Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm
Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm
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DOI：
10.1093/bja/aes264
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发表时间：
2012-09-01
影响因子：
9.8
通讯作者：
Pattinson, K. T. S.
中科院分区：
文献类型：
--
作者：
Rowland, M. J.;Hadjipavlou, G.;Pattinson, K. T. S.
尽管在过去十年中蛛网膜下腔出血的临床治疗有所改善，但迟发性脑缺血（DCI）仍然是初次出血后存活患者发病和死亡的唯一最重要原因。DCI的病理机制尚不清楚，钙通道阻滞剂尼莫地平仍然是唯一被证明可以改善SAH后功能结局的治疗干预。最近，尽管药物clazosentan减少了血管收缩，但未能改善功能结局，这使得对DCI的研究重点从脑动脉收缩转向更多的多因素病因学。新的病理机制已被提出，包括动脉瘤破裂后72小时内脑组织的损伤（“早期脑损伤”），皮质扩散性抑制和微血栓形成。如果要开发预防、诊断和治疗DCI的新方法，则需要更深入地了解这些病理生理机制和潜在遗传风险因素的意义。此外，需要客观和可靠的生物标志物来诊断需要镇静的低级别SAH患者的DCI，并评估新的治疗干预措施的疗效。本文的目的是评价这些最新进展的研究到DCI，将它们与当前的临床实践，并建议潜在的新途径，为未来的研究。
Despite improvements in the clinical management of aneurysmal subarachnoid haemorrhage over the last decade, delayed cerebral ischaemia (DCI) remains the single most important cause of morbidity and mortality in those patients who survive the initial bleed. The pathological mechanisms underlying DCI are still unclear and the calcium channel blocker nimodipine remains the only therapeutic intervention proven to improve functional outcomes after SAH. The recent failure of the drug clazosentan to improve functional outcomes despite reducing vasoconstriction has moved the focus of research into DCI away from cerebral artery constriction towards a more multifactorial aetiology. Novel pathological mechanisms have been suggested, including damage to cerebral tissue in the first 72 h after aneurysm rupture ('early brain injury'), cortical spreading depression, and microthrombosis. A greater understanding of the significance of these pathophysiological mechanisms and potential genetic risk factors is required, if new approaches to the prophylaxis, diagnosis, and treatment of DCI are to be developed. Furthermore, objective and reliable biomarkers are needed for the diagnosis of DCI in poor grade SAH patients requiring sedation and to assess the efficacy of new therapeutic interventions. The purpose of this article is to appraise these recent advances in research into DCI, relate them to current clinical practice, and suggest potential novel avenues for future research.