Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage.
Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage.
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DOI：
10.1371/journal.pone.0174676
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发表时间：
2017
期刊：
影响因子：
3.7
通讯作者：
Gupta R
中科院分区：
文献类型：
--
作者：
Daftari Besheli L;Tan CO;Bell DL;Hirsch JA;Gupta R
动脉内（IA）血管扩张剂治疗是推荐的治疗方法之一，可最大限度地减少蛛网膜下腔出血引起的标准治疗难治性脑血管痉挛的影响。然而，其实用性和有效性尚未得到很好的确定。我们评估了IA血管扩张剂治疗对大脑中动脉血流和出院结果的影响。我们回顾了115名入住神经重症监护室的成人的记录，以测试接受IA输注的患者的临床结局（出院mRS）是否存在差异。在使用IA治疗的19例患者（33支血管）的亚组中，我们测试了治疗是否能有效逆转血流趋势。从输注前第-2天至第-1天，MCA血流量的所有指标均增加（最大峰值收缩速度（PSV）232.2±9.4至262.4±12.5 cm/s [p = 0.02];平均PSV 202.1±8.5至229.9±10.9 [p = 0.02];最高平均流速（MFV）154.3±8.3至172.9±10.5 [p = 0.10];平均MFV 125.5±6.3至147.8±9.5 cm/s，[p = 0.02]），但不是输注后（最大PSV 261.2±14.6 cm/s [p = 0.89];平均PSV 223.4±11.4 [p = 0.56];最高MFV 182.9±12.4 cm/s [p = 0.38];平均MFV 153.0±10.2 cm/s [p = 0.54]）。IA治疗后，流速持续降低（所有测量值的第X天输注相互作用p<0.01）。然而，IA输注组的出院mRS更高，即使在调整性别、年龄和入院等级后。因此，虽然IA血管扩张剂治疗可有效逆转血管痉挛介导的血流恶化，但治疗组的临床结局比未治疗组更差。需要进行前瞻性随机对照试验，以避免选择偏倚的潜在混杂效应。
Intra-arterial (IA) vasodilator therapy is one of the recommended treatments to minimize the impact of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm refractory to standard management. However, its usefulness and efficacy is not well established. We evaluated the effect IA vasodilator therapy on middle cerebral artery blood flow and on discharge outcome. We reviewed records for 115 adults admitted to Neurointensive Care Unit to test whether there was a difference in clinical outcome (discharge mRS) in those who received IA infusions. In a subset of 19 patients (33 vessels) treated using IA therapy, we tested whether therapy was effective in reversing the trends in blood flow. All measures of MCA blood flow increased from day -2 to -1 before infusion (maximum Peak Systolic Velocity (PSV) 232.2±9.4 to 262.4±12.5 cm/s [p = 0.02]; average PSV 202.1±8.5 to 229.9±10.9 [p = 0.02]; highest Mean Flow Velocity (MFV) 154.3±8.3 to 172.9±10.5 [p = 0.10]; average MFV 125.5±6.3 to 147.8±9.5 cm/s, [p = 0.02]) but not post-infusion (maximum PSV 261.2±14.6 cm/s [p = .89]; average PSV 223.4±11.4 [p = 0.56]; highest MFV 182.9±12.4 cm/s [p = 0.38]; average MFV 153.0±10.2 cm/s [p = 0.54]). After IA therapy, flow velocities were consistently reduced (day X infusion interaction p<0.01 for all measures). However, discharge mRS was higher in IA infusion group, even after adjusting for sex, age, and admission grades. Thus, while IA vasodilator therapy was effective in reversing the vasospasm-mediated deterioration in blood flow, clinical outcomes in the treated group were worse than the untreated group. There is need for a prospective randomized controlled trial to avoid potential confounding effect of selection bias.