Интенсивная терапия нетравматического субарахноидального кровоизлияния презентация

Снижается вероятность повторного разрыва (летальность при повторном разрыве 70-80%)
Уменьшается тяжесть церебрального вазоспазма (удаление сгустков крови)
Повышается безопасность мероприятий интенсивной терапии (3 «Н»-терапии и т.д.)

Преимущества раннего хирургического вмешательства

С разрешения А.В.Щеголева

Частота:
15-20% при ясном сознании
30-60% при угнетенном сознании

Гидроцефалия при нетравматическом субарахноидальном кровоизлиянии

Т.М. Исакова, А.Э. Цориев, А.Н. Мирошниченко, М.М. Бухер, М.В.Налесник

Верифицированная
аневризма

Неверифицированная
аневризма

Неотложная
операция

Повторная диагностика
в «холодном» периоде

Ликворный дренаж 5-10 мл/ч
Контроль и лечение ангиоспазма
ТКДГ-мониторинг 2 раза/сутки
Нимодипин (+в/а папаверин?)
Магнезия 10-40 г/сутки
Антиагреганты (при развитии ишемии)
Triple-H терапия
Гиперволемия
Гипертензия
Гемодилюция
Контроль гидроцефалии
Коррекция гипонатриемии
Контроль гемостаза
Базовая терапия ОЦН

Dale Hoekema . Richard H. Schmidt Ian Ross

При полиурии – минирин 0.1 мг 3 раза в сутки, максимально – 1,2 мг
Эффект – сокращение диуреза до 200 мл/ч
Или вазопрессин 0.1-0.5 Ед/мин

We performed a randomized, double-blind, pilot study on magnesium sulfate (MgSO4) infusion for aneurysmal subarachnoid hemorrhage (SAH).
Sixty patients with SAH were randomly allocated to receive either MgSO4 80 mmol/day or saline infusion for 14 days. Patients also received intravenous nimodipine. Episodes of vasospasm were treated with hypertensive and hypervolemic therapy. Neurologic status was assessed 6 months after hemorrhage using the Barthel index and Glasgow Outcome Scale. Incidences of cardiac and pulmonary complications were also recorded.
Patient characteristics, severity of SAH, and surgical treatment did not differ between groups. The incidence of symptomatic vasospasm decreased from 43% in the saline group to 23% in patients receiving MgSO4 infusion, but it did not reach statistical significance, P=0.06. For patients who had transcranial Doppler-detected vasospasm, defined as mean flow velocity >120 cm/s and a Lindegaard index >3, the duration was shorter in the magnesium group compared with controls (P<0.01). There was, however, no difference between groups in functional recovery or Glasgow Outcome Scale score. The incidence of adverse events such as brain swelling, hydrocephalus, and nosocomial infection was also similar in patients receiving MgSO4 or saline.
In this small pilot study, MgSO4 infusion for aneurysmal SAH is feasible. On the basis of the preliminary data, a larger study recruiting approximately 800 patients is required to test for a possible neuroprotective effect of magnesium after SAH.

In the previous studies we determined the increase of cerebral blood flow velocity after childbirth in all pregnant women and found 3 types of maternal cerebral circulation (MCC) depending on the dynamics of linear velocity of the blood flow before and after the childbirth. Patients with the third type were characterized as the risk group for development of angiospasm with clinics of eclampsia.
We hypothesized that the therapy with nimodipin would be effective in prevention of development of eclampsia in patients with 3 type of MCC. We investigated the influence of Nimodipin as Ca-antagonist on the development of angiospasm in postnatal period in patients with the third type of MCC.
Six patients with the 3rd type of MCC without MRI signs of cerebral injury, who developed 1-2 seizures, were examined with transcranial dopplerography by Companion (Nicolet, USA) portable TCD set on the 2,83±0,65 day after the childbirth and 2,16 ± 0,99 days after administration of 40 mg i.v. of Nimodipin (Nimotop, Bayer).

THE INFLUENCE OF NIMODIPIN THERAPY ON MATERNAL CEREBRAL FLOW VELOCITIES (n=6)
Parameter Before nimodipinAfter nimodipin administration DifferencePair Student criteria*Criteria sensitivityVs, sм/s
200,54 ± 30,86142,85 ± 31,0257,7 ± 27,15,211,035%Vd, sм/s126,2 ± 20,3470,32 ± 9,9255,9 ± 19,66,992,495%Vm, sм/s151 ± 22,6494,5 ± 15,0656,5 ± 20,36,811,985%MAP, mm Hg95,56 ± 8,3890,33 ± 11,195,2 ± 8,01,60,015%Vs= systolic velocity, Vs= mean velocity, Vd=diastolic velocity, MAP= mean arterial pressure.
*Critical values were used as t0,05>2,571; t0,01>4,032; t0,001>6,869. Sensitivity α=0,05.
Results In all patients (Table) the decrease of cerebral flow velocities and seizure control were achieved
Conclusions: it is possible not only to make the prognosis on development of angiospasm as the main pathological substance of eclampsia, but to treat such abnormalities with Nimodipin.

(Stroke. 2007;38:1655-1711.)

Stroke, V 38, Number 7, July 2007, p.2180-2184