SAH後のスパズムに対する薬物治療 - JSEPTIC

1 SAH ( ) (triple H ) 1. Nimodipine( ) 2. Nicardipine( ) 3. Fasudil( ) 4. Magnesium( ) 5. Sta?n( ) 6. Clazosentan( ) Incidence and Prevalence of Aneurysmal SAH Risk Factors for Aneurysmal SAH : 23/100,000(Australia, New Zealand, Japan) 20000 30000/ (United States) : 40 60 : SAH Stroke 2009 ;40:994- 1025 N Engl J Med 2006; 354:387- 96 Cause (cerebral vasospasm) ruptured aneurysms(85%) non- aneurysmal perimesencephalic haemorrhage(10%) remaining 5% Lancet 2007.

2 369:306- 18 Lancet 2007;369:306- 18 1 (70%) 2 3 4 5 (10%) I GCS15 II GCS13 14 III GCS13 14 IV GCS7 12 V GCS3 6 48 CT I II 1mm III 1mm (30%) IV Washington Manual Cerebral Vasospasm aaer SAH : 30 70% : 3 5 : 5 14 : 2 4 or : 15 20% Stroke 2009 ;40:994- 1025 Cerebral Vasospasm aaer SAH Stroke 2009 ;40:994- 1025 Cerebral Vasospasm aaer SAH (NO) (NO) ( ) NO Acta Neurochir Suppl 1999.

3 72 : 27- 46 Cerebral Vasospasm aaer SAH TCD ( transcranial Doppler ) TCD operator MRI 3D- CT Stroke 2009 ;40:994- 1025 Intensive care of aneurysmal subarachnoid hemorrhage: an interna?onal survey Intensive Care Med 2009 ;35: 1556- 66 Design: survey Interven?on: 45 (10 ) SCCM,ESICM,NCS SAH ICU physician 626 Ini?

4 Al management Aneurysm repair Medical management Monitoring Management of cerebral vasospasm 40 Defining vasospasm aaer subarachnoid hemorrhage what is the most clinically relevant defini?on Stroke 2009; 40: 1963- 68 Design: survey Methods: 1)symptoma?c vasospasm: vasospasm 2)delayed cerebral ischemia (DCI): 1) CT vasospasm 3)angiographic spasm.

5 4)transcranial Doppler (TCD): 120cm/sec n=580 Outcome: 3 QOL(SIP) (TICS) (Lawton score) 3 (mRS) DCI Angiographic vasospasm is strongly correlated with cerebral Infarc?on aaer subarachnoid hemorrhage Stroke 2011;42:919- 923 Background: SAH vasospasm Design: post hoc exploratory analysis of the CONSCIOUS- 1 data Methods: SAH 9 2 SAH 6 CT (n=381) Stroke 2009 ;40:994- 1025 1980 90 triple H ( hypervolemia, hemodilu?

6 On, hypertension) Neurosurgery 1990; 27: 729- 4 Neurosurgery 1988; 23: 699- 704 Neurosurgery 1991; 30: 12- 16 Effect of hypervolemic therapy on cerebral blood flow aaer subarachnoid hemorrhage Stroke 2000.

7 31 : 383- 91 Design: randomized controlled trial Selng: single center Methods: SAH 82 day14 hypervolemic(HV) ,normovolemic(NV) (CBF) crystalloid (80ml/hr)HV :PADP14mmHg or CVP8mmHg NV :PADP7mmHg or CV5mmHg 5%Alb 2hr HV NV PDAP CVP CBF 2 14d,3 ( ) hypervolemia Prophylac?

8 C hyperdynamic postopera?ve fluid therapy aaer aneurysmal subarachnoid hemorrhage Neurosurgery 2001;49: 593- 606 Design: randomized controlled study Selng: single center Methods: A (n=16): 2000ml/day day12 B (n=16): 5000 5500ml/day( 1/3 2/3) day12 ( :CVP8 12,Htct30 35%,MAP.)

9 20% up ) Endpoint TCD SPECT RCT hyperdynamic therapy Hypovolemia TCD vasospasm 1 2 Normovolemic Hyperdynamic 250$/day Effect of different components of triple- H therapy on cerebral Perfusion in pa?ents with aneurysmal subarachnoid haemorrhage Cri?

10 Cal care 2010;14:R23 Design: systema?c review ( triple H CBF ?) Studies: n=11(RCT 1 ) Hypervolemia:7 (Hemodilu?on 3 ) 1 total 250 4000ml Hypertension: 4 Phenylephrie or Dopamine MAP 21 33mmHg s DCI vasospasm ( ) 4 DCI vasospasm ( ):6 :1 CBF 24hr hypervolemia CBF Hypertension CBF (1 ) triple H 2 CBF ( 1 ) 24hr isovolemia hypervolemia CBF Hypetension CBF 1 5- 7 12- 14 hypervolemia 1 RCT CBF meta- analysis hypertension CBF CBF ?