颅内动脉瘤介入治疗术中动脉瘤破裂处理方法

发布时间：2018-03-23 08:54

本文选题：颅内动脉瘤　切入点：术中破裂　出处：《大连医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的：颅内动脉瘤的外科治疗过程中,动脉瘤术中破裂十分凶险,是最为严重的并发症,致残率、致死率高,对患者家属造成沉重的伤害。颅内动脉瘤血管内治疗起步较开颅夹闭晚,但效果令人满意,对多发性动脉瘤、未破裂动脉瘤或合并血管畸形的动脉瘤等更更具有优势。本文通过对介入治疗术中颅内动脉瘤破裂的经验总结,着重探讨血管内介入治疗术中动脉瘤破裂的危险因素、发生机制、预防及处理方法,为临床治疗提供帮助。方法：通过对2009年7月至2014年3月期间在大连医科大学附属第一医院神经外科住院的行介入治疗的颅内动脉瘤患者进行回顾分析,其中9例患者发生术中动脉瘤破裂,男4例,女5例,年龄47岁-68岁,平均年龄58.4岁,Hent-Hess分级Ⅰ-Ⅳ级。动脉瘤均为单发,其中前交通动脉瘤3例,2例大脑中动脉瘤,基底动脉顶端动脉瘤1例,后交通动脉瘤3例(其中1例行支架系统辅助弹簧圈栓塞)。术前均常规应用苯巴比妥、阿托品作为术前用药,术中均采用静脉麻醉,气管插管辅助通气。术前患者均行头CT检查明确诊断为蛛网膜下腔出血,均行头CTA或DSA检查明确诊断为动脉瘤。上述患者均在发病3天内行血管内介入治疗。所有患者均在全身麻醉下行经股动脉应用Seldinger技术置入6F动脉短鞘,全身肝素化下进行,手术均由神经外科医师(副教授以上)按常规介入手术操作。结果：颅内动脉瘤介入治疗术中动脉瘤破裂的9例患者,1例发生在支架系统成功置入后再次填塞弹簧圈过程中,2例发生在输送微导丝过程中,3例发生在置入微导管后,3例发生在填充弹簧圈过程中。术后6例患者进入我科重症监护室(Intensive Care Unit ICU),其中术后4例患者术后完全恢复,1例患者遗留言语障碍(术后3个月后复查,患者可与家人简单言语交流),1例患者遗留一侧肢体偏瘫(术后3个月复查,患者可借助器械行走),其中3例患者转入重症监护室(Intensive Care Unit ICU)病房,呼吸机辅助通气,1例患者家属主动放弃治疗,术后当夜1例患者死于呼吸心跳骤停,术后第三日1例患者于呼吸衰竭死亡。结论：颅内动脉瘤介入治疗术中破裂的患者致残率、死亡率高；导丝、导管、弹簧圈穿通动脉瘤是最常见的术中破裂原因；及时正确的处理颅内动脉瘤术中破裂(Intraoperative aneurysmal rupture IAR),需要神经外科医师掌握颅内动脉瘤的病因、术前患者状态、破裂原因、治疗措施、预防等相关问题,并做出最适当的治疗措施。术中动脉瘤破裂后,神经外科医师需妥善处理有关问题,在同一时间内,术后治疗是患者康复的关键。
[Abstract]:Objective: in the course of surgical treatment of intracranial aneurysms, the rupture of aneurysms during operation is very dangerous, and it is the most serious complication, the rate of disability is high, and the fatality rate is high. Endovascular treatment of intracranial aneurysms started later than open clipping, but the effect was satisfactory. This article summarized the experience of intracranial aneurysm rupture during interventional therapy, and discussed the risk factors of aneurysm rupture in intravascular interventional therapy. The mechanism of occurrence, prevention and treatment are helpful for clinical treatment. Methods: from July 2009 to March 2014, interventional treatment of intracranial aneurysms was performed in the first affiliated Hospital of Dalian Medical University. Among them, 9 patients suffered from ruptured aneurysms during operation. There were 4 males and 5 females, aged from 47 to 68 years, with an average age of 58.4 years. The aneurysms were all single, including 3 cases of anterior communicating artery aneurysms and 2 cases of middle cerebral artery aneurysms, and 1 case of aneurysms at the top of the basilar artery. 3 cases of posterior communicating aneurysm (including 1 case with stent-assisted coils embolization) were treated with phenobarbital and atropine before operation. All patients were diagnosed as subarachnoid hemorrhage by CT. All the patients were diagnosed as aneurysms by CTA or DSA. All the patients were treated with intravascular interventional therapy within 3 days after onset. All the patients were placed 6F artery short sheath via femoral artery under general anesthesia, and heparin was used in the whole body. The operation is performed by neurosurgeon (associate professor or above) according to routine interventional operation. Results: during interventional treatment of intracranial aneurysms, one patient with ruptured aneurysm occurred in 2 cases of intracranial aneurysm rupture during the successful placement of stent system and the re-filling of coils. 3 cases occurred in the process of microguide wire delivery. 3 cases occurred in microimplantation. After operation, 6 patients entered intensive Care Unit ICUU, and 4 patients recovered completely after operation. The patient could communicate with his family in simple words. One patient had left one side of hemiplegia. After 3 months of operation, the patient could walk with instruments. Among them, 3 patients were transferred to intensive Care Unit ICUU. One patient died of respiratory and cardiac arrest at night and one died of respiratory failure on the third day of operation. Conclusion: the rate of disability and mortality in patients with ruptured intracranial aneurysms during interventional treatment are high, the most common causes of rupture are wire guide, catheter and coil perforating aneurysm. Timely and correct treatment of intracranial aneurysm rupture during operation requires neurosurgeon to know the cause of intracranial aneurysm, preoperative condition, cause of rupture, treatment measures, prevention and so on. After rupture of aneurysm, neurosurgeon should deal with the related problems properly. At the same time, postoperative treatment is the key to the recovery of patients.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.41

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