目标温度管理在高分级动脉瘤性蛛网膜下腔出血患者中的应用进展

doi:10.3969/j.issn.1673-5765.2023.11.014

摘要/Abstract

摘要： 高分级动脉瘤性蛛网膜下腔出血（poor grade aneurysmal subarachnoid hemorrage，PaSAH）患者易在发病后迅速出现意识障碍、颅内压增高以及高热等危重症状，其死亡率和致残率均很高。诸多证据表明，目标温度管理（target temperature management，TTM）可以改善心搏骤停后导致的脑损伤等疾病的预后。然而，PaSAH患者能否进行TTM仍存在争议。本文对TTM的适应证和禁忌证、多模态监测方式与前景、应用的结果、诱导方式、实施方案和不良反应的相关研究进行综述，以期为TTM应用于PaSAH提供一定的参考依据。

文章导读： 目前TTM应用于PaSAH取得了一定的进展，但仍需高质量TTM多中心研究进一步验证其安全性、有效性，为未来形成临床规范与实践指南奠定基础。

关键词: 动脉瘤性蛛网膜下腔出血; 高分级; 目标温度; 低温治疗

Abstract: Patients with poor grade aneurysmal subarachnoid hemorrhage (PaSAH) are prone to rapid onset of critical symptoms such as consciousness disorder, increased intracranial pressure, and hyperthermia, which are associated with high rates of mortality and disability. Numerous evidences have shown that target temperature management (TTM) can improve the prognosis of diseases such as brain damage caused after cardiac arrest. However, whether TTM can be performed in PaSAH patients remains controversial. In this paper, indications and contraindications in PaSAH patients, multimodal monitoring modalities and prospects, outcomes of application, induction modalities, implementation protocols and adverse reactions were reviewed, with a view to providing some reference for the application of TTM in PaSAH.

Key words: Aneurysmal subarachnoid hemorrhage; Poor grade; Target temperature; Therapeutic hypothermia

刘洋, 冯光. 目标温度管理在高分级动脉瘤性蛛网膜下腔出血患者中的应用进展[J]. 中国卒中杂志, 2023, 18(11): 1307-1314.

LIU Yang, FENG Guang. Research Progress of Target Temperature Management in Patients with Poor Grade Aneurysmal Subarachnoid Hemorrhage[J]. Chinese Journal of Stroke, 2023, 18(11): 1307-1314.

