Objective To identify an evidence-based treatment for a patient with aneurysmal subarachnoid hemorrhage (aSAH). Methods We first put forward clinical problems about how to prevent complications and how to treat ruptured aneurysm of aSAH, then searched The Cochrane Library (Issue 4, 2006), Ovid ACP Journal Club (1991 to 2006), Ovid MEDLINE (1966 to 2006), NGC (1998 to 2006) and CBM (1978 to 2006) to identify systematic reviews, randomized controlled trials, controlled clinical trials and treatment guidelines. Results Eleven studies and five guidelines were included. Current evidence indicated that nimodipine was effective for prophylaxis of poor outcome after vasospasm, while tirilazad was not effective in female patients with good grades. The effectiveness of other treatments to prevent complications was not clear. Evidence on the use of antifibrinolytics for the prevention of re-bleeding was inconsistent. If a ruptured aneurysm was considered suitable for both surgical clipping and endovascular coiling, coiling was associated with a better outcome. According to the available evidence and guidelines, considering the patient’s conditions and preferences, nimodipine and antifibrinolytics were administered to prevent complications and her aneurysm was treated by early endovascular embolization. She did not experience vasospasm or re-bleeding during her hospital stay. Short-term follow-up showed a good outcome. Long-term prognostic benefits after endovascular therapy need to be confirmed by prolonged follow-up. Conclusions Therapies based on the best clinical evidence and guidelines should be given to prevent complications and improve outcome for patients after an aSAH.
Objective To investigate the influence of different transplantating times on the survival and immigration of the bone marrow mesenchymal stem cells (BMSCs) in injured spinal cord by subarachnoid administration, and to evaluate the most optimal subarachnoid administration times for BMSCs. Methods Eight adult male rats (weighing 120 g) were used to isolate BMSCs that were cultured, purified and labeled with Hoechst 33342 in vitro. Another 75 adult Wistar rats (weighing 220 g) were made the spinal cord injury (SCI) models at T9,10 level according to the improved Allen’s method and were randomly divided into 5 groups (groups A, B, C, D, and E, n=15). The labeled BMSCs at 1 × 107/mL 0.1 mL were injected into subarachnoid space of the rats via a catheters under the subarachnoid space in groups A (one time at 1 week), B ( two times at 1 and 3 weeks), C (3 times at 1, 3, and 5 weeks) and D (5 times at 1, 3, 5, 7, and 9 weeks) and 0.2 mL phosphate-buffered sal ine (PBS) was injected in group E (5 times at 1, 3, 5, 7, and 9 weeks) as blank control. The neurological functions were evaluated using the Basso-Beattie-Bresnahan (BBB) scale 1, 3, 5, 7, 9, and 12 weeks after transplantation. The migration, survival, differentiation, and histomorphological changes of BMSCs were observed by HE, immunohistochemistry, and fluorescence microscopy. Results At 3 weeks after injury, there were significant differences in the BBB scores between group E and groups A, B, C, D (P lt; 0.01), and between groups A, B and groups C, D (P lt; 0.01). At 7, 9, and 12 weeks, the BBB scores were significantly higher in groups C and D than in groups A and B (P lt; 0.01), and in group B than in group A (P lt; 0.01). There were no significant differences in the BBB scores between groups C and D (P gt; 0.05). The fluorescence microscopy showed that the transplanted BMSCs survived and grew in the injured region at 3 weeks after injury and as time went on, the transplanted cells gradually decreased in group A; in groups B, C, and D, BMSCs count reached the peak values at 5 and 7 weeks and then gradually decreased. At 12 weeks, the survival BMSCs were significantly