罂粟碱不同给药途径防治脑动脉瘤术后脑血管痉挛临床分析

Effect of papaverine administered via different routes in preventing cerebral vasospasm following intracranial aneurysm surgery

目的探讨罂粟碱不同给药途径(脑底池连续泵注与鞘内注射)防治脑动脉瘤术后脑血管痉挛的疗效。方法回顾性分析2014年3月至2017年10月我院收治的147例脑动脉瘤破裂出血患者的临床资料,分为对照组(47例)、脑底池组(50例)和腰大池组(50例)。3组均行开颅显微手术,对照组采用腰大池置管+脑脊液置换+引流;在对照组治疗基础上,脑底池组采用脑底池连续泵注罂粟碱;腰大池组采用腰大池经鞘内注射罂粟碱。比较3组术前及其术后1、7、14 d时术侧大脑中动脉血流动力学指标[收缩期血流峰速度(peak systolic velocity,Vs)、舒张期血流峰速度(peak diastolic velocity,Vd)、平均血流速度(mean velocity,Vm)、搏动指数(pulsatility index,PI)、阻力指数(resistance index,RI)]、并发症及临床预后。结果脑底池组术侧大脑中动脉血流指标(Vs、Vd、Vm、PI、RI)均显著低于腰大池组及对照组(P<0.01);术后14 d随访,脑底池组患者CVS及其脑积水的发生率显著低于腰大池组及对照组(P<0.05,P<0.01);术后30 d随访,脑底池组患者临床预后显著优于腰大池组及对照组(P<0.05)。结论脑底池连续输注罂粟碱防治脑动脉瘤破裂术后血管痉挛,疗效优于腰大池鞘内注射及单纯的脑脊液置换+引流,安全可行。

Objective To compare the effect of papaverine administered via different routes （continuous pumping into the basal cistern vs intrathecal injection） in preventing cerebral vascular spasm （CVS） after surgeries for cerebral aneurysms. Methods A retrospective analysis of the clinical data was conducted for 147 patients undergoing open microsurgical treatment of ruptured cerebral aneurysm in our hospital between March, 2014 and October, 2017. The patients were divided into control group （47 cases）, basal cistern group （50 cases） and lumbar cistern group （50 cases）. The patients in the control group received lumbar cistern catheterization with cerebrospinal fluid replacement and drainage; in addition to the control treatments, the patients in cerebral cistern group were treated with continuous pumping of papaverine into the basal cistern, and those in lumbar cistern group received intrathecal injection of papaverine after the operation. The patients in the 3 groups were compared for hemodynamic parameters of the middle cerebral artery on the surgical side, including the peak systolic velocity （Vs）, peak diastolic velocity （Vd）, mean flow velocity （Vm）, pulsatility index （PI）, and resistance index （RI） and for postoperative complications and outcomes at days 1, 7, and 14 after the surgery. Results Compared with those in lumbar cistern group, the patients in basal cistern group exhibited significantly lower Vs （P〈0.001）, Vd （P〈0.001）, Vm （P〈0.001）, PI （P〈0.001）, and RI （P〈0.003） of the middle cerebral artery on the surgical side. At 14 d after the surgery, the incidence of CVS was significantly lower in basal cistern group than in lumbar cistern group （Chi-square=9.756, P=0.002） and the control group （Chi-square=12.096, P=0.001）; The incidence of hydrocephalus was also significantly lower in basal cistern group than that in lumbar cistern group （Chisquare=5.005, P=0.025） and the control group （Chi-square=5.530, P=0.019）. At 30 d after the operation, the patients in basal cistern group showed significantly better outcomes than those in lumbar cistern group （Z=-2.114, P=0.035） and the control group （Z=-2.437, P=0.015）. Conclusion Continuous pumping of papaverine into the basal cistern produces better effect for preventing CVS following intracranial aneurysm surgery than intrathecal papaverine injection into the lumbar cistern and simple lumbar cistern catheterization with cerebrospinal fluid replacement and drainage.