切换至 "中华医学电子期刊资源库"
高级检索
中华神经创伤外科电子杂志

中华神经创伤外科电子杂志 ›› 2024, Vol. 10 ›› Issue (04) : 248 -253. doi: 10.3877/cma.j.issn.2095-9141.2024.04.010

综述

动脉瘤性蛛网膜下腔出血的颅内压监测与管理
冯铭1, 孙洪涛2,†()   
  1. 1.300162 天津，中国人民武装警察部队特色医学中心神经外科
    2.300162 天津，武警特色医学中心神经创伤修复研究所
  • 收稿日期:2024-04-23 出版日期:2024-08-15
  • 通信作者: 孙洪涛
  • 基金资助:
    国家自然科学基金（32070791）

Intracranial pressure monitoring and management in aneurysmal subarachnoid hemorrhage

Ming Feng1, Hongtao Sun2,†()   

  1. 1.Department of Neurosurgery, Special Medical Center of Chinese People's Armed Police Force, Tianjin 300162, China
    2.Institute of Nerve Trauma Repair, Characteristic Medical Center of Armed Police Force,Tianjin Key Experiment of Nerve Trauma Repair,Tianjin 300162,China
  • Received:2024-04-23 Published:2024-08-15
  • Corresponding author: Hongtao Sun
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

冯铭, 孙洪涛. 动脉瘤性蛛网膜下腔出血的颅内压监测与管理[J]. 中华神经创伤外科电子杂志, 2024, 10(04): 248-253.

Ming Feng, Hongtao Sun. Intracranial pressure monitoring and management in aneurysmal subarachnoid hemorrhage[J]. Chinese Journal of Neurotraumatic Surgery(Electronic Edition), 2024, 10(04): 248-253.

动脉瘤性蛛网膜下腔出血（aSAH）作为一种神经系统急症，具有极高的死亡率和致残率。颅内压（ICP）增高是aSAH 患者常见的临床表现之一，早期脑损伤（包括血脑屏障破坏、脑水肿和脑血管自动调节受损）被认为是aSAH 后ICP增高的常见原因，若未及时治疗，将严重威胁患者生命。然而，aSAH 后ICP增高的病理生理机制复杂，目前尚未完全阐明。近年来，越来越多的证据表明，氧化应激与aSAH 后ICP 增高密切相关。尽管目前aSAH 的治疗已取得一定的进展，但针对aSAH后ICP增高的管理尚无统一的共识指南。本文总结了aSAH后ICP增高的病理生理学特点，并回顾现有的各种治疗管理策略，旨在探讨ICP监测和管理的最佳方案，以期为临床实践提供参考。

关键词: 蛛网膜下腔出血, 颅内动脉瘤, 颅内压, 氧化应激

Aneurysmal subarachnoid hemorrhage (aSAH) is a neurological emergency with extremely high rates of mortality and disability. Elevated intracranial pressure (ICP) is a common clinical manifestation of aSAH. Early brain injury, including blood-brain barrier disruption, brain edema, and impaired cerebral autoregulation,is considered to be a major cause of elevated ICP following aSAH.If left untreated, elevated ICP can pose a serious threat to the patient's life. However, the pathophysiological mechanisms underlying ICP elevation after aSAH are complex and not yet fully understood. In recent years, growing evidence has indicated that oxidative stress is closely associated with ICP elevation following aSAH. Although there have been certain advances in the treatment of aSAH, there is currently no unified consensus or guideline for managing elevated ICP in aSAH. This review summarizes the pathophysiological characteristics of ICP elevation in aSAH and examines the existing management strategies, aiming to identify the best approaches for ICP monitoring and management, with the goal of providing reference for clinical practice.