more in groups C and D than in groups A and B (P lt; 0.01). HE staining showed that the formation of cavity was observed in each group at 3 weeks after injury and the area of cavity gradually decreased in groups A, B, C, and D. At 12 weeks, the area of cavity was the miximal in groups C and D, moderate in groups A and B, and the maximal in group E. The immunohistochemistry staining indicated that the expression of NF-200 was more intense in groups C and D than in groups A and B. The expression of NF-200-positive fibers was more intense in group C. Conclusion Multiple administration of BMSCs promotes the restoration of injured spinal cord and improves neurological functions, and three times for BMSCs transplantation is best
【摘要】 目的 探讨基层医院显微外科手术治疗动脉瘤性蛛网膜下腔出血（aSAH）的手术时机、方法以及疗效。 方法 回顾分析2005年1月-2009年12月经翼点入路行显微外科手术治疗的36例aSAH患者的临床资料。 结果 所有aSAH患者经数字减影血管造影检查确诊，均行瘤颈夹闭术。手术效果按GOS评分，恢复良好30例（83%）、中度残疾4例（11%）、死亡2例（6%）。 结论 aSAH按Hunt-Hess分级为Ⅰ～Ⅱ级的患者应尽早手术， Ⅲ～Ⅳ级应结合患者颅内出血量及全身状况综合考虑，Ⅴ级待病情稳定后积极手术治疗。经翼点入路显微外科手术治疗前循ASAH，手术中暴露清楚，夹闭瘤颈可靠，疗效满意。【Abstract】 Objective To explore the operative time, methods and curative effect of microsurgical treatment on aneurysmal subarachnoid hemorrhage (aSAH) in basic-level hospitals. Methods The data of 36 patients with aSAH who had undergone microsurgery from January 2005 to December 2009, were retrospectively analyzed. Results All the patients were confirmed as aSAH by digital subtraction angiography, and all of them had undergone clapping of aneurism. According to GOS, 30 patients (83%) had good recovery, four patients (11%) had moderate disability and two patients (6%) died. Conclusions The operation should be done as early as possible in the patients with gradeⅠ-Ⅱ of Hunt-Hess, the volume of intracranial hemorrhage and patient’s condition should be considered to decide when to operate of grade Ⅲ-Ⅳ, patients with grade Ⅴ aneurysms should be treated by conservative therapy first. They should consider an operation only when their condition is stable after conservative therapy. The peritoneal approach is a good procedure because of clear exposure, reliable clipping and satisfactory results.
Objectives To assess the effectiveness and safety of lumbar continuous drainage of the cerebrospinal fluid therapy for subarachnoid hemorrhage (SAH). Methods The method of Cochrane systematic review was used to evaluate the randomized controlled trials (RCTs) of lumbar contiunous drainage of the cerebrospinal fluid therapy for SAH. Results We included 7 RCTs involving 390 patients. The methodological quality of all the trials was poor. The poor outcome and adverse event evaluation of the SAH patients at the end of long-term follow-up (at least three months) were not reported in all studies. Meta-analysis of fatality showed a better effect of lumbar continuous drainage of the cerebrospinal fluid therapy for SAH than the control group with statistical significance [RR=0.32, 95%CI (0.15, 0.70)]. Meta-analysis of complications also showed a better effect of lumbar continuous drainage of the cerebrospinal fluid therapy for SAH than the control group with statistical significance (except re-bleeding) [cerebral vasospasm RR=0.15, 95%CI (0.06, 0.33), hydrocephalus RR=0.22, 95%CI (0.10, 0.52), cerebral infarction RR=0.25, 95%CI (0.08, 0.82)]. Only one trial reported the adverse events of lumbar continuous drainage of the cerebrospinal fluid therapy including intracranial infection and intracranial hypotension reaction, while the other trials did not report the adverse events. Conclusion With poor quality of the most included trials, insufficient evidence is obtained to support the conclusion that lumbar continuous drainage of the cerebrospinal fluid therapy is safe and effective in the treatment of SAH. Further high-quality RCTs should be carried out to provide more reliable evidence.
