Cập nhật quản lý biến chứng co thắt mạch và thiếu máu não muộn sau chảy máu dưới nhện do vỡ phình mạch=Update on the management of complications of vasospasm and delayed cerebral ischemia following subarachnoid bleeding due to aneurysm

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Tác giả: Chi Viện Lê, Văn Tuyến Nguyễn

Ngôn ngữ: vie

Ký hiệu phân loại:

Thông tin xuất bản: Tạp chí Y học Việt Nam (Tổng hội Y học Việt Nam), 2024

Mô tả vật lý: tr.43-53

Bộ sưu tập: Metadata

ID: 242225

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Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening acute disease with complicated diagnosis and treatment. Delayed cerebral ischemia (DCI) is one of the most common complications leading to poor outcomes, especially in poor-grade aSAH. Increased understanding of the pathogenesis of vasospasm and DCI has shifted the diagnostic and therapeutic focus away from the macrovascular system to the microvascular system and other mechanisms, including spreading cortical depolarization and inflammation. This highlights the need to combine existing modalities and develop new approaches to the monitoring, detection, prevention, and treatment of DCI after aSAH. Multimodal monitoring is the preferred approach in comatose patients, but neuroclinical assessment remains the mainstay of diagnosing DCI in most aSAH patients. Similarly, eliminating risk factors that trigger cerebral vasospasm and DCI should be optimized to prevent this complication, of which two evidence – based therapies are ensuring euvolemia and early use of oral nimodipin. In patients with aSAH and symptomatic vasospasm, elevating systolic blood pressure values may be reasonable to reduce the progression and severity of DCI but selected patients should be individualized. Endovascular rescue therapies including intraarterial vasodilator infusion and/or cerebral angioplasty may be reasonable to reverse cerebral vasospasm and reduce the progression and severity of DCI. Recently, several new therapies are being studied and applied, including intravenous milrinone, cerebrospinal fluid drainage, ntrathecal delivery of medications targeting heme or vasodilators. In recent years, several guidelines have been published, such as AHA/ASA (2023), Neurocritical Care Society - NCS (2023), and Japan Stroke Society - JSS (2021). Therefore, we update some important new points on prevention, diagnosis, and treatment of DCI complications after aSAH.Chảy máu dưới nhện do vỡ phình động mạch (aSAH) là một bệnh cấp tính đe dọa tính mạng, tuy nhiên việc chẩn đoán và điều trị rất phức tạp. Co thắt mạch/thiếu máu não muộn (DCI) là biến chứng phổ biến và dẫn tới kết cục xấu, đặc biệt đối với bệnh nhân (BN) aSAH nặng. Kết quả nghiên cứu mới về cơ chế bệnh sinh của co thắt mạch và DCI đã chuyển mục tiêu chẩn đoán và điều trị khỏi hệ thống mạch máu lớn sang hệ thống mạch máu nhỏ và các cơ chế khác, bao gồm hiện tượng khử cực lan tỏa vỏ não và cơ chế viêm. Đây là tiền đề để thay đổi chiến lược tiếp cận toàn diện trong theo dõi, chẩn đoán, dự phòng và điều trị biến chứng DCI sau aSAH. Theo dõi đa mô thức là mô hình áp dụng ở BN hôn mê, nhưng khám lâm sàng thần kinh vẫn là trụ cột chính trong sàng lọc thường quy co thắt mạch có triệu chứng/DCI. Trên khía cạnh dự phòng, tối ưu hóa điều trị để triệt tiêu các yếu tố nguy cơ kích hoạt quá trình co thắt mạch não và các cơ chế khác dẫn đến DCI, trong đó 2 liệu pháp có bằng chứng tác dụng là duy trì đẳng thể tích tuần hoàn và sử dụng sớm nimodipin đường uống. Để điều trị co thắt mạch có triệu chứng/DCI, có thể sử dụng liệu pháp nâng huyết áp, nhưng cần cá thể hóa và đề phòng nguy cơ biến chứng do quá tải dịch có thể xảy ra. Các biện pháp cứu hộ bằng can thiệp nội mạch (truyền thuốc dãn mạch đường động mạch hoặc/và nong động mạch) áp dụng đối với co thắt mạch nghiêm trọng, tuy nhiên tỷ lệ tái co thắt cao, chính vì vậy một số liệu pháp mới đang được nghiên cứu và ứng dụng, trong đó có milrinone truyền đường tĩnh mạch, dẫn lưu dịch não tủy ra ngoài thông qua dẫn lưu tủy sống hoặc dẫn lưu não thất mở, tiêm nội tủy một số thuốc có tác động vào quá trình giáng hóa heme hoặc thuốc giãn mạch. Trong những năm gần đây, một số guideline đã được công bố như AHA/ASA (2023), Hiệp hội Hồi sức thần kinh - NCS (2023) và Hội Đột quỵ Nhật Bản -JSS (2021). Do đó, chúng tôi cập nhật một số điểm mới quan trọng về dự phòng, chẩn đoán và điều trị biến chứng DCI sau aSAH.

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