Key words: Subarachnoid hemorrhage, Intracranial aneurysm, Intracranial pressure, Oxidative stress
图1 aSAH后氧化应激对ICP增高的作用示意图 aSAH：动脉瘤性蛛网膜下腔出血；OS：氧化应激；ICP：颅内压
Fig.1 Schematic diagram of the effect of OS on ICP increase after aSAH
[1]
李文虎,付帅,武玉亮,等.动脉瘤性蛛网膜下腔出血后认知功能障碍的研究进展[J].中华脑科疾病与康复杂志(电子版),2022,12(2):115-119.DOI:10.3877/cma.j.issn.2095-123X.2022.02.010.Li WH, Fu S, Wu YL, et al. Research progress of cognitive dysfunction after aneurysmal subarachnoid hemorrhage[J]. Chin J Brain Dis Rehabil (Electronic Edition), 2022, 12(2): 115-119.DOI:10.3877/cma.j.issn.2095-123X.2022.02.010.
[2]
Petridis AK, Kamp MA, Cornelius JF, et al. Aneurysmal Subarachnoid Hemorrhage[J]. Dtsch Arztebl Int, 2017, 114(13):226-236.DOI:10.3238/arztebl.2017.0226.
[3]
刘洋,刘秀,张玺,等.血清尿酸与动脉瘤性蛛网膜下腔出血患者Hunt-Hess 分级及短期预后相关性研究[J].中华神经创伤外科电子杂志,2019,5(4):201-205.DOI:10.3877/cma.j.issn.2095-9141.2019.04.003.Liu Y, Liu X, Zhang X, et al. Correlation between serum uric acid and hunt Hess classification and short-term prognosis in patients with aneurysmal subarachnoid hemorrhage[J]. Chin J Neurotrauma Surg (Electronic Edition),2019,5(4):201-205.DOI:10.3877/cma.j.issn.2095-9141.2019.04.003.
[4]
Czorlich P, Schweingruber N, Göttsche J, et al. Acute low -pressure hydrocephalus in aneurysmal subarachnoid hemorrhage[J]. Neurosurg Focus, 2023, 54(4): E5. DOI: 10.3171/2023.1.FOCUS22639.
[5]
Etminan N, Macdonald RL. Management of aneurysmal subarachnoid hemorrhage[J]. Handb Clin Neurol, 2017, 140: 195-228.DOI:10.1016/B978-0-444-63600-3.00012-X.
[6]
Marko NF. Hypertonic saline, not mannitol, should be considered gold-standard medical therapy for intracranial hypertension[J].Crit Care,2012,16(1):113.DOI:10.1186/cc11182.
[7]
Sabri M, Lass E, Macdonald RL. Early brain injury: a common mechanism in subarachnoid hemorrhage and global cerebral ischemia[J].Stroke Res Treat,2013,2013:394036.DOI:10.1155/2013/394036.
[8]
Brinker T, Seifert V, Stolke D. Acute changes in the dynamics of the cerebrospinal fluid system during experimental subarachnoid hemorrhage[J].Neurosurgery,1990,27(3):369-372.DOI:10.1097/00006123-199009000-00005.
[9]
Grote E, Hassler W. The critical first minutes after subarachnoid hemorrhage[J]. Neurosurgery, 1988, 22(4): 654 - 661. DOI:10.1227/00006123-198804000-00006.
[10]
Graetz D, Nagel A, Schlenk F, et al. High ICP as trigger of proinflammatory IL - 6 cytokine activation in aneurysmal subarachnoid hemorrhage[J]. Neurol Res, 2010, 32(7): 728-735.DOI:10.1179/016164109X12464612122650.
[11]
Shimizu T, Hishikawa T, Nishihiro S, et al. NADH fluorescence imaging and the histological impact of cortical spreading depolarization during the acute phase of subarachnoid hemorrhage in rats[J]. J Neurosurg, 2018, 128(1): 137-143. DOI:10.3171/2016.9.JNS161385.
[12]
Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage[J]. Lancet, 2017, 389(10069): 655 - 666. DOI:10.1016/S0140-6736(16)30668-7.
[13]
Altay O,Suzuki H,Hasegawa Y,et al.Isoflurane attenuates bloodbrain barrier disruption in ipsilateral hemisphere after subarachnoid hemorrhage in mice[J]. Stroke, 2012, 43(9): 2513-2516.DOI:10.1161/STROKEAHA.112.661728.
[14]
