NCC:诱导性高血压治疗SAH后迟发性脑缺血

2017-09-29 杨中华 脑血管病及重症文献导读

诱导高血压是治疗SAH后迟发性脑缺血(DCI)的常用治疗措施。这项治疗措施通过提高脑灌注压,从而维持或改善脑血流量(CBF)。尽管可能改善预后,但是DCI后诱导性高血压改善预后的有效性和安全性并不清楚。


诱导高血压是治疗SAH后迟发性脑缺血(DCI)的常用治疗措施。这项治疗措施通过提高脑灌注压,从而维持或改善脑血流量(CBF)。尽管可能改善预后,但是DCI后诱导性高血压改善预后的有效性和安全性并不清楚。

目前罕有随机对照试验评价诱导性高血压对预防和治疗DCI的作用,诱导性高血压对脑灌注和临床预后的作用还不清楚,但是这项措施被当前指南推荐,很多中心也采用这项策略。以前有研究显示为了预防DCI预防性诱导高血压能够增加CBF,但是这些研究未设对照组(未接受诱导性高血压)。最近一项关于DCI患者治疗性诱导高血压的研究发现并不能改善CBF,但是该研究仅检测了DCI时和诱导性高血压后的灌注参数,未检测DCI前的灌注参数。

2017年8月来自加拿大多伦多大学的Amanda Murphy等在Neurocrit Care上发表了他们的先导和可行性研究结果。目的:1.诱导性高血压前后CBF、CBV和MTT是否存在差别;2.采用和不采用诱导性高血压者梗死和临床预后是否存在差异。

该回顾性队列分析纳入了25例aSAH患者。当患者发生DCI的临床症状时开始诱导性高血压治疗。比较诱导性高血压患者(n=13)和未诱导高血压患者(n=12)的早期CTP(动脉瘤破裂<72h)及延迟CTP(动脉瘤破裂7-10天)CBF、CBV和MTT的差异。预后评价包括脑梗死和3个月临床预后。

所有患者收入NCU进行监护和治疗,包括尼莫地平21天,脑积水者进行脑是外引流。当患者出现DCI症状时(不是基于CTP影像)采取诱导性高血压策略,静脉输注去甲肾上腺素。在诱导性高血压组,收缩压控制目标为:神经功能缺损完全缓解的最低血压值。逐阶段把收缩压升高到180、190和200mmHg,每个血压阶段都评价神经系统状态。如果收缩压达到200mmHg,神经系统症状仍未完全缓解,采取挽救疗法包括静脉输注米力农,随后血管内球囊血管成形术或动脉内给予米力农。

下图为多伦多大学迟发性脑缺血治疗流程:



结果发现诱导性高血压组的早期CTP-MTT明显高于未诱导高血压组。两组间早期或延迟CTP-CBV或CBF没有差异。对于接受诱导性高血压的患者,早期CTP扫描(7.0+-1.2s)和延迟CTP扫描(5.8+-1.6)的MTT显著降低,P=0.005。诱导性高血压组和未诱导高血压组梗死和不良预后没有显著性差异。

最终作者认为在最终需要诱导性高血压治疗的患者中MTT升高是发展为DCI的重要因素,经过诱导性高血压治疗后能够改善MTT。一经发现脑灌注异常,需要尽早采取预防DCI和改善临床预后的措施。

译者注:过程可能比结果还重要。

原文出处:

Murphy A, de Oliveira Manoel AL, Macdonald RL,et al.Changes in Cerebral Perfusion with Induced Hypertension in Aneurysmal Subarachnoid Hemorrhage: A Pilot and Feasibility Study.Neurocrit Care. 2017 Aug;27(1):3-10. doi: 10.1007/s12028-017-0379-6.

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    2017-12-06 ideal肿瘤医

    学习了

    0

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    2017-10-01 zexyw03
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    2017-09-29 1e145228m78(暂无匿称)

    学习了谢谢作者分享!

    0