颅内动脉瘤显微手术治疗的临床应用研究

发布时间：2017-12-27 18:24

本文关键词：颅内动脉瘤显微手术治疗的临床应用研究　出处：《青岛大学》2017年博士论文　论文类型：学位论文

【摘要】：颅内动脉瘤是颅内动脉管壁的向外异常膨出,是造成自发性蛛网膜下腔出血(subarachnoid hemorrhage,SAH)的主要原因。随着手术显微镜和神经外科显微器械,以及治疗理念和技术的不断改进,显微手术夹闭颅内动脉瘤的治疗效果得到进一步提高。但仍然有一些问题需要提升和解决,如部分患者会发展为慢性分流依赖性脑积水;一些相对少见的颅内动脉瘤,如多发动脉瘤、血泡样动脉瘤等的治疗效果仍需进一步提高等。本研究基于颅内动脉瘤显微手术治疗存在的部分问题,对1996年10月至2015年12月期间行显微手术治疗的1534例颅内动脉瘤病例进行回顾性分析,为今后的诊疗提供依据和指导。研究分为四部分:一是对1534例颅内动脉瘤的诊治资料进行临床分析;二是研究术中终板造瘘+有效脑脊液引流对慢性分流依赖性脑积水的影响;三是分析一侧翼点入路夹闭对侧动脉瘤的优势及技术可行性;四是探讨显微手术治疗血泡样动脉瘤的新方法。第一部分1534例颅内动脉瘤显微手术治疗临床分析目的总结显微手术治疗颅内动脉瘤的经验,分析本组病例的性别、年龄分布,动脉瘤大小、位置,临床表现以及治疗效果等,探讨颅内动脉瘤显微手术治疗的安全性和有效性。方法收集1996年10月~2015年12月青岛大学附属医院神经外科完成的显微手术治疗的部分颅内动脉瘤患者资料。对性别、年龄、Hunt-Hess分级、动脉瘤的大小、部位、手术并发症、出院时评估、以及影像学和临床随访结果等进行总结分析。结果本组患者1534例,其中男性650例(42.4%)、女性884例(57.6%),男性患者平均年龄49.8±10.5岁、女性患者平均年龄52.6±11.6。Hunt-Hess分级:0级75例(4.9%),I级42例(2.7%),II级742例(48.4%),III级493例(32.1%),IV级161例(10.5%),V级21例(1.4%)。1534个责任动脉瘤中,前交通动脉、后交通动脉及大脑中动脉为动脉瘤高发部位,分别占36.6%、27.7%及19.7%。发病后小于3天手术的患者898例,占58.5%;发病后3~14天手术的患者488例,占31.8%;发病后2周以上手术的患者148例,占9.6%。1755个动脉瘤中,显微手术成功夹闭1698个,肌肉包裹23个,前期或后期栓塞6个,术中行孤立术、闭塞颈内动脉4个,外院夹闭1个,未夹闭23个。手术破裂率为16.6%。出院时,按照格拉斯哥结局评分(GOS),治愈(GOS 5分)1345例(87.7%),生活自理(GOS 4分)98例(6.4%),植物生存(GOS 3~2分)21例(1.4%),死亡(GOS 1分)70例(4.6%)。结论本组大宗颅内动脉瘤病例有其独有的特点,显微手术治疗颅内动脉瘤是安全有效的治疗方法,可以取得良好的预后效果。第二部分术中终板造瘘+脑脊液有效引流对慢性分流依赖性脑积水的影响目的导致慢性分流依赖性脑积水的原因很多,各种技术措施对预防其发生的有效性存在争论,终板造瘘是争论较为激烈的技术之一。本部分的目的是研究终板造瘘、脑脊液有效引流对慢性分流依赖性脑积水发生的影响,探索更为有效的预防技术手段。方法回顾性分析本文第一部分中提到的1534例颅内动脉瘤患者资料,选取Hunt-Hess分级III~IV级的病例进行研究。以常规引流为第一组;有效脑脊液引流为第二组;终板造瘘+常规引流为第三组;终板造瘘+有效脑脊液引流为第四组。比较各组的脑脊液引流量、慢性分流依赖性脑积水的发生率等。所有统计资料用SPSS16.0统计软件进行分析。当P0.05时差异有统计学意义。结果符合入组条件、各项观察指标资料完整的病例共512例,常规引流组192例,有效引流组108例,终板造瘘+常规引流组120例,终板造瘘+有效引流组92例。t检验分析显示有效引流量明显多于常规引流,差异具有统计学意义(t=92.5,P0.001);有效引流时间明显长于常规引流,差异具有统计学意义(t=39.4,P0.001)。趋势性卡方检验显示从常规引流组—有效引流组—终板造瘘+常规引流组—终板造瘘+有效引流组发生慢性分流依赖性脑积水的可能逐渐降低(趋势性,p=0.004)。结论Hunt-Hess分级III~IV级的颅内动脉瘤患者,显微手术夹闭术中行终板造瘘,同时行脑脊液有效引流会显著降低慢性分流依赖性脑积水的发生率。第三部分一侧翼点入路显微手术夹闭对侧动脉瘤的优势和技术可行性研究目的颅内多发动脉瘤发生破裂的机会比单发动脉瘤高,其自然死亡率亦高。一次手术经一侧翼点入路显微手术夹闭双侧动脉瘤需要较高的技术要求。本部分的目的是探讨一侧翼点入路显微手术夹闭对侧动脉瘤的优势和技术可行性。方法回顾性分析本文第一部分中提到的1534例颅内动脉瘤患者资料,选取前循环多发动脉瘤的病例进行研究。以分期分侧为第一组;一期分侧为第二组;一期一侧为第三组。比较各组的手术时间、出血量、住院天数等。同时分析一侧翼点入路显微手术夹闭对侧动脉瘤的可及范围。所有统计资料用SPSS16.0统计软件进行分析。当p0.05时差异有统计学意义。结果符合入组条件、各项观察指标资料完整的病例149例,其中分期分侧组52例,一期分侧组34例,一期一侧组63例。方差分析结果显示三组间手术时间差异具有统计学意义(p0.05),进一步两两比较结果显示手术时间一期一侧组一期分侧组分期分侧组。三组间出血量差异具有统计学意义(p0.05),进一步两两比较结果显示一期一侧组出血量明显少于分期分侧组及一期分侧组;而分期分侧组与一期分侧组出血量差异无统计学意义。三组间住院时间差异具有统计学意义(p0.05),进一步两两比较结果显示分期分侧组住院天数明显长于一期分侧组及一期一侧组,一期分侧组与一期一侧组住院天数无统计学差异。结论一期一侧显微手术夹闭颅内多发动脉瘤较分期、分侧手术更加有利于患者,其治疗效果良好。一侧翼点入路显微手术夹闭对侧动脉瘤虽然技术要求高,但有较强的可行性,可夹闭对侧眼动脉至大脑中动脉分叉部位的绝大多数动脉瘤。第四部分血泡样动脉瘤的显微手术治疗目的血泡样动脉瘤是起自颈内动脉床突上段前壁或上壁的非分叉部位的血泡样的罕见动脉瘤。无论采用何种治疗手段,其治疗效果均欠佳。本部分回顾性分析血泡样动脉瘤的特点和显微手术治疗技巧,以期指导未来诊治,提高治疗效果。方法回顾性分析本文第一部分中提到的1534例颅内动脉瘤患者中资料完整的11例血泡样动脉瘤,分析其临床表现等特点,探讨显微手术治疗技巧,总结其治疗效果。同时观察离断血运的硬脑膜的病理学改变。结果符合纳入标准的患者共11例,其中男性4例、占36.4%,女性7例、占63.6%。发病年龄均为40~59岁年龄段。入院时Hunt-Hess分级:0级0例,I级0例,II级3例(27.3%),III级4例(36.4%),IV级3例(27.3%),V级1例(9.1%)。本组11枚动脉瘤均采用翼点入路显微手术治疗。直接夹闭1例(9.1%),孤立手术4例(36.4%),包裹复合夹闭手术6例(54.6%),其中棉片纤维包裹1例、自体硬膜包裹5例。术中夹闭前破裂10个,破裂率90.9%。按照格拉斯哥结局评分(GOS),治愈5例(45.5%),生活自理4例(36.4%),死亡1例(9.1%)。结论显微手术夹闭血泡样动脉瘤可以取得良好的效果,自体硬膜辅助显微手术夹闭血泡样动脉瘤需要较高的手术技巧,该技术可以提高手术治疗效果。自体硬膜是理想的辅助夹闭血泡样动脉瘤的材料。
