重症くも膜下出血の管理．根治術施行までの問題点

Abstract

We evaluated the management of patients with subarachnoid hemorrhage (SAH) after arrival for surgical intervention in the ultra-acute stage. Immediately after brief neurological and systemic examination, patients were deeply sedated to prevent aneurysmal rerupture. Principally they were intubated with intensive control of systolic blood pressure below 120 mmHg by radial arterial monitoring. Buprenorphine, midazolam, and vecuronium were rontinely intravenously administered; and propofol, barbiturate, nicardipine, or prostaglandin was added to lower blood pressure if necessary. A total of 163 consecutive patients with SAH (59 men and 104 women, mean age of 61.1 years) arrived between 2003 and 2005 were enrolled. The majority of patients were in poor grade: 26 with Grade IV, 54 with Grade V by grading scale of the World Federation of Neurological Society, and 32 with cardiopulmonary arrest. Eighty-seven patients (53%) arrived within 1 hour after onset of SAH and 127 patients (78%) arrived within 3 hours. Most of the poor-grade patients were intubated before initial brain CT scan. Mean systolic blood pressure was around 170 mmHg at the time of arrival, which was controlled around 120 mmHg or less during resuscitation and angiography. A total of 117 patients had DSA, 111 of them (68%) within 3 hours, and 111 patients underwent surgery, 81 of them (85%) within 6 hours. Despite intensive resuscitation, 36 episodes of rebleeding were detected in 32 patients, 24 before and 12 after arrival. Extravasation of contrast media was seen in 6 patients during cerebral angiography. Favorable outcome (good recovery and moderate disability) was obtained in 69% of Grade IV and 24% of the Grade V patients. The risk of ultra-early rebleeding is highest for patients with poor grades. Deep sedation and strict blood pressure control followed by urgent obliteration of the ruptured aneurysm have a strong rationale to prevent rerupture and to achieve better overall outcome.