床旁TCD监测对蛛网膜下腔出血后迟发性脑缺血价值研究

摘要/Abstract

摘要：

目的探讨床旁经颅多普勒超声（transcranial Doppler，TCD）监测在蛛网膜下腔出血（subarachnoid hemorrhage，SAH）后预测和发现脑血管痉挛，减少迟发性脑缺血（delayed cerebral ischemia，DCI）发生的价值。方法连续纳入2011年10月至2013年10月首都医科大学附属北京天坛医院神内重症监护病房（intensive care unit，ICU）住院的完成床旁TCD监测的222例SAH患者。记录患者的临床及影像资料、治疗及并发症。入院24小时内完成TCD基线监测，根据结果分成正常组85例、流速增快组14例、血管痉挛组123例，比较患者抗血管痉挛强化治疗的使用率、DCI及不良预后［3个月后改良Rankin量表（modified Rankin Scale，mRS）评分4～6分］的发生率和治疗改善率的差异。结果 3组患者比较，血管痉挛组和血流增快组的GCS评分低、Hunt-Hess分级Ⅰ～Ⅲ级比例少、世界神经外科医师联盟（World Federation of Neurosurgical Society，WFNS）分级Ⅰ～Ⅲ级比例少、改良Fisher 分级3～4级所占比例多、颅内血肿发生率多，差异均具有显著性（P <0.05）。血管痉挛组和流速增快组患者DCI 发生率高于正常组（68.2%、35.7%、3.2%，P＜0.01）。TCD流速增快组和血管痉挛组患者给予的抗血管痉挛加强治疗（70.6%、100%、4.1%）及脑脊液置换治疗（21.2%、7.1%、5.7%）多，临床缓解率（56.5%、28.6%、10.6%）高（P＜0.01）。90天随访血管痉挛组和流速增快组预后不良高于正常组（30.6%、21.4%、15.4%，P =0.031）。结论 TCD结果异常的患者（血管痉挛组和血流增快组）发病后的病情重，出血量大，尽管给予加强治疗，DCI的发生率及预后不良率仍高于正常组。床旁TCD监测能够筛查出DCI高危患者并评价治疗效果，是防治DCI所需的有效检测工具。

文章导读： 通过比较SAH患者TCD异常与正常者的抗血管痉挛强化治疗的选择率、DCI及不良预后发生率和治疗效果，评价床旁TCD监测对DCI的临床价值。

关键词: 蛛网膜下腔出血; 经颅多普勒超声; 血管痉挛; 迟发性脑缺血

Abstract:

Objective Transcranial Doppler(TCD) is recommended to monitor for the development of arterial vasospasm. Our aim is to evaluate the effect of TCD in prediction, finding and treating delayed cerebral ischemia(DCI). Methods We analyzed 222 patients(Pts) who had at least 1 transcranial Doppler examination after the admission in neuro-ICU of Tiantan hospital from Oct. 27, 2011 to Oct. 31, 2013. Abnormal MCA mean blood flow velocity(mBFV) was defined as >80 cm/s. Arterial vasospasm was defined as >120cm/s. Patients were divided into 3 groups that were 85 Pts in vasospasm group, 14 Pts in increasing mBFV group and 123 Pts in normal group respectively. Results There were more DCI in the vasospasm group and increasing mBFV group than normal group(68.2%, 35.7%, 3.2%, P <0.1). Intensive treatments were given to them and the higher alleviation rate were found in the above two groups than normal group(P <0.01). But the poor outcomes in 90 days that was defined as mRS≥4 were more in vasospasm group and increasingmBFV group(30.6%, 21.4%, 15.4%, P =0.031)because of being serious conditions at the baseline. This two groups had less GCS, Hent-Hess Ⅰ~Ⅲ, WFNS Ⅰ~Ⅲ and more Modified Fisher Grades Ⅲ~Ⅳ, Intracranial hematoma than normal group. Conclusion Although given intensive treatments, the Transcranial Doppler vasospasm and increasing mBFV groups had more DCIs and more poor outcomes than normal group. Transcranial Doppler should be use as an essential tool to identify patients at higher risk to develop DCI after subarachnoid hemorrhage.

Key words: Subarachnoid hemorrhage; Transcranial Doppler; Cerebral vasospasm; Delayed cerebral ischemia

丁则昱，张倩，吴建维，杨中华，赵性泉. 床旁TCD监测对蛛网膜下腔出血后迟发性脑缺血价值研究[J]. 中国卒中杂志, 2015, 10(10): 841-848.

DING Ze-Yu, ZHANG Qian, WU Jian-Wei, et al.. Bedside Transcranial Doppler Ultrasound Monitoring in the Managements of Subarachnoid Hemorrhage[J]. Chinese Journal of Stroke, 2015, 10(10): 841-848.

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