rest & Diamox study Keywords: cerebral blood flow, vasospasm, subarachnoid hemorrhage, SPECT, cerebral aneurysm Table 1 Clinical summary of 26 patient
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1 rest & Diamox study Keywords: cerebral blood flow, vasospasm, subarachnoid hemorrhage, SPECT, cerebral aneurysm Table 1 Clinical summary of 26 patients Total patients :26(Men =10 : Women =16) Mean age (yrs) :58.8 }12.2 (range : 41 `77) Hunt & Kosnik grade: I 2, II 12, III 8, IV 4 Aneurysm sites :AcomA 8, MCA 8(R7, L1), ICA 6 (R3, L3), ACA distal 1, BA top 3 Ope. (neck clipping) :Day1.5 }0.8(range : 0 `4) SPECT :Day5.3 }1.1(range : 4 `8) Outcome :GR 17, MD 4, SD 2, VS 2, Dead 1
2 Fig. 1 Comparison of patients outcome with various mean CBF values on rest and diamox (Dx) CBF studies according to Mann-Whitney's U analysis. Note the statistical significance in the rcbf value (*p<0.002) and also in other values of hcbf, rdx and hdx (**0.05).
3 Fig. 2 Individual CBF changes plotted on rest and diamox (Dx) studies in good and poor outcome patients. Among these data plotted, all the patients that cleared any level of minimum rcbf 26, hcbf 38.1, rdx 39 and hdx 47.8 showed good outcome. The intracerebral steal phenomenon (paradoxical rdx response) was shown shown in three cases in this series (asterisk)
4 破 裂脳動 脈瘤 術 後早 期 の脳血流SPELT定量 Fig. 3 Case yrs. F.: ruptured regional Fig. 4 and hemispheric Case yrs, F.: ruptured mum regional \corn.a aneurysm. CBF values and hemispheric H&K Gr : II. outcome: both responded rt. MCA aneurysm. CBF were preserved 評価 の 検 討 23:177 GR. Decreased well after Dx administration. H&K Gr : IV. outcome: well and showed SD. Both the mini- good Dx response.
5 23:178 脳 卒 中23巻2号(2001:6) Fig. 5 Case yrs, F.: ruptured rt. MCA aneurysm, creased regional and hemispheric temporal ischemia which resulted と 述 べ て い る.ま たspasmの CBF and poor rdx response showed 目が ピー ク と述 べ て い 今 回 は 安 静 時 とDx負 る. 今 回,我 々 はDay5をSAH自 focal fronto- を 行 っ た が,中 荷 時 の両 方の 脳血 流 値 の 評価 川 原 ら はDx負 で も 中 等 度 のspasmが え て,spasmの : SD. Both de- in the low density area on CT. 時 期 に つ い て はKassell ら は 血 管 撮 影 上,発 症 か ら7日 H & K Gr : III, outcome 体 に よる脳 損傷 に加 初期 段 階 で血流 の低 下が 始 ま ってい る 荷 に つ い て,無 症 候 性 認 め ら れ た 症 例 で はspasmの 灌 流 域 に お い てDxに 対す る局所脳 血 管拡 張 能 が 一時 的 に低 下 す る こ と,ま た 症 候 性 で 脳 梗 塞 を 形 成 しな い 場 合 で もDxに 対 す る 局 所 脳 血 管 拡 張 能 が 著 し く低 下 血 を把 握 しそ れ に 応 じた 対 策 を 講 じ る こ と に よ り良 好 す る と述 べ,潜 在 的 脳 虚 血 域 の 出 現 と持 続 の 予 知 に 関 な 転 帰 が 得 ら れ る か を 各CBF値 す る 情 報 を得 ら れ る こ とが 可 能 で あ る と 述 べ て い る. 時 期 と考 え,spasmが 症 候 性 と な る 前 か ら潜 在 的 脳 虚 の 面 か ら検 討 した. そ の 結 果,自 験 例 で は術 前 のH&K 金 例 良 好 な 転 帰 が 得 られ た.し 群 全 体 のDay5で GrがI,IIの 症例 は か し な が ら,転 帰 良 好 の 平 均hCBFは38.8±6.6で あ り, こ の 値 は 当 施 設 の 健 常 人 の 平 均hCBF47.9±7.1に 比 べ る と 明 ら か に低 値 で あ っ た.こ の 中に は術 後の 意識 レベ ル が 良 く て もhCBFが30近 くまで低 下 し虚血 閾 値 と考 え られ,強 力 なspasm対 存 在 した.ま た 術 前 のH&K て は 各CBF値 ら れ,そ CBF値 策 を 必 要 と した 症 例 が GrがIII,IVの 症 例 にお い に よ って 予後 が左 右 され やす い と考 え れ に 応 じて 様 々 な 転 帰 を 示 し た.重 に 応 じ た 厳 重 なspasm対 症例 で は 策 が 必 要 で あ る が, 一 方,限 界 もあ る こ とが 示 さ れ た. 自験 例 で はrest&Dx負 象 を 認 め た が,こ 荷rCBF値 低 下 状 態 を 示 す 実 際 のdataと を 高 め る こ とやsteal現 にspasmが か ら3例 にsteal現 れ は局所 脳 虚血 部位 の血 管拡 張能 の 考 え られ る.Dxは 象 を 起 こ す こ とか ら,明 脳圧 らか み られ る症 例 で は悪 影響 を与 え る可 能 性 も あ る と思 わ れ る.今 回 の 検 討 で も安 静 時(rest)CBF 値 の 評 価 が 最 も有 用 で あ っ た こ とか ら,症 例 に よ っ て は 敢 え てDxを 使 用 す る意 義 は 少 な く,悪 影 響 を与 え た 可 能 性 も否 定 で き な い(症 例3),今 の 工 夫 やSPECT機 後,ROIの 器 の 精 度 向 上 に よ り,さ 設定 ら に詳細 な 局所 脳 虚 血 部 の 評価 が 可 能 に な る こ とを期 待 した い.ま た,Dx反 応 性 に つ い て はCBF増 加 率で は な く
