CAJ | 학술논문

目的探讨床旁经颅多普勒超声（transcranial Doppler，TCD）监测在蛛网膜下腔出血（subarachnoid hemorrhage，SAH）后预测和发现脑血管痉挛，减少迟发性脑缺血（delayed cerebral ischemia，DCI）发生的价值。 　　方法连续纳入2011年10月至2013年10月首都医科大学附属北京天坛医院神内重症监护病房（intensive care unit，ICU）住院的完成床旁TCD监测的222例SAH患者。记录患者的临床及影像资料、治疗及并发症。入院24小时内完成TCD基线监测，根据结果分成正常组85例、流速增快组14例、血管痉挛组123例，比较患者抗血管痉挛强化治疗的使用率、DCI及不良预后[3个月后改良Rankin量表（modified Rankin Scale，mRS）评分4～6分]的发生率和治疗改善率的差异。 　　结果3组患者比较，血管痉挛组和血流增快组的GCS评分低、Hunt-Hess分级Ⅰ～Ⅲ级比例少、世界神经外科医师联盟（World Federation of Neurosurgical Society，WFNS）分级Ⅰ～Ⅲ级比例少、改良Fisher分级3～4级所占比例多、颅内血肿发生率多，差异均具有显著性（P<0.05）。血管痉挛组和流速增快组患者DCI发生率高于正常组（68.2%、35.7%、3.2%，P＜0.01）。TCD流速增快组和血管痉挛组患者给予的抗血管痉挛加强治疗（70.6%、100%、4.1%）及脑脊液置换治疗（21.2%、7.1%、5.7%）多，临床缓解率（56.5%、28.6%、10.6%）高（P＜0.01）。90天随访血管痉挛组和流速增快组预后不良高于正常组（30.6%、21.4%、15.4%，P=0.031）。 　　结论 TCD结果异常的患者（血管痉挛组和血流增快组）发病后的病情重，出血量大，尽管给予加强治疗，DCI的发生率及预后不良率仍高于正常组。床旁TCD监测能够筛查出DCI高危患者并评价治疗效果，是防治DCI所需的有效检测工具。
목적탐토상방경로다보륵초성（transcranial Doppler，TCD）감측재주망막하강출혈（subarachnoid hemorrhage，SAH）후예측화발현뇌혈관경련，감소지발성뇌결혈（delayed cerebral ischemia，DCI）발생적개치。 　　방법련속납입2011년10월지2013년10월수도의과대학부속북경천단의원신내중증감호병방（intensive care unit，ICU）주원적완성상방TCD감측적222례SAH환자。기록환자적림상급영상자료、치료급병발증。입원24소시내완성TCD기선감측，근거결과분성정상조85례、류속증쾌조14례、혈관경련조123례，비교환자항혈관경련강화치료적사용솔、DCI급불량예후[3개월후개량Rankin량표（modified Rankin Scale，mRS）평분4～6분]적발생솔화치료개선솔적차이。 　　결과3조환자비교，혈관경련조화혈류증쾌조적GCS평분저、Hunt-Hess분급Ⅰ～Ⅲ급비례소、세계신경외과의사련맹（World Federation of Neurosurgical Society，WFNS）분급Ⅰ～Ⅲ급비례소、개량Fisher분급3～4급소점비례다、로내혈종발생솔다，차이균구유현저성（P<0.05）。혈관경련조화류속증쾌조환자DCI발생솔고우정상조（68.2%、35.7%、3.2%，P＜0.01）。TCD류속증쾌조화혈관경련조환자급여적항혈관경련가강치료（70.6%、100%、4.1%）급뇌척액치환치료（21.2%、7.1%、5.7%）다，림상완해솔（56.5%、28.6%、10.6%）고（P＜0.01）。90천수방혈관경련조화류속증쾌조예후불량고우정상조（30.6%、21.4%、15.4%，P=0.031）。 　　결론 TCD결과이상적환자（혈관경련조화혈류증쾌조）발병후적병정중，출혈량대，진관급여가강치료，DCI적발생솔급예후불량솔잉고우정상조。상방TCD감측능구사사출DCI고위환자병평개치료효과，시방치DCI소수적유효검측공구。
Objective Transcranial Doppler(TCD) is recommended to monitor for the development of arterial vasospasm. Our aim is to evaluate the effect of TCD in prediction, ifnding and treating delayed cerebral ischemia(DCI). Methods We analyzed 222 patients(Pts) who had at least 1 transcranial Doppler examination after the admission in neuro-ICU of Tiantan hospital from Oct. 27, 2011 to Oct. 31, 2013. Abnormal MCA mean blood lfow velocity(mBFV) was deifned as>80 cm/s. Arterial vasospasm was deifned as>120cm/s. Patients were divided into 3 groups that were 85 Pts in vasospasm group, 14 Pts in increasing mBFV group and 123 Pts in normal group respectively. Results There were more DCI in the vasospasm group and increasing mBFV group than normal group(68.2%, 35.7%, 3.2%, P<0.1). Intensive treatments were given to them and the higher alleviation rate were found in the above two groups than normal group(P<0.01). But the poor outcomes in 90 days that was deifned as mRS≥4 were more in vasospasm group and increasing mBFV group(30.6%, 21.4%, 15.4%, P=0.031)because of being serious conditions at the baseline. This two groups had less GCS, Hent-HessⅠ~Ⅲ, WFNSⅠ~Ⅲand more Modiifed Fisher GradesⅢ~Ⅳ, Intracranial hematoma than normal group. Conclusion Although given intensive treatments, the Transcranial Doppler vasospasm and increasing mBFV groups had more DCIs and more poor outcomes than normal group. Transcranial Doppler should be use as an essential tool to identify patients at higher risk to develop DCI after subarachnoid hemorrhage.