参考文献

[1] BÖSEL J. What do we mean by poor-grade aneurysmal subarachnoid hemorrhage and what can we do?[J]. Neurocrit Care，2016，25（3）：335-337.
[2] ETMINAN N，CHANG H S，HACKENBERG K，et al. Worldwide incidence of aneurysmal subarachnoid hemorrhage according to region，time period，blood pressure，and smoking prevalence in the population：a systematic review and meta-analysis[J]. JAMA Neurol，2019，76（5）：588-597.
[3] 曲鑫，王光明，王宁，等. 长时程亚低温治疗高分级动脉瘤性蛛网膜下腔出血的临床分析[J]. 中华神经外科杂志，2018，34（4）：388-392.
QU X，WANG G M，WANG N，et al. Clinical analysis of long-time mild hypothermia in patients with high-grade aneurysmal subarachnoid hemorrhage[J]. Chin J Neurosurg，2018，34（4）：388-392.
[4] 河南省医师协会神经介入专业委员会，河南省微循环学会神经重症分会. 《高分级动脉瘤性蛛网膜下腔出血综合救治》试行方案中原区域专家共识[J]. 中国临床神经外科杂志，2022，27（6）：513-521.
Neurointervention Professional Committee of Henan Medical Association，Neurocritical Branch of Henan Microcirculatory Society. The pilot plan of expert consensus for the comprehensive treatment of high-grade aneurysmal subarachnoid hemorrhage for the central plains[J]. Chin J Clin Neurosurg，2022，27（6）：513-521.
[5] ZHAO B，TAN X X，YANG H，et al. A multicenter prospective study of poor-grade aneurysmal subarachnoid hemorrhage（AMPAS）：observational registry study[J/OL]. BMC Neurol，2014，14（1）：86[2023-04-18]. https://doi.org/10.1186/1471-2377-14-86.
[6] 中国医师协会神经外科分会神经重症专家委员会，北京医学会神经外科分会神经外科危重症学组，中国神经外科重症管理协作组. 神经重症目标温度管理中国专家共识（2022版）[J]. 中华神经医学杂志，2022，21（7）：649-656.
Neurocritical Care Expert Committee of Neurosurgery Branch of Chinese Medical Doctor Association；Critical Care Group of Neurosurgery，Neurosurgery Branch，Beijing Medical Association；Chinese Neurosurgery Critical Care Management Cooperative Group. Consensus of Chinese experts on targeted temperature management for neurocritical care（2022）[J]. Chin J Neuromed，2022，21（7）：649-656.
[7] 水涛，郭再玉，张国哲，等. 亚低温对重症蛛网膜下腔出血后脑血流速和脑氧摄取率的影响和意义[J]. 中华医学杂志，2018，98（19）：1489-1492.
SHUI T，GUO Z Y，ZHANG G Z，et al. Effect and significance of mild hypothermia on cerebral blood flow velocity and cerebral extraction rate of oxygen in patients with severe subarachnoid hemorrhage[J]. Natl Med J China，2018，98（19）：1489-1492.
[8] 封晓燕，董月娇，焦薇，等. 多模态监测在重型颅脑损伤患者低温治疗中的价值[J]. 创伤外科杂志，2022，24（4）：271-275.
FENG X Y，DONG Y J，JIAO W，et al. Value of multimodal monitoring in hypothermia therapy for patients with severe traumatic brain injury[J]. J Trauma Surg，2022，24（4）：271-275.
[9] GASSER S，KHAN N，YONEKAWA Y，et al. Long-term hypothermia in patients with severe brain edema after poor-grade subarachnoid hemorrhage feasibility and intensive care complications[J]. J Neurosurg Anesthesiol，2003，15（3）：240-248.
[10] HELBOK R，SCHIEFECKER A J，BEER R，et al. Early brain injury after aneurysmal subarachnoid hemorrhage：a multimodal neuromonitoring study[J/OL]. Crit Care，2015，19（1）：75[2023-04-20]. https://doi.org/10.1186/s13054-015-0809-9.
[11] RHIM J K，PARK J J，KIM H，et al. Early and prolonged mild hypothermia in patients with poor-grade subarachnoid hemorrhage：a pilot study[J]. Ther Hypothermia Temp Manag，2022，12（4）：229-234.
[12] SEULE M A，MUROI C，MINK S，et al. Therapeutic hypothermia in patients with aneurysmal subarachnoid hemorrhage，refractory intracranial hypertension，or cerebral vasospasm[J]. Neurosurgery，2009，64（1）：86-93.
[13] SEULE M，MUROI C，SIKORSKI C，et al. Therapeutic hypothermia reduces middle cerebral artery flow velocity in patients with severe aneurysmal subarachnoid hemorrhage[J]. Neurocrit Care，2014，20（2）：255-262.
[14] KURAMATSU J B，KOLLMAR R，GERNER S T，et al. Is hypothermia helpful in severe subarachnoid hemorrhage? An exploratory study on macro vascular spasm，delayed cerebral infarction and functional outcome after prolonged hypothermia[J]. Cerebrovasc Dis，2015，40（5/6）：228-235.
[15] CHOI W，KWON S C，LEE W J，et al. Feasibility and safety of mild therapeutic hypothermia in poor-grade subarachnoid hemorrhage：prospective pilot study[J]. J Korean Med Sci，2017，32（8）：1337-1344.
[16] 张建平. 长时程亚低温治疗动脉瘤性蛛网膜下腔出血效果[J]. 中国城乡企业卫生，2021，36（5）：24-27.
ZHANG J P. Effect of long-term mild hypothermia in the treatment of aneurysmal subarachnoid hemorrhage[J]. Chin J Urban Rural Enterp Hyg，2021，36（5）：24-27.
