CT灌注引导下血管内治疗伴脑周非动脉瘤性蛛网膜下腔出血的症状性脑血管痉挛1例

症状性血管痉挛是脑膜周围非动脉瘤性蛛网膜下腔出血(SAH)的一种罕见并发症，它是一种良性SAH，没有任何可识别的出血来源，约占非创伤性SAH的15%[1,2]。

在这里，我们描述了一个36岁的健康女性的病例，她被收治在我们的急诊科，以急性发作为特征的4天持续严重头痛。入组时，检查未发现神经功能缺损，包括脑膜。

CT扫描显示位于中脑池周围的SAH，而CT血管造影(CTA)和4血管脑数字减影血管造影(DSA)均正常。在这种情况下，我们通常在14-20天后重复DSA检查，以确认没有任何血管畸形。开始口服尼莫地平治疗。入院后11天，患者出现构音障碍和轻微的右偏瘫。重复的CT扫描发现在prepontin池内有一个持续的小血块，没有病灶或脑积水。64节CT扫描仪进行的CT灌注(CTP)研究显示，左大脑中动脉(MCA)区域的脑血流量(CBF)减少，平均传输时间(MMT)延长，脑血容量(CBV)保留，提示可逆缺血(图1 A- h)。在随后的大脑DSA中，确认没有任何血管畸形，在颈内动脉和左MCA M1段发现了严重的血管痉挛(图1i,J)。根据神经示踪，我们决定开始动脉内注射3mg尼莫地平，导致血管造影图像轻度改善(图1k,L)和临床症状完全缓解。然后开始进行三联H疗法。第二天临床恶化发生，因为她经历了失语和更明显的右偏瘫。 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].