6 7) Kassell NF, Sasaki T, Colohan ART, et al : Cerebral vasospasm following aneurysmal subarach- noid hemorrhage. Stroke 16: ,1985 4) Kassell NF, Torner JC, Haley EC Jr, et al : The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1 : Overall management results. J Neurosurg 73: 18-36, ) Kassell NF, Torner JC, Jane JA, et al : The International Cooperative Study on thr Timing of Aneurysm Surgery. Part 2 : Surgical results. J Neurosurg 73:37 47,1990 9) Powers WJ, Grubb RL, Baker RP, et al : Regional cerebral blood flow and metabolism in reversible ischemia due to vasospasm. J Neurosurg 62 : , ) Yonas H, Sekhar L, Johnson DW, et al : Determination of irreversible ischemia by xenon-enhanced computed tomographic monitoring of cerebral blood flow in patients with symptomatic vasospasm. Neurosurgery 24: , ) Tanaka A, Yoshinaga S, Nakayama Y, et al : Cerebral blood flow and the response to acetazolamide during the acute, subacute, and chronic stages of aneurysmal subarachnoid hemorrhage. Neurol Mid Chir (Tokyo) 38:
7 Abstract Evaluation of cerebral blood flow by SPECT studies at the early stage in postoperative ruptured aueurysiin cases Shiro Kawasaki, M.D., Yuji Yamamoto, M.D., Norio Sunami, M.D., Masakazu Suga, M.D. and Shinichiro Mizumatsu, M.D. Department of Neurosurgery, Matsuyama Shimin Hospital Ceredral blood flow (CBF) at the early stage of ruptured cerebral aneurysm after surgery was evaluated in relation to clinical grade, course and outcome of subarachnoid hemorrhage (SAH) which is commonly associated with delayed cerebral vasospasm. Employing 123I-IMP SPECT by the modified early method, CBF values at rest and in Diamox (Dx) studies were obtained in 26 consecutive cases, mainly on the 5 th day of SAH, when the cerebral vasospasm was expected to start with reduction of the CBF. The patients were commonly treated by hypervolemic therapy and cisternal drainage after aneurysmal neck clipping within the 2nd day of SAH. Their prognoses resulted in a good outcome group consisting of 21 cases, including 17 good recovery (GR) and 4 moderately disabled (MD) patients, and a poor outcome group consisting of 5 cases, including 2 severely disabled (SD), 2 vegetative survival (VS) and on dead patient. The mean CBF values of the good group were : minimum regional (r) CBF = 31.0, hemispheric (h) CBF = 38.8, rdx = 44.8, and hdx = 53.3 (ml /100 g/minx). Those of the poor group were : minimum rcbf = 19.2, hcbf = 30.2, rdx = 25.3, and hdx = Comparative statistical analysis between the two groups showed the most significant difference in the minimum rcbf values (p<0.002) and also significant differences in the other CBF values (p<0.05). The CBF values at the early stage of SAH were lower than those at the steady state of normal candidates (hcbf = 47.9 } 7.1), although their clinical grades and courses were good. These findings suggest that early estimation and preservation of CBF are useful for the treatment of cerebral vasospasm following SAH. (Jpn J Stroke 23: , 2001)
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