重症くも膜下出血の急性期治療 重症くも膜下出血急性期治療における頭蓋内および全身的複合病態の意義

Abstract

To elucidate actual clinical features of patients at the poorest grade with subarachnoid hemorrhage (SAH), we studied the relation of intracranial and systemic insults. We studied 524 severely ill cases admitted within 72 hours after the onset of SAH with a Glasgow Coma Scale score (GCS) of 8 to 3 and compared them with patients with a GCS of 9 or more (907 cases) as a less ill group. As an outcome of GCS 6 is nearly the same as that of GCS 7 and significantly different from that of GCS 5, the poorest case with SAH is to be defined as those with GCS 5 or less, and a case with GCS 6 should not be regarded as Grade 5 although the WFNS grading classifies it as Grade 5. Among cases in Grade 5, some with GCS 3 on admission showed remarkable recovery, suggesting that score 3 by GCS includes improving case though it looks as GCS 3 at present. However, cases at GCS 3 who underwent resuscitation (RES) for complete cardio-pulmonary arrest all died, while some of those receiving RES for apnea without complete cardiac arrest survived. Assuming the value obtained from a simple formula [blood sugar level (mg/dl) / serum potassium concentration (mEq/L)] as stress index (SI), SI correlates well with serum catecholamine level at acute stage. This means that we can expect the extent of sympathetic tonus in acute SAH by SI, an easily and quickly calculable index. Cases with SI over 40 are seriously ill both neurologically and as to systemic complications (COMP) produced by a so-called sympathetic storm. Further deterioration with an SI over 50 is not predominantly brought about by pure SAH, but by additional hemorrhagic damage to the brain such as intracerebral hematoma or massive intraventricular hemorrhage. The severely ill group (GCS8-3) exhibited an extremely high mean SI of around 60 with or without COMP, while in the less ill group (GCS≥9) those with COMP showed a significantly higher mean SI (59) than those without (43). If the patient's neurological condition is not serious but the patient shows an SI over 60, one should pay much attention to possible cardio-pulmonary complications such as cardiac arrhythmia, heart failure or pulmonary edema.