Bejjani G K, Bank W O, Olan W J, Sekhar L N
Department of Neurological Surgery, George Washington University, Washington, District of Columbia 20037, USA.
Neurosurgery. 1998 May;42(5):979-86; discussion 986-7. doi: 10.1097/00006123-199805000-00013.
Cerebral angioplasty is being increasingly used for symptomatic vasospasm secondary to subarachnoid hemorrhage. We attempted to determine the safety and efficacy of angioplasty for refractory vasospasm. We also looked at the influence of timing of angioplasty on outcome.
We retrospectively studied patients with subarachnoid hemorrhage who underwent angioplasty in our institution to determine the safety and the success rate achieved with this procedure. The study period extended from August 1993 until February 1997. Clinical and radiological data were collected, with emphasis on clinical improvement after angioplasty and its relationship with timing of intervention. Thirty-one patients with 43 aneurysms and one case of arteriovenous malformations were included. Their ages varied between 28 and 68 years, with an average age of 44 years. Five patients were assigned Hunt and Hess Grade IV, 15 were assigned Grade III, 7 were assigned Grade II, and 4 were assigned Grade I. All patients except two underwent angioplasty after aneurysm clipping or coiling.
Angioplasty was performed an average of 6.9 days after the occurrence of subarachnoid hemorrhage, with a range from 1 to 14 days. It was performed early (within 24 h) after refractory clinical deterioration in 21 patients. A total of 81 vessels were dilated. Three angioplasty-related complications occurred: two femoral hematomas and one retroperitoneal hematoma. Clinical improvement was dramatic after 12 procedures, moderate after 11 procedures, and minimal or nonexistent after 9 procedures. There was a clear tendency toward more significant improvement in patients with earlier angioplasty (<24 h from onset of neurological deficit) (P=0.0038). At discharge, 8 patients had achieved good recoveries (Glasgow Outcome Scale score of 1), 11 had moderate disabilities (Glasgow Outcome Scale score of 2), and 10 had severe disabilities (Glasgow Outcome Scale score of 3). Two deaths were encountered, and they were unrelated to angioplasty. Follow-up was obtained for 27 patients: 25 had good outcomes, 1 was moderately disabled, and 1 died. There was no significant correlation between interval and outcome.
Our results indicate that angioplasty is a safe and effective treatment for symptomatic vasospasm that is refractory to hyperdynamic hypervolemic therapy. When used early (<24 h), it leads to significant clinical improvement. However, the long-term outcome is good, even in cases of delayed angioplasty. The prevention of worsening of the cerebral ischemia and its extension to other territories may be the reason.
脑动脉血管成形术越来越多地用于治疗蛛网膜下腔出血继发的症状性血管痉挛。我们试图确定血管成形术治疗难治性血管痉挛的安全性和有效性。我们还研究了血管成形术时机对预后的影响。
我们回顾性研究了在我们机构接受血管成形术的蛛网膜下腔出血患者，以确定该手术的安全性和成功率。研究时间段从1993年8月至1997年2月。收集了临床和放射学数据，重点是血管成形术后的临床改善情况及其与干预时机的关系。纳入了31例患有43个动脉瘤和1例动静脉畸形的患者。他们的年龄在28岁至68岁之间，平均年龄为44岁。5例患者为Hunt和Hess分级IV级，15例为III级，7例为II级，4例为I级。除2例患者外，所有患者均在动脉瘤夹闭或栓塞后接受了血管成形术。
血管成形术平均在蛛网膜下腔出血发生后6.9天进行，范围为1至14天。21例患者在难治性临床病情恶化后早期（24小时内）进行了血管成形术。总共扩张了81条血管。发生了3例与血管成形术相关的并发症：2例股部血肿和1例腹膜后血肿。12例手术后临床改善显著，11例手术后改善中等，9例手术后改善轻微或无改善。血管成形术较早（神经功能缺损发作后<24小时）的患者有更明显改善的明显趋势（P = 0.0038）。出院时，8例患者恢复良好（格拉斯哥预后评分1分），11例有中度残疾（格拉斯哥预后评分2分），10例有严重残疾（格拉斯哥预后评分3分）。有2例死亡，与血管成形术无关。对27例患者进行了随访：其中25例预后良好，1例有中度残疾，1例死亡。时间间隔与预后之间无显著相关性。
我们的结果表明，血管成形术是治疗对高动力性高血容量疗法难治的症状性血管痉挛的一种安全有效的治疗方法。早期（<24小时）使用时，可导致显著的临床改善。然而，即使是延迟进行血管成形术的病例，长期预后也良好。预防脑缺血恶化及其扩展到其他区域可能是原因所在。
