蛛网膜下腔出血后迟发性脑血管痉挛综合防治的疗效观察

Effective evaluation of combined treatment in delayed cerebrovascular spasm after subarachnoid hemorrhage

目的探讨动脉瘤性蛛网膜下腔出血（aneurysmal subarachnoid hemorrhage，aSAH）后迟发性脑血管痉挛（delayed eerebrovascular spasm，DCVS）综合防治的临床疗效。方法96例aSAH患者随机分成两组，对照组（n=48）：常规治疗加尼莫地平1—2mg／h持续泵入14d。治疗组（n=48）：在对照组治疗基础上同时应用（1）甲基强的松龙30mg／kg体重静点，1次／d，连用7d。（2）盐酸法舒地尔30mg入液静点，3次／d，连用14d。（3）依达拉奉30mg入液静点，2次／d，连用14d。（4）腰穿或脑室穿刺放血性脑脊液。两组均持续监测生命体征，比较治疗前后两组临床表现，意识变化以GCS、病情以Hunt＆Hess分级、预后以格拉斯哥（GOS）评分、CT、MRI、TCD结果为评价指标。结果（1）总体病情GCS、Hunt＆Hess分级及Fisher分级治疗前两组无明显差异（P〉0．05）。（2）头部CT或MRI：治疗组出现脑梗死灶10例（10．4％）低于对照组21例（43．8％）（P〈0．05）。（3）TCD：出血后1d大脑中动脉（MCA）平均流速（单位：cm／s）对照组为115．8±11．5，治疗组为112．5±12．1，两组比较无差异（P〉0．05）。治疗后3、7、14d对照组分别为158．9±13．6，199．4±17．2，129．5±14．4；治疗组130．7±11．8，140．1±16．4，116．7±13．9，在7d治疗组血流速度比对照组明显下降（P〈0．05）；（4）疗效：治疗组显效率（75．0％）明显高于对照组（52．1％）（P〈0．05）。结论SAH后迟发性脑血管痉挛的综合防治效果更佳。

Objective To discuss the clinical effects of combined treatment of delayed cerebrovascular spasm （DCVS） after subarachnoid hemorrhage. Methods 96 cases with intracranial aneurysmal SAH were randomly divided into control group and therapeutic group. The patients in control group were given the routine treatment including Nimodipine 1-2mg/h pumping in continuely for 14 days. The patients in therapeutic group were given the same treatment and Edaravone at dose of 30mg twice a day for14 days, Methylprednisolone at dose of 30rag/（ kg ·d） for 7 days, Fasudil at dose of 30mg three times a day for 14 days. Lumbar puncture or ventricular puncture was given to drain bloody CSF. Vital signs were monitored continuously in all patients. Comparison of clinical data between per and post-therapy in the two groups was done by the statistical analysis, such as clinical manifestation, the level of consciousness as GCS, the conditions of patients as Hunt＆Hess,clinical outcome as GOS and CT, TCD, MRI. Results There were no significantly different between two groups in grade of GCS, Hunt＆Hess, Fisher pre-therapy （ P 〉 0.05 ）. CT and MRI showed that the cases of cerebral infarction were 10（ 10.4% ）in therapeutic group,lowed than 21 （43.8%）in control group （P 〈 0.05 ）. TCD showed the mean blood flow of median cerebral artery（MCA） was（ 115.8 ± 11.5 ） cm/s in control group and（ 112.5 ± 12.1 ） cm/s in therapeutic group （ 1 st day ）, and there was no difference between two groups （ P 〉 0.05 ）. It were separately （ 158.9 ± 13.6） cm/ s on 3d, （ 199.4 ± 17.2） cm/s on 7d and（ 129.5 ± 14.4） cm/s on 14d in control group and （ 130.7 ± 11.8 ） cm/s on 3d, （140.1 ± 16.4）cm/s on 7d,and（ 116.7 ± 13.9）cm/s on 14d in therapeutic group. Compared the results with that in control group the mean blood flow of MCA on 7d in therapeutic group was obviosly slower（ P 〈 0.05 ）. Curative effect comparison showed significant effective rate in therapeutic group （ 75.0% ） was higher than that in control group （52.1% ） （ P 〈 0.05）. Conclusion The combined treatment is a better way for DCVS after SAH.