Lv Y,Wang D,Lei J,et al.Clinical observation of the time course of raised intracranial pressure after subarachnoid hemorrhage[J].Neurol Sci, 2015, 36(7): 1203-1210. DOI: 10.1007/s10072-015-2073-9.
[15]
Wu F, Liu Z, Li G, et al. Inflammation and Oxidative Stress:Potential Targets for Improving Prognosis After Subarachnoid Hemorrhage[J]. Front Cell Neurosci, 2021, 15: 739506. DOI:10.3389/fncel.2021.739506.
[16]
Ayer RE, Zhang JH. Oxidative stress in subarachnoid haemorrhage: significance in acute brain injury and vasospasm[J].Acta Neurochir Suppl,2008,104:33-41.DOI:10.1007/978-3-211-75718-5_7.
[17]
Fumoto T, Naraoka M, Katagai T, et al. The Role of Oxidative Stress in Microvascular Disturbances after Experimental Subarachnoid Hemorrhage[J]. Transl Stroke Res, 2019, 10(6): 684-694.DOI:10.1007/s12975-018-0685-0.
[18]
Sabri M, Ai J, Knight B, et al. Uncoupling of endothelial nitric oxide synthase after experimental subarachnoid hemorrhage[J]. J Cereb Blood Flow Metab, 2011, 31(1): 190-199. DOI: 10.1038/jcbfm.2010.76.
[19]
Ishiguro M, Morielli AD, Zvarova K, et al. Oxyhemoglobin -induced suppression of voltage - dependent K+ channels in cerebral arteries by enhanced tyrosine kinase activity[J].Circ Res,2006, 99(11): 1252-1260. DOI: 10.1161/01.RES.0000250821.32324.e1.
[20]
Link TE, Murakami K, Beem-Miller M, et al. Oxyhemoglobininduced expression of R-type Ca2+channels in cerebral arteries[J].Stroke, 2008, 39(7): 2122-2128. DOI: 10.1161/STROKEAHA.107.508754.
[21]
Robba C, Graziano F, Rebora P, et al. Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study[J]. Lancet Neurol, 2021, 20(7): 548 - 558. DOI:10.1016/S1474-4422(21)00138-1.
[22]
中国医师协会神经外科医师分会神经重症专家委员会,中华医学会神经外科学分会脑血管病学组,中国医师协会神经介入专业委员,等.重症动脉瘤性蛛网膜下腔出血管理专家共识(2023)[J]. 中国脑血管病杂志, 2023, 20(2): 126-145. DOI:10.3969/j.issn.1672-5921.2023.02.009.Neurointensive Care Expert Committee of Chinese Neurosurgeons Association; Cerebrovascular Group, Chinese Neurosurgical Society; Chinese Federation of Interventional Clinical Neurosciences (CFITN), et al. Expert consensus on the management of severe aneurysmal subarachnoid hemorrhage(2023)[J]. Chin J Cerebrovasc Dis, 2023, 20 (2): 126-145. DOI:10.3969/j.issn.1672-5921.2023.02.009.
[23]
Springborg JB, Frederiksen HJ, Eskesen V, et al. Trends in monitoring patients with aneurysmal subarachnoid haemorrhage[J].Br J Anaesth,2005,94(3):259-270.DOI:10.1093/bja/aei004.
[24]
Müller SJ, Henkes E, Gounis MJ, et al. Non-Invasive Intracranial Pressure Monitoring[J]. J Clin Med, 2023, 12(6): 2209. DOI:10.3390/jcm12062209.
[25]
Carney N, Totten AM, O ' Reilly C, et al. Guidelines for the management of severe traumatic brain injury[J]. Neurosurgery,2017,80(1):6-15.DOI:10.1227/NEU.0000000000001432.
[26]
Pasarikovski CR, Alotaibi NM, Al-Mufti F, et al. Hypertonic saline for increased intracranial pressure after aneurysmal subarachnoid hemorrhage: A systematic review[J]. World Neurosurg,2017,105:1-6.DOI:10.1016/j.wneu.2017.05.085.
[27]
Steiner T, Juvela S, Unterberg A, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage[J]. Cerebrovasc Dis,2013,35(2):93-112.DOI:10.1159/000346087.
[28]
Wang AY, Hsieh PC, Chen CC, et al. Effect of intracranial pressure control on improvement of cerebral perfusion after acute subarachnoid hemorrhage: A comparative angiography study based on temporal changes of intracranial pressure and systemic pressure[J]. World Neurosurg, 2018, 120: e290 - e296. DOI:10.1016/j.wneu.2018.08.053.
