Objective: To report a patient’s clinical course illustrative of the NPPB mechanism for hyperperfusion-induced injury. Methods: A 65-year-old female presented with a severe headache and was found to have a 6-cm right...Objective: To report a patient’s clinical course illustrative of the NPPB mechanism for hyperperfusion-induced injury. Methods: A 65-year-old female presented with a severe headache and was found to have a 6-cm right parietal AVM on imaging. The patient underwent staged, pre-operative embolization and the AVM was surgically resected without intra-operative complication. After the patient emerged from anesthesia she exhibited left hemiplegia and hemispatial neglect. Her systolic blood pressure (SBP) at that time was between 110-120 mmHg. SBP was reduced to 90-100 mmHg and the patient’s symptoms resolved shortly thereafter. The patient’s strict blood pressure goal was relaxed the next morning. However, with her SBP 110-120 mmHg in the ensuing hours, the patient’s left-sided neglect and hemiparesis returned. Her SBP was reduced again to 90-100 mmHg, leading to resolution of her symptoms. Results: This patient’s clinical course supports the NPPB theory of hyperperfusion-induced injury. Despite CT imaging demonstrating no residual AVM following resection, the patient developed neurological deficits in the immediate postoperative period. Aggressive systemic hypotension improved clinical symptoms repeatedly, whereas a brief period of normotension triggered a return of neurological deficits. As a result, there was a direct correlation between fluctuations of neurological status and SBP. This case suggests that the intrinsic autoregulatory capacity was altered in our patient, and that aggressive hypotension was necessary to compensate for diminished autonomic reactivity. Conclusions: This case provides further evidence that NPPB plays a role in hyperperfusion-induced injury following AVM excision and that blood pressure control is vital in managing hyperemic complications following complete resection of cerebral AVMs.展开更多
Background:Elevated intracranial pressure(ICP)occurs in several physiological and pathological conditions,yet long-term sequellae are not common,which implies that blood flow is preserved above ischemic thresholds.Met...Background:Elevated intracranial pressure(ICP)occurs in several physiological and pathological conditions,yet long-term sequellae are not common,which implies that blood flow is preserved above ischemic thresholds.Methods:This pilot study sought to confirm this hypothesis using a closed cranial window model in a rat in which ICP was elevated to 120 mmHg for 12 min,and superficial cortical perfusion was measured by laser Doppler flowmetry and laser speckle flowmetry.Results:Following a transient increase,cortical blood flow decreased to between 25%and 75%of baseline.These levels correspond to disrupted metabolism and decreased protein synthesis but did not exceed thresholds for electrical signaling or membrane integrity.This may partially explain how some episodes of elevated ICP remain benign.Conclusion:The closed cranial window model provides a platform for prospective study of physiologic responses to artificially elevated ICP during neurosurgery to promote hemostasis.展开更多
目的探讨血压水平对急性缺血性脑卒中血管内治疗后脑灌注的影响。方法80例急性缺血性脑卒中合并高血压接受血管内治疗患者,随机分为积极降压组和指南降压组,每组40例。积极降压组在血管再通后1 h内将血压降至110~140/60~90 mm Hg(1 mm H...目的探讨血压水平对急性缺血性脑卒中血管内治疗后脑灌注的影响。方法80例急性缺血性脑卒中合并高血压接受血管内治疗患者,随机分为积极降压组和指南降压组,每组40例。积极降压组在血管再通后1 h内将血压降至110~140/60~90 mm Hg(1 mm Hg=0.133 kPa)并至少维持72 h;指南降压组按照指南推荐将血压降至<180/110 mm Hg。比较两组患者性别、年龄、卒中部位、入院时的血压(收缩压/舒张压)情况、头颅影像学检查结果[脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT)]、再通术后90 d美国国立卫生研究院卒中量表(NIHSS)评分、改良Rankin量表(mRS)评分、吸烟史、饮酒史、糖尿病史、既往脑梗死病史和冠心病病史情况、病死率,分析脑灌注情况与血压、机械开通成功率、MTT、CBF的相关性。结果两组性别、年龄、卒中部位、病程、入院时血压(收缩压/舒张压)、吸烟史、饮酒史、糖尿病史、既往脑梗死病史和冠心病病史、病死率比较无差异(P>0.05)。积极降压组的机械开通成功率90.0%高于指南降压组的70.0%,头颅影像学检查结果MTT(35.12±2.63)s短于指南降压组的(41.99±2.56)s,CBF(65.72±3.50)ml/(100 g·min)、CBV(4.92±1.03)ml/100 g均大于指南降压组的(50.69±3.49)ml/(100 g·min)、(4.39±1.13)ml/100 g,再通术后90 d NIHSS评分(10.72±3.48)分低于指南降压组的(15.69±3.27)分,预后良好占比87.5%高于指南降压组的67.5%(P<0.05)。急性缺血性脑卒中患者脑灌注充分与否与血压水平呈负相关,与机械开通成功率、MTT、CBF呈正相关(P<0.05)。结论血压水平的控制范围会对急性缺血性脑卒中血管内治疗后脑灌注产生一定影响,而使用积极降压干预有助于改善患者预后,提高机械开通效果。展开更多
