颅内夹层动脉瘤的血管内治疗和随访研究

发布时间：2018-03-23 12:42

本文选题：颅内动脉瘤　切入点：夹层动脉瘤　出处：《首都医科大学》2017年博士论文

【摘要】：目的:通过对颅内夹层动脉瘤患者术后临床和影像学结果进行随访,评估颅内夹层动脉瘤血管内治疗的安全性和有效性,提出颅内夹层动脉瘤的影像学分型,并总结出基于影像学分型的治疗原则。方法:本研究分两部分,第一部分研究对象为2010年1月至2014年6月在我院神经介入中心接受血管内治疗的40例连续性自发性出血性颅内椎基底夹层动脉瘤患者,对患者的术前术后的临床资料和影像学资料进行分析,记录术中和术后的并发症情况,以及术后患者的随访情况,评价血管内治疗对于出血性椎基底夹层动脉瘤的疗效。第二部分研究对象为2010年1月至2015年12月,在我院神经介入中心接受治疗的309例连续性病例,共323个颅内夹层动脉瘤。采集所有患者的临床和影像学资料。所有入组患者均接受脑血管造影检查并行血管内治疗,所有患者都进行半年以上临床随访。分析每个病变的血管壁成像特征和管腔构型。在前人分型的基础上,将颅内夹层动脉瘤分为四型:Ⅰ型,经典型;Ⅱ型,节段扩张型;Ⅲ型,延长扩张型;Ⅳ型,局部巨大占位型。比较每组亚型的病变临床症状、治疗方式、治疗效果、并发症情况以及长期预后情况。应用多因素回归分析寻找影响预后的危险因素。应用SPSS22.0进行统计学分析。结果:本研究第一部分,40名出血性夹层动脉瘤患者中,男性30人,女性10人,平均随访时间5.2个月。采用载瘤动脉闭塞治疗的7名患者治疗效果满意,无明显术中及术后并发症,复查无影像学复发;26名采用支架辅助弹簧圈栓塞的患者中,1名患者基底动脉夹层动脉瘤的患者术中支架内血栓形成;1名患者术后出现脑梗死;1名患者术后发生再出血;1名患者影像学复查显示复发。采用单纯支架治疗的7名患者中,2名患者出现再出血,其中一名死亡;1名患者影像学复查显示复发。本研究的第二部分,309例患者中男性233名(75.4%),所有患者平均年龄为50.43±11.93岁。共发现323个颅内夹层动脉瘤,其中前循环动脉瘤27个,后循环动脉瘤296个。按照改良的形态学分类,I型动脉瘤262例(81.11%),II型22例(7.12%),III型14例(4.53%),IV型25例(8.09%)。216例(66.87%)动脉瘤采用支架辅助弹簧圈栓塞治疗,47例(14.55%)动脉瘤采用载瘤动脉闭塞治疗,60例(18.58%)动脉瘤采用单纯支架治疗。共有262名(84.74%)患者(274个动脉瘤)进行了影像学随访,平均随访时间7.10月(3-60个月)。28例行载瘤动脉闭塞的动脉瘤影像学随访结果满意,未见动脉瘤复发;246例采用重建性治疗(使用支架辅助弹簧圈栓塞193例,使用单纯支架成形治疗53例)的动脉瘤中有24例动脉瘤出现复发(9.16%)。单因素分析显示有两个以上危险因素,动脉瘤大小,动脉瘤分型和治疗方式的不同与临床预后相关。多因素回归分析显示动脉瘤大小是预后不同的独立危险因素(P=0.004)。与I型相比,III型预后比I型患者差(P=0.013,OR值7.091,95%可信区间1.520-3.076);IV型也比I型患者预后差(OR,6.798;95%CI,2.200-21.008;P=0.001);但是II型与I型相比预后未见明显不同(P=0.941)。结论:如果选择合适的治疗方案,血管内治疗出血性椎基底夹层动脉瘤是安全有效的。颅内夹层动脉瘤患者的预后和动脉瘤的大小以及动脉瘤的不同分型存在着密切关联。本研究提出的颅内夹层动脉瘤改良分型能评估患者的临床预后,对临床治疗方案的选择有较好的指导作用。
[Abstract]:Objective: through the follow-up of the clinical and radiographic results of intracranial aneurysm patients, treatment safety and efficacy evaluation of intracranial aneurysm endovascular, the classification of intracranial aneurysm, and summed up the principle of treatment based on imaging classification. Methods: This study is divided into two parts, the first part of the research object from January 2010 to June 2014 in our hospital received endovascular interventional Center for treatment of 40 cases of spontaneous hemorrhage of continuous intracranial vertebrobasilar dissecting aneurysm patients, the clinical data and effects of the patients with preoperative and postoperative imaging data were analyzed and recorded the complications during and after surgery, and postoperative patients the follow-up, evaluation of endovascular treatment for hemorrhage of vertebrobasilar dissecting aneurysms. The second part of the study from January 2010 to December 2015, the heart in our hospital in neurointervention 309 consecutive patients treated, 323 intracranial aneurysm. All patients collected the clinical and imaging data. All patients received cerebral angiography underwent endovascular treatment, all patients were more than half of the clinical follow-up. Analysis of each lesion blood vessel wall and lumen in the imaging features of configuration. Based on the classification, the intracranial aneurysm were divided into four types: the first type of classic; type II, Section III, extend the expansion; expansion; type IV, local huge occupying type. The clinical symptoms of lesions in each