Inflammation, Cerebral Vasospasm, and Brain Injury in Subarachnoid Hemorrhage-A Shifting Paradigm and a New Beginning.
Inflammation, Cerebral Vasospasm, and Brain Injury in Subarachnoid Hemorrhage-A Shifting Paradigm and a New Beginning.
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DOI：
10.1097/ccm.0000000000003373
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发表时间：
2018-11
影响因子：
8.8
通讯作者：
Chou SH
中科院分区：
文献类型：
--
作者：
Chou SH
蛛网膜下腔出血（SAH）患者的重症监护管理仍然是重症监护医师的日常挑战。SAH突然且不可预测地发生，主要影响相对年轻和健康的人，需要长期的重症监护支持，并使超过50%的幸存者长期严重残疾（1，2）。在最初的出血和出血性动脉瘤的手术或血管内闭塞中存活仅标志着14-21天长的复杂病程的开始。在此期间，超过50%的患者会发生脑血管收缩，约30%的患者会出现新的神经功能缺损，而其他患者可能会在无症状的情况下累积损伤，因为其神经功能缺损的严重程度妨碍了对持续损伤的充分临床检测（3，4）。到目前为止，还没有床旁监护仪或生物标志物可以及时检测SAH相关脑损伤的发作或反映其严重程度（5），重症监护医生经常发现自己在液体复苏、血管加压药和离子支持方面“在黑暗中射击”。目前迫切需要开发生物标志物，如脓毒症中的乳酸，以指导SAH后脑复苏过程中的目标导向治疗。脑血管痉挛和迟发性脑缺血（DCI）是SAH的重要后遗症。这两个实体的定义在文献中有很大的不同，导致这些术语的混淆和难以比较不同SAH临床研究的结果。脑血管痉挛通常是指在放射成像模式上看到的脑动脉狭窄，但许多研究也定义了脑血管痉挛。
Critical care management of subarachnoid hemor-rhage (SAH) patients remains a daily challenge for intensivists. SAH comes on suddenly and unpredictably, primarily afflicts relatively young and healthy people, requires prolonged critical care support, and leaves over 50% of survivors in protracted severe disability (1, 2). Surviving the initial hemorrhage and surgical or endovascular obliteration of the bleeding aneurysm only marks the beginning of a 14–21 days long complex disease course. During this time, over 50% patients would develop cerebral vasoconstriction and~ 30% develop new neurologic deficits whereas others may accrue injuries silently because the severity of their neurologic deficit precludes adequate clinical detection of ongoing injury (3, 4). To date, there are no bedside monitors or biomarkers that can timely detect onset or reflect severity of SAH-associated brain injury (5), and intensivists often find ourselves “shooting in the dark” with fluid resuscitation, vasopressors, and ionotropic support. There is a dire need to develop biomarkers—such as lactate in sepsis—to guide goal-directed therapy in this prolonged course of brain resuscitation after SAH.Cerebral vasospasm and delayed cerebral ischemia (DCI) are important sequalae of SAH. The definitions of these two entities have varied widely in the literature, leading to much confusion over these terminologies and difficulty comparing results from different SAH clinical studies. Cerebral vasospasm often refers to narrowing of cerebral arteries seen on radiographic imaging modalities, but many studies also defined