颈内动脉—后交通动脉瘤术中破裂的原因及处理

发布时间：2018-05-10 11:52

本文选题：颅内动脉瘤 + 后交通动脉瘤　；参考：《泸州医学院》2014年硕士论文

【摘要】：目的：颈内动脉-后交通动脉瘤是最常见颅内动脉瘤之一，尽管显微夹闭及介入栓塞治疗技术不断改进和提高，动脉瘤术中破裂(Intraoperativeaneurysm rupture，IAR)仍无法完全避免。动脉瘤术中破裂与多种因素有关，为动脉瘤术中的突发事件，是动脉瘤术中最大的风险，常导致患者术后预后不良，甚至危及生命。通过对颈内动脉-后交通动脉瘤显微夹闭及介入栓塞治疗术中破裂的相关因素的分析研究，以期降低术中破裂的发生率，提高术中破裂的预防处理水平，最终改善病人预后。方法：回顾分析泸州医学院附属医院神经外科2004年1月至2012年12月手术治疗的颈内动脉-后交通动脉瘤患者发生术中破裂的63例临床治疗资料，分为显微夹闭组和介入栓塞治疗组，对比分析两组动脉瘤术中破裂的发生率、类型、表现、原因、处理要点，以及术中破裂对预后的影响。入院后即行头颅CT平扫检查，院外已行CT检查者除外，怀疑有颅内动脉瘤者尽快行CTA检查，明确诊断为颈内动脉-后交通动脉瘤。积极术前准备，在充分告知家属病情的基础上，除介入治疗偏向选择瘤颈较窄及夹闭手术风险较大者外，一般由家属决定选择显微夹闭手术或介入治疗。对显微夹闭手术，，明显中断、改变了手术进程、影响手术气氛的动脉瘤爆裂性出血为动脉瘤术中破裂。夹闭术中动脉瘤破裂后通过：(1)药物控制血压及颅内压；(2)加深麻醉；(3)压迫颈部颈总动脉；(4)未成熟破裂者保持脑压板位置，立即双吸引器吸去术腔积血，必要时切除部分脑组织，显露并阻断载瘤动脉，继续解剖分离动脉瘤颈，夹闭动脉瘤；(5)成熟破裂者，吸引游离法(Poppen法)，压迫止血法、双极电凝法、调整动脉瘤夹位置等直至夹闭满意。(6)动脉瘤颈撕脱者自体硬脑膜包裹术加夹闭术，夹闭颈内动脉行动脉瘤孤立、动脉瘤夹直接夹闭破裂口术等；(7)必要时内外减压术等处理方法。介入治疗动脉瘤术中破裂的定义：造影时发现造影剂外溢，微导管或导丝突出瘤壁，弹簧圈突出瘤壁。介入组术中破裂的处理：(1)停用一切含有肝素的药物；(2)立即静脉注射鱼精蛋白和肝素钠逆转抗凝；在术中动脉瘤破裂时，可给予输注血小板来迅速逆转抗血小板效应；(3)保持冷静的情绪，快速填塞动脉瘤直至对比剂不外溢；(4)如果是微导管头端造成的术中破裂，此时将不能撤出微导管，使破口变大，可通过此微导管继续栓塞，或应用另一微导管进行后续栓塞；(5)球囊暂时阻断载瘤动脉，为争取导管导丝到位争取时间；(6)栓塞困难，保留导管，改行开颅手术。术后及时复查CT和CTA检查，所有病例在术后3月、6月、每年通过电话预约及来院复查的方式定期随访复查。按照GOS评分评估预后。并作统计分析。结果：CT平扫发现自发性蛛网膜下腔出血51例(81.0%)(夹闭组50/56，介入组6/7)，蛛网膜下腔出血主要位于侧裂区、鞍上池，其中15例破入脑室。单纯脑内血肿6例(9.5%)(夹闭组6/56，介入组0/7)，额叶血肿2例，颞叶血肿4例。CT-Fisher分级，Ⅰ级12例(19.0%)(夹闭组11/56，介入组1/7)，Ⅱ级21例(33.33%)(夹闭组19/56，介入组2/7)，Ⅲ级20例(31.7%)(夹闭组16/56，介入组4/7)，Ⅳ级10例(15.9%)(夹闭组10/56，介入组1/7)。DSA检查23例(36.5%)(夹闭组16/56，介入组7/7)，MRA检查2例(3.2%)(夹闭组1/56，介入组1/7)。CTA检查均确诊动脉瘤，并与DSA一致，共发现的65个动脉瘤，其中多发动脉瘤2例(3.2%)。血管痉挛29例(46.0%)(夹闭组27/56，介入组2/7)，原始后交通动脉16例(25.4%)(夹闭组14/56，介入组2/7)。总共有63例患者的动脉瘤发生术中破裂，其中夹闭组术中破裂56例，术中破裂率16.2%；夹闭组未成熟破裂16例(25.4%)，成熟破裂47例(74.6%)，行动脉瘤颈夹闭43例，行动脉瘤夹闭加包裹术5例(7.9%)，动脉瘤夹直接夹闭破裂口2例(3.6%)，动脉瘤孤立1例(1.6%)，术后去骨瓣减压10例(15.9%)。介入组7例发生术中破裂，术中破裂率6.0%，单纯药物治疗2例(28.6%)，腰大池引流2例(28.6%)，开颅血肿清除去骨瓣减压2例(28.6%)。两组在年龄、性别、Hunt-Hess分级、动脉瘤位置、动脉瘤体颈比上比较，差异无统计学意义(P0.05)；而在动脉瘤形状和大小、术中破裂发生率上，夹闭组和介入组比较，差异有统计学意义(P0.05)。显微夹闭术中破裂发生率高，以未成熟破裂多见，多为动脉瘤瘤体破裂。介入栓塞术中动脉瘤破裂发生率相对比夹闭组低，且多发生在弹簧圈栓塞过程中。此外，夹闭组术后并发症多。术后随访6个月至9年，平均随访时间3年，动脉瘤复发者3例(夹闭组2及介入组1例)。预后GOS评分，37例恢复良好(夹闭组34例及介入组3例)，11例中残(夹闭组9例及介入组2例)，10例重残(夹闭组10例)，夹闭组死亡3例，死亡率为5.4%，介入组死亡2例，死亡率为28.6%。夹闭组和介入组在残废率和死亡率上比较，差异有统计学意义(P0.05)，术中破裂发生后介入组患者死亡率较高，但存活者预后较好，夹闭组死亡率较低，但残废率高。结论：(1)后交通动脉瘤夹闭术中破裂发生率高，临时阻断是术中破裂的保护因素。双吸引器暴露术腔，临时阻断载瘤动脉，尽快夹闭瘤颈是术中破裂抢救的重点。 (2)介入栓塞术中破裂发生率低，IAR发生后立即快速静脉注射鱼精蛋白中和肝素钠逆转抗凝,快速填塞弹簧圈栓塞动脉瘤是介入术中动脉瘤破裂急诊救治的关键。 (3)术中破裂发生后介入组患者死亡率较高，但存活者预后较好，夹闭组死亡率较低，但残废率高
[Abstract]:Objective: the internal carotid artery posterior communicating artery aneurysm is one of the most common intracranial aneurysms. Despite the continuous improvement and improvement of the technique of microocclusion and interventional embolization, the rupture of Intraoperativeaneurysm rupture (IAR) is still not completely avoided. The rupture of the aneurysm is associated with a variety of factors and is an emergency in the operation of the aneurysm. It is the greatest risk in aneurysm surgery, which often leads to poor prognosis and even life. Through the analysis and study of the related factors of internal carotid artery posterior communicating artery aneurysm microclamping and interventional embolization in order to reduce the incidence of intraoperative rupture, improve the prevention and treatment level of intraoperative rupture, and ultimately improve the patient. Prognosis.