subtype, treatment, therapeutic effect and complications and the long-term prognosis. The application of multiple factors regression analysis for the risk factors influencing the prognosis. The application of SPSS22.0 for statistical analysis. Results: the first part of this study, 40 hemorrhagic dissecting aneurysm patients, male 30, female 10, average follow-up Time for 5.2 months. The parent artery occlusion in 7 patients, treatment satisfaction, no intraoperative and postoperative complications, follow-up imaging shadowless recurrence; 26 with stent assisted coil embolization in patients with stent thrombosis in 1 patients with basilar artery dissection in patients with cerebral infarction; 1 patients developed postoperative rebleeding; 1 patients after surgery; 1 patients with postoperative imaging showed recurrence. 7 patients treated with single stent, then bleeding occurred in 2 patients, one died; 1 patients with postoperative imaging showed recurrence. The second part of this study, 309 cases in 233 male patients (75.4%), all patients with an average age of 50.43 + 11.93 years. There were 323 intracranial aneurysm, including 27 anterior circulation aneurysms, 296 aneurysms of posterior circulation. According to the morphological classification of the modified type I aneurysm in 262 cases (81.11%), II 22 (7.12% cases), 14 cases of type III (4.53%), 25 cases of type IV (8.09%).216 (66.87% cases) treated by stent assisted coil embolization of aneurysm, 47 cases (14.55% aneurysms) with parent artery occlusion, 60 cases (18.58%) with stent in the treatment of aneurysms with a total of 262. A (84.74%) patients (274 aneurysms) were imaging follow-up, the mean follow-up time was 7.10 months (3-60 months) aneurysm in.28 cases of parent artery occlusion. The follow-up results were satisfactory, no aneurysm recurrence; 246 cases treated by reconstruction (using stent assisted coil embolization in 193 cases, the use of simple stent treatment of 53 cases of aneurysms) in 24 cases of aneurysm recurrence (9.16%). Univariate analysis showed that there are two or more risk factors, the size of the aneurysm, aneurysm type and the different ways of treatment and clinical prognosis. Multivariate regression analysis showed that the size of the aneurysm is a different prognosis Independent risk factors (P=0.004). Compared with I type, III type I patients with poor prognosis than type (P=0.013 = 7.091,95% CI OR, 1.520-3.076); type IV than type I patients with poor prognosis (OR, 6.798; 95%CI, 2.200-21.008; P=0.001); but the II type compared with I type was significantly different prognosis (P=0.941). Conclusion: if the choice of appropriate treatment, endovascular treatment of hemorrhagic vertebrobasilar dissecting aneurysms is safe and effective. Patients with intracranial aneurysm prognosis and the size of aneurysms and aneurysms of different types are closely related. Improvement of intracranial aneurysm dissection the typing to assess the prognosis of the patients, has good guidance for clinical treatment.

【学位授予单位】：首都医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R651.12

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