文摘Objective: To report a patient’s clinical course illustrative of the NPPB mechanism for hyperperfusion-induced injury. Methods: A 65-year-old female presented with a severe headache and was found to have a 6-cm right parietal AVM on imaging. The patient underwent staged, pre-operative embolization and the AVM was surgically resected without intra-operative complication. After the patient emerged from anesthesia she exhibited left hemiplegia and hemispatial neglect. Her systolic blood pressure (SBP) at that time was between 110-120 mmHg. SBP was reduced to 90-100 mmHg and the patient’s symptoms resolved shortly thereafter. The patient’s strict blood pressure goal was relaxed the next morning. However, with her SBP 110-120 mmHg in the ensuing hours, the patient’s left-sided neglect and hemiparesis returned. Her SBP was reduced again to 90-100 mmHg, leading to resolution of her symptoms. Results: This patient’s clinical course supports the NPPB theory of hyperperfusion-induced injury. Despite CT imaging demonstrating no residual AVM following resection, the patient developed neurological deficits in the immediate postoperative period. Aggressive systemic hypotension improved clinical symptoms repeatedly, whereas a brief period of normotension triggered a return of neurological deficits. As a result, there was a direct correlation between fluctuations of neurological status and SBP. This case suggests that the intrinsic autoregulatory capacity was altered in our patient, and that aggressive hypotension was necessary to compensate for diminished autonomic reactivity. Conclusions: This case provides further evidence that NPPB plays a role in hyperperfusion-induced injury following AVM excision and that blood pressure control is vital in managing hyperemic complications following complete resection of cerebral AVMs.
基金This work was supported by a grant from the National Institute of General Medical Sciences(F31GM089135)to MTO.
文摘Background:Elevated intracranial pressure(ICP)occurs in several physiological and pathological conditions,yet long-term sequellae are not common,which implies that blood flow is preserved above ischemic thresholds.Methods:This pilot study sought to confirm this hypothesis using a closed cranial window model in a rat in which ICP was elevated to 120 mmHg for 12 min,and superficial cortical perfusion was measured by laser Doppler flowmetry and laser speckle flowmetry.Results:Following a transient increase,cortical blood flow decreased to between 25%and 75%of baseline.These levels correspond to disrupted metabolism and decreased protein synthesis but did not exceed thresholds for electrical signaling or membrane integrity.This may partially explain how some episodes of elevated ICP remain benign.Conclusion:The closed cranial window model provides a platform for prospective study of physiologic responses to artificially elevated ICP during neurosurgery to promote hemostasis.
文摘目的探讨血压水平对急性缺血性脑卒中血管内治疗后脑灌注的影响。方法80例急性缺血性脑卒中合并高血压接受血管内治疗患者,随机分为积极降压组和指南降压组,每组40例。积极降压组在血管再通后1 h内将血压降至110~140/60~90 mm Hg(1 mm Hg=0.133 kPa)并至少维持72 h;指南降压组按照指南推荐将血压降至<180/110 mm Hg。比较两组患者性别、年龄、卒中部位、入院时的血压(收缩压/舒张压)情况、头颅影像学检查结果[脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT)]、再通术后90 d美国国立卫生研究院卒中量表(NIHSS)评分、改良Rankin量表(mRS)评分、吸烟史、饮酒史、糖尿病史、既往脑梗死病史和冠心病病史情况、病死率,分析脑灌注情况与血压、机械开通成功率、MTT、CBF的相关性。结果两组性别、年龄、卒中部位、病程、入院时血压(收缩压/舒张压)、吸烟史、饮酒史、糖尿病史、既往脑梗死病史和冠心病病史、病死率比较无差异(P>0.05)。积极降压组的机械开通成功率90.0%高于指南降压组的70.0%,头颅影像学检查结果MTT(35.12±2.63)s短于指南降压组的(41.99±2.56)s,CBF(65.72±3.50)ml/(100 g·min)、CBV(4.92±1.03)ml/100 g均大于指南降压组的(50.69±3.49)ml/(100 g·min)、(4.39±1.13)ml/100 g,再通术后90 d NIHSS评分(10.72±3.48)分低于指南降压组的(15.69±3.27)分,预后良好占比87.5%高于指南降压组的67.5%(P<0.05)。急性缺血性脑卒中患者脑灌注充分与否与血压水平呈负相关,与机械开通成功率、MTT、CBF呈正相关(P<0.05)。结论血压水平的控制范围会对急性缺血性脑卒中血管内治疗后脑灌注产生一定影响,而使用积极降压干预有助于改善患者预后,提高机械开通效果。