Methods: the clinical data of 63 cases of intraoperative rupture of internal carotid artery aneurysm operated in the Department of Neurosurgery of Affiliated Hospital of Luzhou Medical College from January 2004 to December 2012 were analyzed and analyzed. The results were divided into micro clamp group and interventional embolization therapy group. The incidence, type, manifestation, and the original rate of rupture were compared and analyzed in the two groups. The main points of treatment, and the effect of intraoperative rupture on the prognosis. CT plain scan after admission, except for CT examiners outside the hospital, suspected of intracranial aneurysm by CTA examination as soon as possible, clearly diagnosed as internal carotid artery aneurysm. Pre operation preparation, on the basis of full disclosure of the family's condition, except for interventional treatment preference selection Generally speaking, the family members decided to choose microsurgical clipping or interventional therapy.
The operation process was obviously interrupted and the operation process was obviously interrupted and the operation process was changed. The aneurysm burst bleeding affected the operation atmosphere. The aneurysm was ruptured during the operation. (1) the drug controlled the blood pressure and intracranial pressure; (2) the deepening anaesthesia; (3) the compression of the neck and neck common artery; (4) the unripe ruptured person kept the position of the brain pressure plate, immediately The double suction apparatus sucked the blood of the cavity, removed part of the brain tissue, exposed and blocked the aneurysm arteries, continued dissecting the aneurysm neck and clipping the aneurysm; (5) the mature ruptured, the free method (Poppen), the compression hemostasis method, the bipolar electrocoagulation, the adjustment of the position of the aneurysm clip were satisfied. (6) the autologous brain of the aneurysm neck avulsion was in the autologous brain. Membrane encapsulation and clipping, clamping internal carotid artery aneurysm isolated, aneurysm clipping and rupture, and so on; (7) internal and external decompression, such as necessary treatment. Interventional treatment of aneurysm rupture definition: contrast medium spillover, micro catheter or filaments out of the tumor wall, coils protruding the tumor wall. Intraoperative rupture of the interventional group. Treatment: (1) discontinuation of all drugs containing heparin; (2) immediate intravenous injection of protamine and heparin sodium to reverse anticoagulation; when intraoperative aneurysm ruptures, infusion of platelets can be given to quickly reverse the antiplatelet effect; (3) keep calm and quickly fill the vein tumor until the contrast agent does not spilt; (4) if it is the head end of the micro catheter In the case of intraoperative rupture, the microcatheter could not be withdrawn at this time to make the breach larger, and the microcatheter could be embolized by this microcatheter or the other microcatheter was used for subsequent embolization; (5) the balloon was temporarily blocked by the balloon to strive for the time of the catheter guide in place; (6) the catheter was retained and the catheter was retained, and a craniotomy was performed.
CT and CTA were reviewed in time after operation. All cases were reviewed in March and June after the operation. The prognosis was evaluated according to the GOS score.
Results: 51 cases of spontaneous subarachnoid hemorrhage (50/56, 6/7) were found in 51 cases of spontaneous subarachnoid hemorrhage (50/56, 6/7). Subarachnoid hemorrhage was mainly located in the lateral fissure area, in which 15 cases were broken into the ventricle, 6 cases of intracerebral hematoma (9.5%) (6/56, 0/7), 2 cases of frontal hematoma, 4 cases of temporal lobe hematoma, 12 cases (19%) (19%) (19%). 11/56, interventional group 1/7), 21 cases (33.33%) of grade II (19/56 in clipping group, 2/7 in interventional group), 20 cases (31.7%) of grade III (4/7 in clipping group, 4/7), 10 cases (15.9%) of grade IV (10/56 in clipping group, 1/7) in 23 cases (36.5%) (clipping group 16/ 56, 7/7 in intervention group), 2 cases of MRA examination (3.2%) (interlocking group, interventional group) examination all confirmed arteries 65 aneurysms were found in common with DSA, including 2 cases (3.2%) of multiple aneurysms, 29 cases of vasospasm (46%) (27/56 in clipping group, 2/7 in interventional group), 16 cases of primary posterior communicating artery (25.4%) (14/56 in clipping group and 2/7 in interventional group).
