ＳＡＨ重症例 重症くも膜下出血の治療―適応決定の問題点―:―適応決定の問題点―
スポンサーリンク
概要
- 論文の詳細を見る
There have been 2 major treatment approaches for patients with severe subarachnoid hemorrhage (SAH): aggressive treatment for all patients irrespective of grade, and treatment of patients selected based on certain indices. We treated 34 patients with poor-grade SAH classified by the Hunt and Kosnik criteria according to an aggressive protocol we had devised (A). To evaluate its efficacy, we compared the results with those obtained in 103 patients treated by the previous protocol (B) involving a selective strategy, and focused on the problems of treating patients with poor-grade SAH. Protocol A: Patients showing no flow in the initial angiogram received supportive care alone; the remaining patients underwent clipping surgery with or without external decompression, or coil embolization; hypothermia or normothermia (for elderly patients or those with complications) was introduced when intracranial pressure (ICP) exceeded 25 mmHg. Protocol B: Patients with SAH+hematoma causing a mass effect underwent emergency surgery; the remaining patients were pretreated for 12 h with control of blood pressure and intracranial pressure, and then radical surgery was performed on all patients who were Grade III or better and on patients at Grade IV below 75 years of age and without systemic complications. Mean arrival time of patients treated by protocol A was 4 h, compared with 1 h in the protocol B group, and the difference was significant. The proportion of patients who underwent radical treatment was 87.5% in A and 53.4% in B, and the difference was also significant. However, a favorable outcome classified as GR or MD by the GOS was seen in 43.8% of patients in group A and 42.7% of those in group B; the death rate was 28.1% and 36.9%, respectively, indicating no significant difference of outcome between the 2 protocols. Hypothermia was effective for management of ICP, but this carries a risk of vasospasm. SjO2 monitoring was useful for control of rewarming and also for predicting outcome during the ultra-early phase. The significantly delayed arrival of patients treated by protocol A suggests that a proportion of patients whose neurological grade may improve within several hours might be initially excluded. If so, the figure of 43.8% for patients achieving GR+MD in protocol A might be improved further.
- 一般社団法人 日本脳卒中の外科学会の論文
一般社団法人 日本脳卒中の外科学会 | 論文
- 頸部内頸動脈のｎｅａｒ ｏｃｃｌｕｓｉｏｎに対するＳＴＡ‐ＭＣＡ吻合術
- 未破裂脳動脈瘤の外科手術の合併症とその対策―慢性硬膜下血腫および後頭蓋窩出血の発生予防―:―慢性硬膜下血腫および後頭蓋窩出血の発生予防―
- 周術期管理指針に基づいたもやもや病に対する血行再建術:―急性期脳血流評価と予防的降圧の効果と限界―
- 未破裂脳動脈瘤クリッピング術の治療成績‐脳動脈瘤手術初心者の経験‐:―脳動脈瘤手術初心者の経験―
- 脳底動脈上小脳動脈分岐部動脈りゅう５８手術例の検討