[29]
Cagnazzo F, Chalard K, Lefevre PH, et al. Optimal intracranial pressure in patients with aneurysmal subarachnoid hemorrhage treated with coiling and requiring external ventricular drainage[J].Neurosurg Rev, 2021, 44(2): 1191-1204. DOI: 10.1007/s10143-020-01322-2.
[30]
Chung DY,Olson DM,John S,et al.Evidence-based management of external ventricular drains[J]. Curr Neurol Neurosci Rep, 2019,19(12):94.DOI:10.1007/s11910-019-1009-9.
[31]
Konovalov A, Shekhtman O, Pilipenko Y, et al. External ventricular drainage in patients with acute aneurysmal subarachnoid hemorrhage after microsurgical clipping: Our 2006-2018 experience and a literature review[J]. Cureus, 2021, 13(1):e12951.DOI:10.7759/cureus.12951.
[32]
Klopfenstein JD, Kim LJ, Feiz-Erfan I, et al. Comparison of rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage: a prospective randomized trial[J]. J Neurosurg, 2004, 100(2): 225-229. DOI:10.3171/jns.2004.100.2.0225.
[33]
Fried HI, Nathan BR, Rowe AS, et al. The insertion and management of external ventricular drains: An evidence-based consensus statement: A statement for healthcare professionals from the neurocritical care society[J]. Neurocrit Care, 2016, 24(1):61-81.DOI:10.1007/s12028-015-0224-8.
[34]
Kim GS, Amato A, James ML, et al. Continuous and intermittent CSF diversion after subarachnoid hemorrhage: a pilot study[J].Neurocrit Care, 2011, 14(1): 68-72. DOI: 10.1007/s12028-010-9401-y.
[35]
Palasz J, D'Antona L, Farrell S, et al. External ventricular drain management in subarachnoid haemorrhage: a systematic review and meta-analysis[J]. Neurosurg Rev, 2022, 45(1): 365-373. DOI:10.1007/s10143-021-01627-w.
[36]
Al - Tamimi YZ, Bhargava D, Feltbower RG, et al. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS)[J]. Stroke, 2012, 43(3): 677-682. DOI: 10.1161/STROKEAHA.111.625731.
[37]
Hoh BL, Ko NU, Amin-Hanjani S, et al. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the american heart association/american stroke association[J]. Stroke, 2023, 54(7): e314-e370.DOI:10.1161/STR.0000000000000436.
[38]
黄学才,杨玲玲.高渗盐水和甘露醇在动脉瘤性蛛网膜下腔出血患者降低颅内压中的应用.浙江大学学报（医学版）,2015,44(4):389-395.DOI:10.3785/j.issn.1008-9292.2015.07.07.Huang XC, Yang LL. Comparison clinical efficacy of 3%hypertonic saline solution with 20% mannitol in treatment of intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage[J].J Zhejiang Univ (Medical Sci),2015,44(4):389-395.DOI:10.3785/j.issn.1008-9292.2015.07.07.
[39]
Meng L, Gelb AW. Regulation of cerebral autoregulation by carbon dioxide[J]. Anesthesiology, 2015, 122(1): 196-205. DOI:10.1097/ALN.0000000000000506.
[40]
Inoue S. Temperature management for deliberate mild hypothermia during neurosurgical procedures[J]. Fukushima J Med Sci,2022,68(3):143-151.DOI:10.5387/fms.2022-28.
[41]
Piepgras A, Elste V, Frietsch T, et al. Effect of moderate hypothermia on experimental severe subarachnoid hemorrhage, as evaluated by apparent diffusion coefficient changes[J].Neurosurgery,2001, 48(5): 1128-1134; discussion 1134-1135. DOI: 10.1097/00006123-200105000-00033.
[42]
