症候性血管攣縮に対するOptimal Hypervolemic療法

Optimal Hypervolemic Therapy for Symptomatic Vasospasm

I．はじめに

　現在，くも膜下出血（SAH）後の症候性血管攣縮（SV）に対する治療として血圧，体液量の種々な調節が試みられ，ある程度の効果が得られている^{1,7，−11）}．しかし，各各の症例において，至適血旺，体液量をいずれに設定するかについての論議はまだその結論をみるに至っていない．著者らはSVに対し，その症状の改善が得られるまで積極的にvolume expansionを行いその時点の体循環動態値をoptimal valueとして管理する療法（Optimal Hy—pervolemic Therapy：OHT）を行っており，その有効性，合併症等に関して報告する．

Thirty-five patients with symptomatic vasospasm (SV) following aneurysmal subarachnoid hemorrhage (SAH) were managed according to a method based on hemodynamic manipulation, montiored by Swan-Ganz catheter. Nine out of these had delayed surgery. For those who developed SV, the pulmonary wedge pres-sure (Pcwp) and/or central venous pressure (CVP) were immediately increased up to the point at which neurological deficit was reversed by rapid injection of fresh frozen plasma, albuminates, low molecular dex-trose, and glycerol. On this regimen, patients were closely observed for any neurological change. Then the hemodynamic parameters were maintained as optimalvalues until they could be reduced below optimal values without reappearance of neurological deficit. In inoperable patients, special attention was given in mak-ing a decision about discontinuing the regimen. The re-sults were compared with thirty-seven patients with SV who were treated with conventional hypervolemic ther-apy (CHT) by continuous administration of albumin-ates. In the treatment of CHT, optimal values could hardly be established, so the same hemodynamic para-meters were apllied in all the cases.

From this study, in the majority of the cases optimal values were found as follows: Pcwp up to 10 - 15 mmHg, and CVP below 11 cmH2O. On the contrary, in 20% of patients, neurological deficit was reversed by in-creasing CVP to a point not above 7 cmH2O. Correla-tion between neurological reversal and systemic blood pressure was not statistically significant. After this re-gimen (OHT), 74% of patients showed immediate im-provement after volume expansion, and, in 80%, out-come was good, while 20% died. The motor function at the time of discharge was more than 3 on the manual test in all cases. With regard to complications, incidence of cardiac failure, aggravation of brain edema, hemor-rhagic infarction and rebleeding were 14%, 9%, 3%, and 11% respectively. Compared to the results using the CHT regimen, these results were definitely better, espe-cially as far as mobility and life preservation were con-cerned.

The authors conclude that there are individually different optimal hemodynamic values which overcome symptomatic vasospasm, and establishment of a suffi-cient way of treatment could be accomplished by find-ing the optimal hemodynamic values when SV is aggressively managed.