Objective To evaluate the effectiveness and safety of ropivacaine in spinal anesthesia. Methods We searched PubMed (1999 to 2008), OVID (1999 to 2008), EBSCO (1999 to 2008), The Cochrane Library (2000 to 2008), and CNKI (1999 to 2008) databases to identify randomized controlled trials (RCTs) that compared ropivacaine and bupivacaine for spinal anesthesia. The quality of the included RCTs was evaluated by two reviewers independently, and meta-analysis was performed by RevMan 5.0 software. Results Six RCTs were included. The methodological quality of them were all poor. Among the six RCTs, 215 patients received ropivacaine and 215 received bupivacaine. The results of meta-analyses showed that the motor-block time to complete block of ropivacaine was significantly shorter than that of bupivacaine (WMD=2.18 min, 95%CI 0.32 to 4.03, P=0.02). The motor-block time to complete recovery of ropivacaine was significantly shorter than that of bupivacaine for cesarean delivery in spinal anesthesia (SMD= – 1.82, 95%CI – 3.05 to – 0.59, P=0.004). The incidence rate of hypotension and bradycardia in spinal anestheisa with ropivacaine was lower than that with bupivacaine (OR=0.49, 95%CI 0.31 to 0.80, P=0.004; OR=0.40, 95%CI 0.03 to 4.99, P=0.47). Conclusion Equivalent doses of ropivacaine and bupivacaine provide similar analgesia in spinal anesthesia for cesarean delivery. However, haemodynamics in spinal anesthesia with ropivacaine fluctuate lightlier than with bupivacaine. Ropivacaine is suitable for spinal anesthesia in low-abdominal operations.
Objective To investigate the therapeutic effects of transplanting allogeneic marrow mesenchymal stem cells (MSCs) via subarachnoid space on spinal cord injury(SCI) and the T cell subpopulation. Methods Density gradient centrifugation was used to isolate and expand MSCs from bone marrow of 10 six-week-old SD rats. The SCI model was produced by weightbeating from 60 eight-week-old female SD rats. Forty survival SCI rats,which BBB scores were zero, were divided randomly into 2 groups:experimental group(group A) and control group(group B). In addition, 20 normal eightweekold SD ratswere used as blank group (group C). In group A, 1 ml cells suspention containing MSCs(the 6th generation, 2×106/ml) was injected via subarachnoid space. Ingroup B, equal volume of L-DMEM was injected in the same way. The BBB score was obtained after 1st,2nd and 3rd weeks of injection. At the same time,T cell subpopulation was detected by flow cytometry. Results The BBB score in group A was better than that in group B, but fewer than that in group C in the 3rd week. CD4+T cells in group A were less than those in groups B and C in the 1st, 2nd, and 3rd weeks. CD8+T cells in group A were less than those in groups B and C in the 2nd and 3rd weeks. The ratio of CD4+/CD8+T cells in group A was less than those in groups B and C in the 1st week. Above differences showed statistically significant difference(P＜0.05). However, there were no statistically significant differences in the ratio of CD4+/CD8+T cells between group A and groups B, C in the 2nd and 3rd weeks (P＞0.05). Conclusion The above results suggest that allogeneic MSCs transplantation via subarachnoid space is beneficial to SCI to some extend, do not result in rejection in vivo. Furthermore, it can lead to immunosuppression in short time. So, it provides clues to apply MSCs to treat SCI and other diseases.
Objective To explore the effectiveness and safety of exchange of cerebrospinal fluid in the treatment of subarachnoid hemorrhage （SAH）. Methods Sixty SAH patients diagnosed by CT and lumbarpuncture were randomly assigned into a control group （n =30, received conventional treatment） and a treatment group （n =30, received exchange of cerebrospinal fluid plus conventional treatment）. The main complications and effectiveness between the two groups were compared. SPSS 10.0 was used for statistical analysis. Results Compared with the control group, complications of persistent headache （ P =0.002 and 0. 007 respectively）, cerebral vasospasm （ P =0. 028 ） and hydrocephalus （ P =0. 038 ） were fewer in the treatment group. No significant difference in the incidence of rehaemorrhagia was found between the two groups （P = 1. 000）. Better effectiveness was observed in the treatment group （RR. 3.00, 95% CI 1. 014 to 8. 880, P = 0. 044 ）. Conclusions Exchange of cerebrospinal fluid plus conventional treatment is more effective than conventional treatment alone in the treatment of SAH.