A total of 63 cases of aneurysm occurred intraoperative rupture, of which 56 cases were ruptured in the clipping group and 16.2% in the intraoperative rupture rate; 16 cases of unripe rupture (25.4%), 47 mature rupture (74.6%), 43 cases of aneurysm neck clipping, 5 cases of aneurysm clipping plus parcels (7.9%), aneurysm clips 2 cases (3.6%) and aneurysm isolating 1. Cases (1.6%), postoperative bone flap decompression in 10 cases (15.9%). 7 cases occurred intraoperative rupture, 6% of intraoperative rupture, 2 cases of pure drug therapy (28.6%), 2 cases (28.6%), craniotomy hematoma removal of 2 cases (28.6%). The difference was not statistically significant in age, sex, Hunt-Hess classification, aneurysm position and comparison of aneurysm neck ratio. Significance (P0.05), but in the shape and size of aneurysm and the incidence of intraoperative rupture, the difference between the clipping group and the interventional group was statistically significant (P0.05). The incidence of rupture was high in the microsurgical clipping, most of which were ruptured with unripe ruptures and most of the aneurysm rupture. The incidence of aneurysm rupture in interventional embolization was relatively lower than that in the clipping group. In addition, in the process of coiling embolism, there were more complications in the clipping group. The follow-up period was 6 months to 9 years, the average follow-up time was 3 years, 3 cases of aneurysm recurrence (2 and 1 cases in the intervention group). The prognosis was GOS score, 37 cases were recovered well (34 cases in the clipping group and 3 cases in the intervention group), 11 cases were disabled (9 in clipping group and 2 cases), and 10 cases were severely disabled (10 cases in clipping group) In the clipping group, 3 cases died, the mortality rate was 5.4% and the intervention group died in 2 cases. The mortality rate was compared with the 28.6%. clipping group and the intervention group, the difference was statistically significant (P0.05). The mortality of the patients in the intervention group was higher after the intraoperative rupture, but the survival rate was better, the mortality rate was lower in the clipping group, but the residual rate was high. Conclusion: (1) after (1) The incidence of rupture is high during the operation of aneurysm clipping. Temporary occlusion is a protective factor for intraoperative rupture. Double suction apparatus exposes the operation cavity, temporarily blocks the aneurysm of the aneurysm, and clips the neck of the tumor as soon as possible.
(2) the incidence of ruptured embolization in interventional embolization is low. Immediately after IAR, protamine and heparin sodium are quickly injected to reverse the anticoagulation. The key to emergency treatment of aneurysm rupture during interventional procedure is to plug the aneurysm quickly by filling the coils.
(3) the mortality rate of the intervention group was higher after the rupture of the operation, but the prognosis of the survivors was better, and the mortality of the clipping group was lower, but the disability rate was high.

【学位授予单位】：泸州医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R651.12

【参考文献】