CT perfusion-guided血管内治疗症状性脑血管痉挛的患者perimesencephalic non-aneurysmal蛛网膜下腔出血

症状性血管痉挛是一种少见的并发症perimesencephalic nonaneurysmal蛛网膜下腔出血(SAH)是一种良性的SAH的没有任何可识别的来源约占15%的非创伤性出血SAH [1, 2]。

之前在这里,我们描述一个36岁的健康女性在急诊室承认了4天持续严重头痛急性发作的特征。在入口,没有神经赤字,包括假性脑膜炎,在检查中被发现。

CT扫描显示SAH位于中脑水池周围,而CT血管造影(CTA)和4-vessels脑数字减影血管造影(DSA)是正常的。在这种情况下我们通常重复DSA 14到20天之后确认没有任何血管畸形。与口服nimodipine开始治疗。十一天后承认,她开发的构音障碍和轻微的进行性加重。重复CT扫描发现一个持久prepontine水箱中的小凝块,在缺乏局部病变或脑积水。CT灌注(CTP)研究上执行64 - CT扫描仪记录部分减少脑血流量(CBF)和长期平均运输时间(MMT)与保存相关脑血容量cb v()都未在左侧大脑中动脉(MCA)领土的可逆缺血(图1 A)的说明。在随后的脑DSA,确认没有任何血管畸形,严重血管痉挛sovraclinoid段颈内动脉和左MCA的M1段识别(图1 I, J)。根据neurosuegeon我们决定开始动脉内的注入3毫克的nimodipine导致轻度改善血管造影照片(图1 K, L)和一个完整的临床症状缓解。三大H治疗开始。临床恶化发生后的第二天因为她经历了正确的轻偏瘫失语和更明显。 A new cerebral DSA showed a recurrence of vasospasm (Figure 1 M) that was treated with the intra-arterial administration of 3 mg of nimodipine followed by balloon angioplasty performed by using an Hyperglide balloon 4 mm x 10 mm (EV3) due to the persistence of vessel narrowing (Figure 1 N,O). At the end of the procedure, a complete resolution of angiographic (Figure 1 P) and clinical abnormalities was observed. A second CTP examination carried out the day after indicated the normalization of CBF and MTT disturbances (Figure 1 Q-X). She was discharged two weeks later with a modified Rankin scale = 0 and a negative CT scan. This report confirms that perimesencephalic non-aneurysmal SAH can be complicated by a symptomatic cerebral vasospasm [1,2], for which endovascular treatment with nimodipine and balloon angioplasty is an effective procedure [3,4]. Our therapeutic approach was further justified by CTP findings demonstrating the presence of critically hypo perfused but potentially salvageable tissue at risk for infarction that, after treatment, was totally reperfused. CTP is a powerful tool for the diagnosis and management of vasospasm not only in aneurismal [5] but also in perimesencephalic non-aneurysmal SAH. In this form of SAH, as transcranial Doppler is not sensitive in determining the degree of vasospasm-related ischemia [6], visual inspection of CTP maps could be considered as the method of choice to guide the decision to treat due to its ability in establishing severity and temporal evolution of vasospasm [7,8].