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Neurosurgery:局麻下行动脉瘤栓塞治疗或可实现

2013-1-31 作者:Neurosurgery   来源:medlive 我要评论0
Tags: Neurosurgery  局麻  动脉瘤  
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近期一项研究报告,在清醒镇静和局部麻醉下可使用弹簧圈栓塞治疗破裂颅内动脉瘤。研究作者美国纽约Buffalo大学Elad Levy博士及其同事称,这种方法有许多潜在的优势,包括避免全身麻醉相关的风险,操作更简单更便宜,减少周转时间等。这篇研究结果发表于《神经外科学》杂志[Neurosurgery 2013 Feb;72(2):216-220]。

但是,研究者也指出,麻醉团队必须随时准备提供协作,以防患者不耐受清醒镇静或出现并发症。Levy等进行的78次清醒镇静操作中有7次转为全身麻醉下进行。在这种情况下,需紧急实施全身麻醉;如果麻醉师处于待命状态,可在不到10分钟的时间内转为全身麻醉。

Levy等人说,“清醒镇静也允许对患者进行直接频繁的神经系统检查而不依赖对电生理监测结果的解读,这可能有利于更快检测术中并发症并及时应对处理。”

研究人员在清醒镇静操作进行频繁的运动、感觉和言语评估。研究人员对哪些患者适合接受清醒镇静有选择性,然而,80.8%的清醒镇静患者Hunt和Hess分级为I和II级。清醒镇静患者无分级差(IV或V),而112例全身麻醉患者则有54.5%分级为IV或V级。

研究总发生率的不良事件 - 穿孔和栓塞并发症(有症状)– 分别为10.2%和2.5%。清醒镇静和全身麻醉组分别有6例和2例发生栓塞并发症,均自行缓解。相应穿孔病例分别为3例和11例。

使用清醒镇静和采用全身麻醉手术过程中的不良事件率分别为9.4%和11.6%,没有显著差异。整体死亡率为15.5%,清醒镇静组只有2.5%,但研究人员认为该组死亡率低主要是由于患者临床分级较低有关。

研究人员指出,另一个潜在的问题是,病人的运动可能会导致成像质量差。他们说:“根据我们的经验,通过固定在血管造影桌上的头固定器轻柔固定患者的头部可以克服这一缺点。”然而, 3例患者因为头部运动过度需转为全身麻醉。

BACKGROUND
Endovascular coil embolization of ruptured aneurysms is performed under general anesthesia at most centers for perceived improved image quality and patient safety. 
OBJECTIVE
To report the feasibility of and outcomes associated with endovascular treatment of subarachnoid hemorrhage (SAH) patients with ruptured cerebral aneurysms performed under conscious sedation with local anesthetics. 
METHODS
Between January 2005 and December 2009, 187 patients with aneurysmal SAH were treated with coil embolization at the authors' hospital. For each patient, procedural details, mode of anesthesia, and clinical and radiographic outcomes were reviewed retrospectively (retrospective case series). 
RESULTS
A total of 197 coil embolizations were performed: 112 under general anesthesia, 78 under conscious sedation with local anesthetics, and 7 converted from conscious sedation to general anesthesia. None of the patients who presented with Hunt & Hess grade IV or V were treated under conscious sedation. For patients who presented with Hunt & Hess grades I, II, and III, 79.2%, 66.7%, and 32.6% of patients, respectively, underwent successful completion of treatment under conscious sedation. The symptomatic procedural complication rate was 2.5% overall and 2.4% for the conscious sedation group alone. Among the 14 interventions with intraprocedural perforation, 11 were performed under general anesthesia and 3 were performed under conscious sedation. 
CONCLUSION
In the authors' experience, conscious sedation with local anesthetics for endovascular treatment of ruptured intracranial aneurysms is feasible and safe in most patients with low-grade SAH. It may allow direct evaluation of the patient's neurological status, potentially leading to earlier detection and response to intraprocedural complications. 
ABBREVIATIONS
HH, Hunt & HessSAH, subarachnoid hemorrhage.



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