Todd MM, Hindman BJ, Clarke WR, et al. Mild intraoperative hypothermia during surgery for intracranial aneurysm[J]. N Engl J Med,2005,352(2):135-145.DOI:10.1056/NEJMoa040975.
[43]
Inamasu J, Ichikizaki K. Mild hypothermia in neurologic emergency: an update[J]. Ann Emerg Med, 2002, 40(2): 220-230.DOI:10.1067/mem.2002.123697.
[44]
de Oliveira Manoel AL, Goffi A, Marotta TR, et al. The critical care management of poor-grade subarachnoid haemorrhage[J].Crit Care,2016,20:21.DOI:10.1186/s13054-016-1193-9.
[45]
Finfer SR, Ferch R, Morgan MK. Barbiturate coma for severe,refractory vasospasm following subarachnoid haemorrhage[J].Intensive Care Med, 1999, 25(4): 406-409. DOI: 10.1007/s00 1340050866.
[46]
Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates[J]. Neurologia (Engl Ed), 2023, 38(5):357-363.DOI:10.1016/j.nrleng.2020.08.024.
[47]
Addis A, Baggiani M, Citerio G. Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage[J].Neurocrit Care, 2023, 39(1): 59-69. DOI: 10.1007/s12028-023-01752-y.
[48]
Björk S, Hånell A, Ronne-Engström E, et al. Thiopental and decompressive craniectomy as last-tier ICP-treatments in aneurysmal subarachnoid hemorrhage: is functional recovery within reach?[J].Neurosurg Rev, 2023, 46(1): 231. DOI: 10.1007/s10143-023-02138-6.
[49]
魏宜功,周焜,陈光唐,等.颅内压监测下改良阶梯减压法结合去骨瓣减压治疗颅内高压的疗效分析[J].中华神经创伤外科电子杂志, 2022, 8(1): 28-33. DOI: 10.3877/cma.j.issn.2095-9141.2022.01.006.Wei YG, Zhou K, Chen GT, et al. Clinical analysis of modified stepwise decompression technique combined with decompressive craniectomy under intracranial pressure monitoring to treat high intracranial pressure[J]. Chin J Neurotrauma Surg (Electronic Edition), 2022, 8(1): 28-33. DOI: 10.3877/cma.j.issn.2095-9141.2022.01.006.
[1] 杨文飞, 郝嘉文, 鲁梦远, 赵学刚, 李聪颖, 盖晨阳, 张晶, 张庆富. 高压电烧伤对大鼠心肌氧化应激的影响及N-乙酰半胱氨酸的干预作用[J]. 中华损伤与修复杂志(电子版), 2024, 19(02): 106-112.
[2] 鲁梦远, 赵学刚, 郝嘉文, 盖晨阳, 李聪颖, 张晶, 张庆富. 高压电烧伤大鼠肝脏氧化应激损伤及灯盏花素的干预作用[J]. 中华损伤与修复杂志(电子版), 2024, 19(02): 113-118.
[3] 李嘉兴, 孙乙文, 李文星. NLRP3炎性小体在急性胰腺炎中作用的研究进展[J]. 中华普通外科学文献(电子版), 2024, 18(04): 300-304.
[4] 张璇, 高杨, 房雅君, 姚艳玲. 保护性机械通气在肺癌胸腔镜肺段切除术中的临床应用[J]. 中华肺部疾病杂志(电子版), 2024, 17(04): 563-567.
[5] 殷国青, 曾莉, 贺斌峰, 孙芬芬. Rab26负性调控Nrf2增强肺癌耐药细胞对奥希替尼的敏感性[J]. 中华肺部疾病杂志(电子版), 2024, 17(03): 349-355.
[6] 王娟, 刘晔, 熊威, 蒋财磊, 贺燕, 叶青松. 间充质干细胞缓解阿尔茨海默病氧化应激的新思路[J]. 中华细胞与干细胞杂志(电子版), 2024, 14(02): 93-106.
[7] 杜霞, 马梦青, 曹长春. 造影剂诱导的急性肾损伤的发病机制及干预靶点研究进展[J]. 中华肾病研究电子杂志, 2024, 13(05): 279-282.
[8] 王子琪, 李萍, 蔡标, 杨秀敏. 雌激素在糖尿病性视网膜病变中作用机制的研究进展[J]. 中华眼科医学杂志(电子版), 2024, 14(03): 187-192.
[9] 唐必英, 李钢. 治疗时机对动脉瘤性蛛网膜下腔出血患者预后的影响[J]. 中华神经创伤外科电子杂志, 2024, 10(04): 213-219.
[10] 李晓东, 李昂, 马龙, 刘亮, 魏云, 王汉宇. 基底动脉顶端动脉瘤显微手术治疗[J]. 中华神经创伤外科电子杂志, 2024, 10(04): 254-256.
[11] 张晟豪, 周杰, 姚鹏飞, 李长栋, 屈晓东, 南亚强, 曹丽. 雷公藤红素在创伤性脑损伤后继发性损伤中的作用及机制研究[J]. 中华神经创伤外科电子杂志, 2024, 10(03): 132-140.
[12] 周章明, 余水, 梁张. 老年破裂前循环动脉瘤患者的急诊显微手术治疗研究[J]. 中华脑科疾病与康复杂志(电子版), 2024, 14(02): 106-111.
[13] 买买提·依斯热依力, 尹强, 尹海龙, 李治建, 董雨微, 王永康, 克力木·阿不都热依木, 阿吉艾克拜尔·艾萨. 罗乐胃蜜膏抑制酸刺激诱导食管上皮细胞炎症发生的机制研究[J]. 中华胃食管反流病电子杂志, 2024, 11(03): 137-142.
[14] 段丽娟, 蒋艳, 樊朝凤, 曹华. 颅内动脉瘤介入治疗术后不留置导尿管的效果及安全性[J]. 中华脑血管病杂志(电子版), 2024, 18(02): 104-109.
[15] 许英, 彭采凤, 曾梁楠, 李倩茜, 杨昌美. 未破裂颅内动脉瘤介入治疗患者自我管理干预方案的构建[J]. 中华脑血管病杂志(电子版), 2024, 18(02): 164-170.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号