The purpose of the present study is to clarified the preventive effects of GTN and Ca
++-antagonist combination therapy for symptomatic vasospasm following ruptured cerebral aneurysm.
It is a well known fact that Ca
++-antagonist has a depressive effect on the contraction of vascular smooth muscle induced by spasmogenics as a Ca
++-entry blocker, and that GTN also has a strong relaxant effect on these contractions as an activator of intracellulary G-kinase. We have applied this combination therapy to 13 patients and obtained good clinical results. Only one patient (8%) showed a symptomatic vasospasm.
1. EXPERIMENTAL STUDY
Using helical strips of the bovine middle cerebral arteries, changes in vascular tension were measured during isometric contractions induced by 5HT, PGF
2α and Oxy-Hb. A helical strip was hung in a small perfusing chamber (1.5ml) and perfused with a modified Tyrode solution with 95% O
2 and 5% CO
2.
The occurrence of contractions induced by 5HT, PGF
2a and Oxy-Hb were depressed by 50-60% of each control in 10
-8M nicardipine (NC). GTN had not depressed the occurrence of these contractions. However, vascular tension on the plateau of these contractions was strongly relaxed by 10
-5-10
-4M GTN. GTN had also strongly relaxed the tension of vascular muscle at the resting tension dose-dependently. GTN caused dose-dependent relaxations in 10
-6M Oxy-Hb-,-10
-6M PGF
2a and 10
-7M 5HT-induced contractions in the presence of 10
-8M nicardipine. The above results suggested that Ca
++-antagonists would be effective drugs for prevention of cerebral vasospasm, and GTN would be an effective drug for relaxation of the cerebral vasospasm.
II. CLINICAL STUDY
142 patients with SAH who underwent early and/or late surgery, were divided into four groups. 80 patients underwent early surgery and were treated without Ca
++-antagonist and/or GTN, as a control group. 36 patients were treated with NC after early surgery. 13 patients were treated with diltiazem (Dil) until late surgery. 13 patients were treated with GTN (0.05 mg-0.10 mg/kg/hr) intravenously until the 14th day after SAH {4 patients of early surgery were treated with intrathecal injections of NC (4 mg 2×1/day-10 day), 9 patients of late surgery were treated with intravenously injections of Dil (0.2 mg-0.3 mg/kg/hr-14 day)}
RESULTS: Symptomatic vasospasm occured in 1 (7%) out of 13 patients treated with GTN combined Ca
++-antagonists, whereas the occurrence in the control group was 41 (51%) out of 80 (early surgery and NC), 5 (38%) out of 13 (late surgery and Dil). The recovery rate was 100% in the 4 patients (early surgery) treated with GTN combined NC, 78% in the late surgery and GTN combined Dil. The recovery rate in the control group was 73% (early surgery only), 86% (early surgery and NC), 60% (late surgery and Dil).
III. CONCLUSION
The intrathecal administration of nicardipine is very effective for prevention of symptomatic vasospasm, however we have sometimes experienced the development of a severe clinical stage due to vasospasm. It is expected for GTN to improve such a permanent symptom. These results depend on the coexistence of the preventive effects of Ca
++-antagonist and relaxing effects of GTN for vasocontraction after subarachnoid hemorrhage.
抄録全体を表示