动脉瘤破裂性蛛网膜下腔出血后脑血管痉挛治疗新进展  

New advances in the treatment of cerebral vasospasm after ruptured aneurysmal subarachnoid hemorrhage

作　　者：袁勇 丁新民 YUAN Yong;DING Xinmin(Third Hospital of Shanxi Medical University,Shanxi Bethune Hospital,Shanxi Academy of Medical Sciences,Tongji Shanxi Hospital,Taiyuan,Shanxi 030032,China)

机构地区：[1]山西医科大学第三医院/山西白求恩医院/山西医学科学院/同济山西医院,山西太原030032

出　　处：《国际神经病学神经外科学杂志》2023年第3期60-65,共6页Journal of International Neurology and Neurosurgery

摘　　要：脑血管痉挛(CVS)会引起脑血管的收缩,从而扰乱血管错综复杂的调控系统。它是蛛网膜下腔出血后残疾和死亡的主要原因之一,也是造成迟发性脑缺血及神经功能障碍的驱动因素。目前临床上对于CVS的治疗选择还很少,药物疗法主要有诱发性升压疗法、钙通道阻滞剂、血管扩张剂、磷酸二酯酶抑制剂、他汀类药物、抗痉挛剂、促红细胞生成剂、内皮素受体拮抗剂等。非药物疗法主要有血管扩张剂的血管内干预、机械血管成形术等。CVS的发病机制至今尚未完全阐明,尚无一种有效的治疗方法可以用来治疗CVS。随着人们对其潜在发病机制认识和理解的扩大,可能会找到好的治疗靶点。在蛛网膜下腔出血后,神经炎症和微凝块的形成是引起血管痉挛和迟发性脑缺血的新兴机制。迄今为止最有希望的疗法是调节一氧化氮或内皮素通路,并通过抑制痉挛的作用获益。钙通道阻滞剂的进一步研究也在进行中,以更好地了解有关血管痉挛的作用机制。尼莫地平能使蛛网膜下腔出血患者的血管舒张,改善神经系统症状,可以在一定程度上防止迟发性脑缺血,但对蛛网膜下腔出血后的死亡率影响不大。因此,针对不同机制的联合治疗可能是更理想的方法。该文对近年来有关CVS的治疗方法进行综述。Cerebral vasospasm(CVS) may cause cerebral vasoconstriction and thus disrupt the complex vascular regulatory system.CVS is one of the leading causes of disability and death after subarachnoid hemorrhage,as well as a driving factor for delayed cerebral ischemia and neurological deficits.At present,there are few treatment options for CVS in clinical practice.Drug therapies mainly include induced blood pressure elevation,calcium channel blockers,vasodilators,phosphodiesterase inhibitors,statins,antispasmodic drugs,erythropoiesis-stimulating agents,and endothelin-receptor antagonists,and non-pharmacological therapies include intravascular intervention with vasodilators and mechanical angioplasty.The pathogenesis of CVS remains unknown at present,and there is still a lack of effective therapies for CVS.With the deep understanding of the potential pathogenesis of CVS,it may be possible to find good therapeutic targets.Neuroinflammation and microthrombosis are new mechanisms that contribute to vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage.Up to now,the most promising therapeutic approach is to modulate nitric oxide or endothelin pathways and benefit from the effect of inhibiting spasm.Further studies are being conducted for calcium channel blockers to better understand their mechanisms of action in vasospasm.Nimodipine can cause vasodilation in patients with subarachnoid hemorrhage,improve neurological symptoms,and prevent delayed cerebral ischemia to a certain degree,but it has little effect on mortality after subarachnoid hemorrhage.Therefore,multimodal combination therapy targeting different mechanisms may be a better option.This article reviews the therapies for CVS in recent years.

关 键 词：动脉瘤 蛛网膜下腔出血 脑血管痉挛 延迟性脑缺血 药物疗法 治疗进展 

分 类 号：R743[医药卫生—神经病学与精神病学]