重症クモ膜下出血の経過中に発症した中枢性肺水腫の検討 ： 急性期手術の適否に関して

Abstract

Neurogenic pulmonary edema (NPE) following severe subarachnoid hemorrhage (SAH) have been reported recently. The incidence, the treatment and the prognosis of NPE are discussed among authors. In this study, 11 cases of SAH complicated with NPE are reported, and clinical features, especially the best timing for surgery, are discussed. Among 460 patients admitted for SAH during a recent three-year period, 11 cases (2.3%) were complicated with NPE. According to Hunt ＆ Kosnik grading on admission, one patient was in Grade Ⅱ, two were in Grade Ⅲ, three were in Grade Ⅳ and five were in Grade Ⅴ. Chest X-ray films demonstrated a typical pattern such as snowstorm-like shadowing in each case. CT revealed a diffuse subarachnoid hemorrhage or intraventricular homorrhage (Fisher type Ⅲ or Ⅳ) in each case. In 8 cases, artificial respiratory control with positive end-expiratory pressure (PEEP) following intratracheal intubation were successful, and NPE was improved within one to 8 days. Four patients underwent an aneurysm surgery combined with the management of NPE in the acute stage. These outcomes were very good and they were discharged without major neurological deficit. The acquired results showed that NPE associated with severe SAH can be successfully treated and promptly improved the distinct management. Therefore direct surgery in the acute stage is not necessarily taboo if the appropriate respiratory and cardiovascular management can be given. The prognosis of patients with severe SAH complicated with NPE depends not the severities of NPE but on those of SAH. In conclusion, we recommend early direct surgery combined with distinct management of NPE in poor grade patients because it encabled us to control increased ICP and apply artificial ventilation with PEEP.