腰池连续引流结合药物治疗蛛网膜下腔出血与单纯脑脊液置换疗效对比分析研究

【作者】 高有安；

【导师】 许予明；

【作者基本信息】 郑州大学 ， 神经内科， 2006， 硕士

【摘要】 目的：蛛网膜下腔出血(subarachnoid hemorrhage，SAH)是神经内科常见急危重症之一，致死、致残率高，除了急性期急性脑脊液循环梗阻、脑积水、高颅压等早期病理因素外，迟发性脑血管痉挛(delayed cerebral vessels spasm，DCVS)是SAH的常见并发症，其发生率可高达30％—60％[1]，是SAH患者致死、致残的主要原因。内科保守治疗SAH愈后较差，采用腰穿脑脊液置换术能加快蛛网膜下腔积血的清除速度，减少并发症、降低致死、致残率，是临床上常用的治疗方法之一，但此方法引流脑脊液的数量有限，且反复腰穿易造成病人紧张。腰池置管脑脊液连续外引流术遵循脑脊液循环的生理机制，每天引流脑脊液量大，积血的清除速度快，联合椎管注入尿激酶(Urokinase，UK)及地塞米松可最大限度的溶解积血，降低颅内压及减少血性脑脊液的刺激，能更有效的减少脑血管痉挛发生，国内外仅有少量报道[2，3，4]。本文以单纯腰穿脑脊液置换术为对照，研究脑脊液连续引流结合椎管内注入UK及地塞米松对SAH的治疗作用，同时应用经颅多普勒(TCD)检测观察脑脊液连续引流结合椎管内注入UK及地塞米松治疗(联合治疗组)对DCVS的预防作用，为临床上采取更有效的治疗SAH和预防DCVS的方法提供试验依据。方法：将我院2003年6月致2006年6月入院的符合1996年全国脑血管病学术会议制订的SAH诊断标准[5]的SAH患者随机分为单纯脑脊液置换组和联合治疗组。患者入院后均作Hunt分级，常规应用脱水剂、止血剂和钙离子拮抗剂等。在无腰穿禁忌症的情况下，脑脊液置换术组：常规腰穿，分次放出脑脊液20ml，注入等量生理盐水置换，入院前4d每同脑脊液置换一次，以后改为隔天一次或三天一次。联合治疗组于入院后4～6 h内应用腰池置管脑脊液持续外引流术，测初压后，置入硬膜外麻醉导管，控制引流速度为每24 h引流150～300ml，以后的3天内，每引流24 h椎管内注射尿激酶(UK)2万U，12 h后椎管内注射地塞米松10mg，每次注药后闭管2h。两组均以头颅CT显示蛛网膜下腔积血消失或脑脊液变清亮、压力正常为结束脑脊液置换和引流指标。观察并记录两组病例头痛缓解时间、脑脊液压力恢复正常时间、意识清醒时间，并于引流后第1、2、4、7、10、15 d作CT检查记录蛛网膜下腔积血的清除时间；所有患者手术后每天应用TCD探测颅内各血管的血流速度(流速>140cm／s视为存在血管痉挛)发现血管痉挛的病例，比较两组DCVS的发生率。结果：共收集SAH患者74人，脑脊液置换术组35例，联合治疗组39例。两组患者在性别，年龄，疾病构成上无显著性差异。治疗前Hunt分级两组间也无显著性差异，联合治疗组在头痛缓解时间、蛛网膜下腔积血清除时间、脑脊液压力正常时间、脑脊液常规、生化恢复正常时间、意识清醒时间、DCVS的发生率等方面均少于脑脊液置换术组(p＜0.05)。结论：1．腰池连续引流联合椎管注入尿激酶(uK)和地塞米松治疗蛛网膜下腔出血方法安全，临床综合效果优于常规脑脊液置换法，DCVS发生率低。2．脑脊液连续引流联合椎管内注入尿激酶和地塞米松治疗SAH的方法，简单易操作，治疗效果好，适合临床使用。更多还原

