5(4):767-87.
Critical care of a patient with SAH should focus on the prevention or immediate treatment of the common sequelae of this disorder that adversely affect outcome: vasospasm, rebleeding, hydrocephalus, seizures, and associated medical problems. The frequency of rebleeding can be lessened by early surgical or endovascular intervention. The extent of SAH on the CT scan can identify those patients at highest risk for vasospasm, and all patients must be closely monitored in the ICU with serial neurological examinations and transcranial Doppler studies. Regional CBF examinations and continuous EEG may also be helpful. Calcium channel blocking agents and volume expansion are recommended prophylatically for all patients. Aggressive hypertensive, hemodilutional, hypervolemic therapy (including pulmonary artery catheter placement) is indicated for symptomatic vasospasm. Transluminal angioplasty can be used in selected patients with vasospasm refractory to these measures. Hydrocephalus can occur in the days, weeks, or months following SAH and is treated effectively with external (acute hydrocephalus) or internal cerebrospinal fluid diversion. Seizures, which can cause intracranial and systemic hypertension, high cerebral metabolic demand, and delayed neurological injury, should be prevented with prophylactic use of anticonvulsants. In addition, early recognition and treatment of associated medical complications are critical. Novel endovascular approaches, meticulous surgical technique, and aggressive ICU care will undoubtedly lead to improved outcome following aneurysmal SAH.
SAH患者的重症监护应着重于预防或立即治疗该疾病对预后产生不利影响的常见后遗症：血管痉挛、再出血、脑积水、癫痫发作及相关的内科问题。早期手术或血管内介入可降低再出血的发生率。CT扫描上SAH的范围可识别出血管痉挛风险最高的患者，所有患者均须在重症监护病房进行密切监测，包括连续的神经学检查和经颅多普勒研究。局部脑血流量检查和连续脑电图检查也可能有帮助。建议对所有患者预防性使用钙通道阻滞剂并扩容。对于有症状的血管痉挛，需进行积极的高血压、血液稀释、高血容量治疗（包括放置肺动脉导管）。对于对这些措施无效的血管痉挛患者，可选用经腔血管成形术。脑积水可在SAH后的数天、数周或数月内发生，可通过外部（急性脑积水）或内部脑脊液分流有效治疗。癫痫发作可导致颅内和全身性高血压、高脑代谢需求及延迟性神经损伤，应预防性使用抗惊厥药物加以预防。此外，早期识别和治疗相关内科并发症至关重要。新型血管内治疗方法、精细的手术技术及积极的重症监护无疑将改善动脉瘤性SAH后的预后。
