动脉瘤夹闭术可能缩短急性动脉瘤性蛛网膜下腔出血相关脑血管痉挛持续时间

Surgical Clipping of Aneurysms may Shorten the Duration of Acute Subarachnoid Hemorrhage Related Vasospasm

目的比较不同治疗方法对动脉瘤性蛛网膜下腔出血（aneurysmal subarachnoid hemorrhage,a SAH）后的血流动力学变化,并分析对a SAH后血管痉挛的影响。方法连续选取2008年4月-2009年10月首都医科大学附属北京天坛医院神经病学中心急诊入院的45例发病在72 h内的a SAH患者,收集基线资料、计算机断层扫描（computed tomography,CT）、经颅多普勒超声（transcranial Doppler,TCD）及90 d改良Rankin量表评分。根据患者接受的治疗分为保守组、填塞组和夹闭组。使用TCD连续测定14 d之内大脑中动脉及大脑前动脉血流速度,计算Lindegaard指数,比较3组的处理平均血流速度、Lindegaard指数及血管痉挛持续时间。结果大脑前动脉/大脑中动脉的平均血流速度及Lindegaard指数由高到低依次为保守组、夹闭组及填塞组[大脑前动脉：平均血流速度为（74.60±5.84）cm/s、（70.00±5.24）cm/s、（65.70±6.03）cm/s,P=0.0001;Lindegaard指数分别为3.87±0.32、3.82±0.31、3.65±0.36,P=0.006;大脑中动脉：平均血流速度分别为（101.2±9.1）cm/s、（87.0±6.2）cm/s、（76.2±9.2）cm/s,P=0.004;Lindegaard指数分别为5.50±0.65、4.15±0.46、3.81±0.55,P=0.005]。夹闭组患者脑血管痉挛持续时间较保守组短[（3.30±1.87）d vs（7.29±2.23）d,P=0.035]。保守组患者90 d预后较差（P=0.028）。结论神经外科夹闭术和血管内动脉瘤填塞术均能缓解急性a SAH后脑血管痉挛的严重程度;外科夹闭术可缩短脑血管痉挛持续时间。

Objective To analyze and compare the value of different treatment methods for acute aneurysmal subarachnoid hemorrhage （aSAH） related vasospasm. Methods The identified population included forty five patients admitted to the Department of Neurology within 72 h after SAH onset from April 2008 to October 2009. Baseline computed tomography （CT） and transcranial Doppler （TCD） were used for assessment. Patients were divided into three groups according to SAH severity and patients’ discretion： non-surgical group, endovascular coiling and neurosurgical clipping. The hemodynamic parameters of middle cerebral artery （MCA） and anterior cerebral artery （ACA） were measured and Lindegaard index was calculated daily from onset to 14th day after SAH. The group mean cerebral blood velocity （MBFV）, Lindegaard index and the duration of vesospasm were compared using repeated measures analysis of variance （reANOVA）. Least signiifcant difference （LSD） test was used for post hoc comparison. Patients were followed for 90 days, and a modified Rankin Scale （mRS） was used to evaluate outcomes. Results The values of MBFV and Lindegaard index of ACA） /MCA from high to low is non-surgical group, clipping and coiling （ACA： MBFV：[74.60±5.84]cm/s, [70.00±5.24]cm/s,[65.70±6.03]cm/s,P=0.0001; Lindegaard index： 3.87±0.32, 3.82±0.31, 3.65±0.36,P=0.006; MCA：MBFV： [101.2±9.1]cm/s, [87.0±6.2]cm/s, [76.2±9.2]cm/s,P=0.004; Lindegaard index：5.50±0.65, 4.15±0.46, 3.81±0.55,P=0.005）. In addition, the duration of cerebral vasospasm in clipping group was substantially shorter than that in non-surgery group （[3.30±1.87]dvs [7.29±2.23]d,P=0.035）. The occurrence rate of poor outcomes in nonsurgical group was higher than the other groups （P=0.028）. Conclusion These results indicate that both neurosurgical clipping and endovascular coiling management may relieve the severity of cerebral vasospasm in acute aSAH. Surgical clipping of aneurysms may shorten the duration of vasospasm in acute aSAH.