【Abstract】 Obejective: subarachnoid hemorrhage (SAH) is one of the emergencies in neurology department, delayed cerebral vessels spasm (DCVS)is its common complication with high incidence rate about 30%-60%. DCVS is the most important death cause of SAIl patients. It is difficult to cure these patients with only medical treatment. Replacement of the cerebrospinal fluid by lumbar puncture can clean up haematocele in subarachnoid space quickly and decrease the incidence of mutilation and death and now it is widely used to treat SAH patients. But with this method the cerebrospinal fluid being drained is limited and patients are easy to be nervous. Persistent cerebrospinal fluid draining by putting a canal in lunar subarachnoid space, which abide by the physiological mechanisms of cerebrospinal fluid circulation and more cerebrospinal fluid could be replaced, more hematocele could be cleared. Combined treatment with Urokinase(UK) and dexamethasone can dissolve most of the hematocele, lower the intracranial pressure, palliate the blood irritation and decrease the incidence of cerebral vessel spasm. Some research have been done in overseas, we did not find any research about this field in china. In this research we investigate the curative effect of persistent cerebrospinal fluid draining by lumbosubarachnoid cannula combining with UK and dexamethasone intradural injection to SAH patients, compared with the common method of replacing the cerebrospinal fluid by lumbar puncture. We also investigate its preservation effect to DCVS diagnosed by TCD.Method: Divide the SAH patients in our hospital from 2003.6 to 2006.6 into treatment group and control group. All these patients were diagnosed by the SAIl diagnostic criteria established by the chinese cerebrovascular disease metting 1996, and confirmed by computed tomography(CT). Hunt level were scored every patient.All of them were treated with dehydrater, haemostat, and calcium channel blocker. Patients in the control group received lumbar puncture and replacement of the cerebrospinal fluid,as 20ml cerebrospinal fluid was released and equal volume of normal saline was injected. In the first 4days once replacement every day, in the after days once every 2 or 3 days.Patients in the treatment group were dealt with persistent cerebrospinal fluid draining by lumbosubarachnoid cannula combining with Urokinase(UK) and dexamethasone intradural injection. Patients received normal lunar puncture. After measuring the intracranial pressure, a 16 code segmental eqidural catheter was put into the cephalad subarachnoid space. A tubing and an asepsis drainage pack were connected to the end of the catheter, controlling the drainage rate to 150～300ml/24h.In.the following 3 days, 20 thousand units UK was injected intradural and the catheter was clipped for 2h after 24h drainage. 12h after UK was injected, 10mg dexamethasone was injected intradural and the catheter was clipped for 2h again. In both group, when the routine and biochemistry examination of the cerebrospinal fluid was completely normal, the replacement or drainage ended. Record the time when the headache was relieved, the cerebrospinal fluid pressure was normal and the patients woke up,respectively. CT scans was done at 1, 2, 4, 7, 10 and 15 days after the drainage ended to record the time when the haematocele was cleared up. All these patients received TCD every day after the operation, to detect the blood flow rate of all intracranial vassels DCVS was diagnosed if the blood flow rate was beyond 140cm/s and identified by MRA. Compared the incidence of DCVS between these two groups.Result: There were 39 patients in the treatment group and 35 patients in the control group. There were e in sex age and disease composition and the hunt level between these two groups,.There were significant differences in time of headache relief, haematocele disappearing, cerebrospinal fluid pressure becoming normal and patients waking up between these two groups. The incidence of DCVS was significant different between these two groups, too. Conclusion: Treating SAH patients with persistent cerebrospinal fluid draining by lumbosubarachnoid cannula combining with UK and dexamethasone intradural injection is safe and effective, which have a better curative effect and a lower incidence of DCVS.than the common method of replacing the cerebrospinal fluid by lumbar puncture更多还原