Subaraknoid kanama sonrası serebral vazospazm

Özet

Anevrizmal subaraknoid kanamadan sonraki günlerde yeni nörolojik kötüleşme gelişen hastada intrakraniyal arterlerin geçici daralması ve buna bağlı gecikmiş iskemi araştırılır. Kontrastsız BT subaraknoid kanamayı ve gelişen infarktı değerlendirmede kullanılır; BT anjiyografi arter lümenindeki daralmayı gösterir, BT perfüzyon ise serebral kan akımını ve perfüzyon bozukluğunu değerlendirmeye yardımcı olur. Anjiyografik vazospazm gecikmiş serebral iskemiyle eş anlamlı değildir ve tek başına klinik kötüleşmeyi kanıtlamaz. Daralma ya da eşlik eden iskemi atlanırsa geri dönüşsüz infarkt gelişene dek tanı gecikebilir.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız BT'de yeni kanamayı ve gelişen infarktı arayın.

BTA tanısal

Willis poligonu, supraklinoid internal karotid arterler ile A1, M1 ve P1 segmentlerinde karşılaştırmalı lümen daralması, düzensizlik ve distal dalların opasifikasyonunu gösterir; önceki BTA veya DSA varsa çap değişimi başlangıç incelemesiyle karşılaştırılarak daha güvenilir yorumlanır.

BTP tanısal

Gecikmiş transit ve azalmış serebral kan akımıyla birlikte uzamış ortalama geçiş zamanı, özellikle daralmış arterin beslediği alanda perfüzyon bozukluğunu gösterir; gecikmiş bolus nedeniyle çekirdek-kurtarılabilir doku ayrımı dikkatle yorumlanır.

Önerilen pencereler: Beyin (G 80 / M 40), İnme (G 40 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Segmental lümen daralması — M1, A1 veya baziler arterde önceki incelemeye göre incelme; damar çapı yakın normal ICA segmenti veya karşı tarafla kıyaslanır.
• Stenozun ötesindeki distal arter dallarında opasifikasyon azalması veya geç dolum gözlenebilir; bu durum daralan proksimal segmentin distal perfüzyonu etkilediğini gösterir.
• Damar alanına uyan perfüzyon gecikmesi — daralmış damarın beslediği kortekste uzamış transit zamanı; geniş infarkt çekirdeği bulunmayabilir.
• Gelişen iskemik infarkt — BT veya MR'da saptanan yeni infarkt, gecikmiş serebral iskemiye bağlı doku hasarını düşündürür.
• Yeniden subaraknoid kan — yeni veya artmış sulkal/sisternal hiperdensite; önceki kan dağılımı ve girişim alanıyla karşılaştırılır.
• İşlem sonrası damar kontur değişikliği — Klip/koil çevresindeki metal blooming komşu lümeni örtebilir veya olduğundan dar gösterebilir; stent içi ya da kenarındaki mekanik stenoz ise gerçek cihaz ilişkili darlıktır. Cihaz konumu ve önceki incelemeler vazospazm ayrımına yardım eder.

Ölçütler ve sınıflamalar

CTA/DSA lümen daralması için semikantitatif derece

BT anjiyografide vazospazm, lümen azalmasının proksimal ve distal segmentler ile karşı taraf damarlarına göre değerlendirilmesiyle tanımlanır.

Normalde

Normal BTA'da supraklinoid internal karotid arterlerin, A1 ve M1 segmentlerinin ve baziler arterin lümen konturları kesintisizdir; aynı hastanın başlangıç anjiyogramı bu kıyas için en yararlı referanstır. BTA'da darlığı değerlendirirken ilgili damarı proksimal ve distal segmentleriyle ve karşı taraftaki damarlarla karşılaştırın.

Ayırıcı tanı

Reversible serebral vazokonstriksiyon sendromu

tekrarlayan gök gürültüsü baş ağrısı ve çok odaklı daralma görülebilir; eşlik eden tipik anevrizmal kan dağılımı bulunmayabilir.

İntrakraniyal ateroskleroz

fokal, sıklıkla eksantrik plak ve sabit darlık; başlangıç görüntülerinde aynı segmentte kronik değişiklik olabilir.

İşleme bağlı stenoz

klip veya stent bitişiğinde mekanik lümen daralması ve metal artefaktı; anatomik olarak cihazla ilişkilidir.

Konjenital hipoplazi

tek arter segmenti boyunca düzgün ve kalıcı küçük kalibre; karşı taraf ve eşlik eden damar varyantları yardımcıdır.

Tuzaklar

• CTA'daki metal klip/koil blooming'i komşu damarın lümenini yapay olarak daraltabilir; kaynak görüntülerde farklı düzlemlerde izle ve önceki CTA/DSA ile kıyasla.
• CTA'nın vazospazm taramasındaki duyarlılığı sınırlı olabilir; bu nedenle negatif CTA, klinik kuşku sürüyorsa vazospazmı tek başına dışlamaz.
• Anjiyografik daralma, gecikmiş serebral iskemi ile aynı kavram değildir; doku perfüzyonu ve yeni infarktı ayrı değerlendir.
• Vazospazmı yalnız tek bir damarın küçük görünmesine dayanarak adlandırma; başlangıç damar çapı, anatomik varyant ve teknik opasifikasyon farkını kontrol et.

Kendini dene

1. Anevrizmal subaraknoid kanama sonrası CTA'da arter lümenindeki daralmayı değerlendirirken hangi karşılaştırmalar yapılmalıdır?

   • Başlangıç BT anjiyografi, proksimal-distal segmentler ve karşı taraf damarlar
   • Kontrastsız BT'deki parankimal hipodensite alanları
   • Transkranyal Doppler ölçülen sistolik akım hızları
   • MR venografi ile görülen kortikal venlerin dolum süreleri
   Cevabı göster

   Başlangıç BT anjiyografi, proksimal-distal segmentler ve karşı taraf damarlar. CTA'da vazospazm, lümen azalmasının proksimal ve distal segmentlere ve karşı taraftaki damarlara göre değerlendirilmesiyle tanımlanır. Başlangıç CTA'sı, aterosklerotik daralma ve hipoplaziyi vazospazm taklitçileri olarak dışlamaya yardımcı olur.

2. Subaraknoid kanama sonrası anjiyografide vazospazm saptanırsa, bu bulgu hangi klinik sonuçlarla birlikte yorumlanmalıdır?

   • Gecikmiş serebral iskemi veya işlevsel sonuçla
   • Yalnızca başlangıçtaki kanama dağılımıyla
   • Yalnızca anevrizmanın yerleşimiyle
   • Yalnızca hastanın yaş grubuyla
   Cevabı göster

   Gecikmiş serebral iskemi veya işlevsel sonuçla. Anjiyografi veya transkraniyal Doppler'de saptanan vazospazm, gecikmiş serebral iskemi ya da işlevsel sonuçla birlikte yorumlanmalıdır.

Kaynaklar

Bu sayfadaki 36 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 17 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.