[Abstract]:Intracranial aneurysm is an outward abnormal expansion of the wall of the intracranial artery, which is the main cause of the spontaneous subarachnoid hemorrhage (subarachnoid hemorrhage, SAH). With the continuous improvement of operative microscope and Department of Neurosurgery microapparatus, as well as the concept and technology of treatment, the effect of microsurgical clipping on intracranial aneurysms has been further improved. But there are still some problems need to improve and solve, such as some patients will develop chronic shunt dependent hydrocephalus; some relatively rare intracranial aneurysms, such as multiple aneurysms, Xuepao aneurysm etc. the treatment effect still needs further improvement. Based on some problems in microsurgical treatment of intracranial aneurysms, 1534 cases of intracranial aneurysms treated by microsurgery from October 1996 to December 2015 were retrospectively analyzed to provide evidence and guidance for future diagnosis and treatment. The research is divided into four parts: diagnosis and treatment data of 1534 cases of intracranial aneurysms were retrospectively analyzed; the two is the study of intraoperative endplate colostomy and effective drainage of cerebrospinal fluid on chronic shunt dependent hydrocephalus; the three is the analysis of side pterional clamping the advantages and technical feasibility of contralateral aneurysm; four is the new method of microsurgery treatment of aneurysm of the xuepao. Objective to summarize the clinical analysis of the treatment of microsurgery treatment of intracranial aneurysms of the experience of the first part of the 1534 cases of intracranial aneurysm microsurgery, analysis of sex and age distribution of patients in this group, aneurysm size, location, clinical manifestations and therapeutic effect of intracranial aneurysm, microsurgery is effective and safe in the treatment of. Methods the data of some patients with intracranial aneurysms were collected from the Department of Neurosurgery of the Affiliated Hospital of Qiingdao University, October 1996 ~2015, which was performed in the Department of Neurosurgery, the Affiliated Hospital of Qiingdao University. Gender, age, Hunt-Hess classification, size and location of aneurysms, operative complications, assessment at discharge, and imaging and clinical follow-up results were analyzed. Results there were 1534 patients in this group, including 650 males (42.4%) and 884 females (57.6%). The average age of male patients is 49.8 + 10.5 years, and the average age of female patients is 52.6 + 11.6. Hunt-Hess classification: 0 grade 75 cases (4.9%), class I 42 cases (2.7%), class II 742 cases (48.4%), III class 493 cases (32.1%), IV level 161 cases (10.5%), V grade 21 (1.4%). Of the 1534 responsible aneurysms, anterior communicating artery, posterior communicating artery and middle cerebral artery were high incidence of aneurysms, which accounted for 36.6%, 27.7% and 19.7% respectively. The patients with less than 3 days after the onset of the disease were 898 cases, accounting for 58.5%; 488 patients were operated on 3~14 days after the onset of the disease, accounting for 31.8%; 148 patients with more than 2 weeks after the onset of the disease accounted for 9.6%. In 1755 aneurysms, 1698 microsurgical clips were successfully clipped, 23 muscles were encapsulated, 6 were embolized at the early stage or late stage, 4 were isolated, 4 were internal carotid artery, 1 were external clipping, and 23 were not clipped. The surgical rupture rate was 16.6%. At discharge, according to Glasgow Outcome Scale (GOS), 1345 (87.7%) patients were cured (GOS 5 points), 98 cases (6.4%) were self-care (GOS 4 points), 21 cases (1.4%) had plant survival (GOS 3~2 score), and death (GOS 1 points) 70 cases (4.6%). Conclusion this group of intracranial aneurysms has its unique characteristics. Microsurgical treatment of intracranial aneurysms is a safe and effective treatment method, which can achieve good prognosis. The second part of endplate colostomy + effective drainage on chronic cerebrospinal fluid shunt dependent hydrocephalus to many causes of chronic shunt dependent hydrocephalus, a variety of technical measures for the prevention of the occurrence of effective dispute, endplate colostomy is one of the more intense debate technology. The purpose of this section is to study the effect of endplate stoma and effective drainage of cerebrospinal fluid on the occurrence of chronic shunt dependent hydrocephalus, and explore more effective preventive techniques. Methods the data of 1534 cases of intracranial aneurysms mentioned in the first part of this article were analyzed retrospectively, and the cases of Hunt-Hess grade III~IV grade were selected. The normal drainage was the first group, the effective cerebrospinal fluid drainage was second groups, the end plate fistula + routine drainage was third groups, and the end plate fistulae + effective cerebrospinal fluid drainage was fourth groups. The flow rate of cerebrospinal fluid (CSF) and the incidence of chronic shunt dependent hydrocephalus were compared in each group. All the statistical data were analyzed by SPSS16.0 software. The difference was statistically significant when P0.05. Results a total of 512 cases were eligible for admission and observation data. There were 192 cases in conventional drainage group, 108 cases in effective drainage group, 120 cases in end plate fistulas plus routine drainage group, and 92 cases in end plate fistulas plus effective drainage group. T test analysis showed that effective drainage volume was significantly more than that of conventional drainage, the difference was statistically significant (t=92.5, P0.001), effective drainage time was significantly longer than that of conventional drainage, the difference was statistically significant (t=39.4, P0.001). Trend chi square test showed that the incidence of chronic shunt dependent hydrocephalus may gradually decrease from conventional drainage group to effective drainage group, endplate fistulas plus routine drainage group, endplate fistulas + effective drainage group (trend, p=0.004). Conclusion Hunt-Hess grade III~IV grade intracranial aneurysms, microsurgical clipping, endplate fistulas and cerebrospinal fluid drainage can significantly reduce the incidence of chronic shunt dependent hydrocephalus. The third part side pterional microsurgery clipping rupture to feasibility study advantages and technology of lateral aneurysms intracranial multiple aneurysms opportunities than single aneurysm, the natural mortality rate is also high. An operation through unilateral pterional microsurgery clipping of bilateral aneurysms require higher technical requirements. The purpose of this part is to investigate the side pterional microsurgery clipping the advantage and feasibility of contralateral aneurysm. Methods the data of 1534 cases of intracranial aneurysms mentioned in the first part of this article were analyzed retrospectively, and the cases of anterior circulation multiple aneurysms were selected. The first group was divided by stages; the first stage was divided.
【学位授予单位】：青岛大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R651.12

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