[17] WON S Y，KIM M K，SONG J，et al. Therapeutic hypothermia in patients with poor-grade aneurysmal subarachnoid hemorrhage[J/OL]. Clin Neurol Neurosurg，2022，221：107369[2023-04-18]. https://doi.org/10.1016/j.clineuro.2022.107369.
[18] KOBATA H，TUCKER A，SARAPUDDIN G，et al. Targeted temperature management for severe subarachnoid hemorrhage using endovascular and surface cooling systems：a nonrandomized interventional study using historical control[J]. Neurosurgery，2022，91（6）：863-871.
[19] KELLER E，IMHOF H G，GASSER S，et al. Endovascular cooling with heat exchange catheters：a new method to induce and maintain hypothermia[J]. Intensive Care Med，2003，29（6）：939-943.
[20] ANNONI F，DONADELLO K，NOBILE L，et al. A practical approach to the use of targeted temperature management after cardiac arrest[J]. Minerva Anestesiol，2020，86（10）：1103-1110.
[21] NIELSEN N，WETTERSLEV J，CRONBERG T，et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest[J]. N Engl J Med，2013，369（23）：2197-2206.
[22] QU X，SHANG F，ZHAO H，et al. Targeted temperature management at 33 degrees celsius in patients with high-grade aneurysmal subarachnoid hemorrhage：a protocol for a multicenter randomized controlled study[J/OL]. Ann Transl Med，2021，9（7）：581[2023-04-18]. https://doi.org/10.21037/atm-20-4719.
[23] TODD M M，HINDMAN B J，CLARKE W R，et al. Mild intraoperative hypothermia during surgery for intracranial aneurysm[J]. N Engl J Med，2005，352（2）：135-145.
[24] LI L R，YOU C，CHAUDHARY B. Intraoperative mild hypothermia for postoperative neurological deficits in people with intracranial aneurysm[J/OL]. Cochrane Database Syst Rev，2016，3（3）：CD008445[2023-04-11]. https://doi.org/10.1002/14651858.CD008445.pub3.
[25] KAWAMURA S，SUZUKI A，HADEISHI H，et al. Cerebral blood flow and oxygen metabolism during mild hypothermia in patients with subarachnoid haemorrhage[J]. Acta Neurochirurgica，2000，42（10）：1117-1122.
[26] KARNATOVSKAIA L V，LEE A S，FESTIC E，et al. Effect of prolonged therapeutic hypothermia on intracranial pressure，organ function，and hospital outcomes among patients with aneurysmal subarachnoid hemorrhage[J]. Neurocrit Care，2014，21（3）：451-461.
[27] 梁红军. 亚低温长时干预治疗高分级动脉瘤继发蛛网膜下腔出血116例疗效分析[J]. 安徽医药，2021，25（1）：111-114.
LIANG H J. Long term mild hypothermia intervention in the treatment of high-gradeaneurysms with subarachnoid hemorrhage：an analysis of 116 cases[J]. Anhui Med Pharmaceut J，2021，25（1）：111-114.
[28] ANDRESEN M，GAZMURI J T，MARÍN A，et al. Therapeutic hypothermia for acute brain injuries[J/OL]. Scand J Trauma Resusc Emerg Med，2015，23：42[2023-03-19]. https://doi.org/10.1186/s13049-015-0121-3.
[29] BADJATIA N，STRONGILIS E，GORDON E，et al. Metabolic impact of shivering during therapeutic temperature modulation：the bedside shivering assessment scale[J]. Stroke，2008，39（12）：3242-3247.
[30] 刘健伟，甄勇，宋炳伟，等. 高分级动脉瘤性蛛网膜
下腔出血患者术后肺炎病原学及耐药性分析[J]. 中国卒中杂志，2023，18（1）：83-89.
LIU J W，ZHEN Y，SONG B W，et al. Etiology and antibacterial drug resistance analysis of post-microsurgery pneumonia in patients with poor-grade aneurysmal subarachnoid hemorrhage[J]. Chin J Stroke，2023，18（1）：83-89.
[31] HILLERSON D B，LAINE M E，BISSELL B D，et al. Contemporary targeted temperature management：clinical evidence and controversies[J]. Perfusion，2023，38（4）：666-680.
[32] SCHEFOLD J C，STORM C，JOERRES A，et al. Mild therapeutic hypothermia after cardiac arrest and the risk of bleeding in patients with acute myocardial infarction[J]. Int J Cardiol，2009，132（3）：387-391.
[33] HE Q G，ZHOU Y，LIU C，et al. Thromboelastography with platelet mapping detects platelet dysfunction in patients with aneurysmal subarachnoid hemorrhage with rebleeding[J/OL]. Neuropsychiatr Dis Treat，2019，15：3443-3451[2023-03-11]. https://doi.org/10.2147/NDT.S229284.
[34] 中国医师协会神经外科医师分会神经重症专家委员会，中华医学会神经外科学分会脑血管病学组，中国医师协会神经介入专业委员会，等. 重症动脉瘤性蛛网膜下腔出血管理专家共识（2023）[J]. 中国脑血管病杂志，2023，20（2）：126-144.
Neurointensive Care Expert Committee of Chinese Neurosurgeons Association，Cerebrovascular Group，Chinese Neurosurgical Society，Chinese Federation of Interventional Clinical Neurosciences（CFITN），et al. Expert consensus on the management of severe aneurysmal subarachnoid hemorrhage 2023[J]. Chin J Cerebrovasc Dis，2023，20（2）：126-144.