VV-ECMO救治动脉瘤性蛛网膜下腔出血后 难治性神经源性肺水肿1例

Successful Management of Refractory Neurogenic Pulmonary Edema with VV-ECMO Following Aneurysmal Subarachnoid Hemorrhage: A Case Report

摘要: 神经源性肺水肿(NPE)是继发于急性中枢神经系统损伤的一种危及生命的急性并发症，蛛网膜下腔出血(SAH)是其最常见的病因之一。本文报告一例65岁女性患者，因左侧颈内动脉囊状动脉瘤破裂导致SAH后，并发重度NPE及急性呼吸窘迫综合征(ARDS)。患者入院时表现为突发意识丧失、严重低氧血症(室内空气下血氧饱和度为63%)，以及双肺广泛湿啰音。患者接受了急诊脑动脉瘤夹闭术联合去骨瓣减压术，但尽管给予高浓度吸氧和压力控制模式机械通气，进行性低氧血症仍持续存在，最终需行静脉–静脉体外膜肺氧合(VV-ECMO)支持。同时给予包括降颅压、预防癫痫、镇痛、镇静及神经肌肉阻滞在内的多模态支持治疗。患者呼吸功能显著改善，ARDS和NPE完全消退，并在7天内成功撤除VV-ECMO，随后转入神经外科病房。本病例突显了早期识别、迅速治疗原发病以及适时启动VV-ECMO在改善重度SAH相关NPE预后中的关键作用。

Abstract: Neurogenic pulmonary edema (NPE) is an acute life-threatening complication secondary to acute central nervous system injury, with subarachnoid hemorrhage (SAH) being one of its most common etiologies. Herein, we report a case of a 65-year-old female with severe NPE complicated by acute respiratory distress syndrome (ARDS) following SAH due to a left internal carotid artery saccular aneurysm rupture. The patient presented with sudden unconsciousness, severe hypoxemia (oxygen saturation 63% on room air), and extensive bilateral pulmonary rales upon admission. Emergency cerebral aneurysm clipping combined with decompressive craniectomy was performed, but progressive hypoxemia persisted despite high-concentration oxygen inhalation and pressure-controlled mechanical ventilation, requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. Multimodal supportive therapies including intracranial pressure reduction, seizure prophylaxis, analgesia, sedation, and neuromuscular blockade were simultaneously administered. The patient achieved significant improvement in respiratory function, resolution of ARDS and NPE, and was successfully weaned off VV-ECMO within 7 days, followed by transfer to the neurosurgery ward. This case highlights the critical role of early recognition, prompt treatment of the underlying cause, and timely initiation of VV-ECMO in improving the prognosis of severe SAH-associated NPE.