手术夹闭治疗与血管内介入治疗颅内前循环动脉瘤的对比研究

发布时间：2018-05-29 03:30

  本文选题：手术夹闭治疗 + 血管内介入　； 参考：《新乡医学院》2014年硕士论文

【摘要】：背景颅内动脉瘤是颅内动脉壁上的异常膨出,是引起蛛网膜下腔出血的主要原因,其破裂出血具有很高的致残率和死亡率。因显微外科手术夹闭术和血管内介入术均较易到达前循环动脉瘤所在位置,故在临床上选择何种治疗方式治疗此类动脉瘤成为研究热点；国际蛛网膜下腔出血动脉瘤试验(ISAT)协作组2003年多中心随机试验得出的试验结果显示,对于同时适合进行手术夹闭治疗和血管内介入治疗的破裂脑动脉瘤患者,根据治疗后1年时的无残疾存活来判断临床转归,血管内治疗组显著优于手术夹闭组。但近年来很多研究显示,手术夹闭治疗与血管内介入治疗术后疗效差异并无统计学意义。目的通过对经手术夹闭治疗与血管内介入治疗的颅内前循环动脉瘤患者的术后主要并发症——脑血管痉挛、脑积水发生率、术后6个月生存状态、复发率等对比分析,比较两种治疗方式的疗效。方法回顾性分析新乡医学院第一附属医院2009年1月至2011年6月收治的367例经头部CTA或全脑血管造影-DSA确诊的颅内前循环动脉瘤患者的临床资料。其中手术组301例,介入组66例,男性161例,女性206例,大脑前动脉动脉瘤150例,大脑中动脉动脉瘤76例,颈内动脉动脉瘤141例,共计424个动脉瘤；患者治疗时机分为3个时段。(1)在颅内动脉瘤破裂后72小时内行手术夹闭治疗或血管内介入治疗；(2)已经超过72小时的患者,部分患者因病情变化在4-10天之间接受治疗,其余病人尽量避免在发病后4-10天的血管痉挛期进行治疗。(3)其余病人在发病10天后行手术夹闭治疗或血管内介入治疗；手术夹闭治疗组手术方法：患者取经典翼点入路或扩大翼点入路,高倍显微镜下仔细分离侧裂,打开邻近脑池放出脑脊液降颅压,显露载瘤动脉,分离动脉瘤颈后选取合适动脉瘤夹将动脉瘤夹闭。本组所有病例均采用气管插管静吸复合麻醉,严格维持血压稳定,根据动脉瘤部位不同,选择不同手术入路,高倍显微镜下操作行动脉瘤颈夹闭。上夹后均对周围穿支血管及神经仔细探查以确定瘤夹的位置是否良好；对可能形成载瘤动脉狭窄或夹闭不全者,术中行显微镜荧光造影；对于瘤体较大,可能存在压迫症状者,行瘤体分离切除。对颅底粘连较重者,仔细分离粘连组织,并行终板造瘘术,以降低脑积水发生几率。术前Hunt-Hess分级低,术中脑组织水肿较轻者,严密缝合脑膜,骨瓣复位；术前Hunt-Hess分级高,术中脑组织水肿较重者,人工硬膜减张缝合硬脑膜,行去骨瓣减压。血管内介入组手术方法：在气管插管全身麻醉并全身肝素化抗凝下,保持导管内生理盐水持续冲洗以预防血栓形成,首先经股动脉插管行全脑血管造影,充分了解脑血管循环情况和动脉瘤的部位、大小、朝向、形态以及与周围血管的关系,选择最佳工作角度精确测量动脉瘤直径和瘤颈宽度,导引管经患侧颈内动脉,适当塑形微导管后超选进入动脉瘤腔。比较两组患者性别、年龄、动脉瘤大小、动脉瘤部位、术前Hunt-Hess分级；对比术后并发症如脑血管痉挛、脑积水等的发生率：对比两组患者术前Hunt—Hess分级与术后6个月后改良Rankin评分之间的关系；分组对比相同术前Hunt-Hess分级水平,行手术夹闭治疗和血管内介入治疗病人的术后6个月改良Rankin评分：手术夹闭治疗患者出院前复查头部CTA,两组患者术后3月均复查DSA,此后每6个月到12个月进行随访,复查DSA,随访9个月-33个月不等,比较两组患者术后的动脉瘤复发率；对比两组患者的平均住院天数。结果1.手术夹闭治疗组与血管内介入组患者术后出现脑血管痉挛、脑积水等主要并发症的发生率,经统计学分析无明显差异,P0.05。2.患者术前Hunt-Hess分级与术后6个月改良Rankin评分之间的关系：经统计结果显示,术前患者Hunt-Hess分级越低,术后6个月患者改良Rankin评分越低；当术前患者Hunt-Hess分级增高时,术后6个月患者改良Rankin评分亦增高,P值0.05。3.分组对比相同术前Hunt-Hess分级水平,行手术夹闭治疗和血管内介入治疗病人的术后6个月改良Rankin评分；结果显示在相同术前Hunt-Hess分级水平对比时,两组患者改良Rankin评分经统计学分析P值分别为Ⅰ级(P=0.21)、Ⅱ级(P=0.79)、Ⅲ级(P＝0.99),均大于0.05,表明两组患者治疗后改良Rankin评分差异无统计学意义。4.手术夹闭组与血管内介入组术后行门诊复查随访9-33个月,平均为17个月,动脉瘤复发患者12个；其中,开颅夹闭组术后有1个复发(由于夹闭不全),复发率0.3%；血管内介入组术后11个复发,复发率16.70%。手术夹闭组与血管内介入组两组复发率之间的差异应用χ2检验,手术夹闭组术后复发率明显低于血管内介入组,差异有统计学意义(P0.05)。5.手术夹闭治疗组患者平均住院天数为17.4±3.8天,血管内介入治疗组患者平均住院天数为12.8+2.9天,血管内介入组小于手术夹闭组,结果差异有统计学意义(P0.05)。结论1.手术夹闭治疗与血管内介入治疗术中动脉瘤破裂几率均低,两种疗法对术后脑血管痉挛的发生率、脑积水发生率的影响无明显差别。2.手术夹闭治疗和血管内介入治疗对患者预后的影响无明显差别。术前Hunt-Hess分级对患者预后影响明显。3.手术夹闭治疗动脉瘤较血管内介入有较低复发率,而血管内介入治疗可缩短患者住院时间。4.颅内前循环动脉瘤患者,年轻者,身体状态好的,建议选择手术夹闭治疗,以求更确切的疗效；老年患者,年龄大于65岁者,身体条件差的,建议选择血管内介入治疗,以降低术后卧床并发症风险。
[Abstract]:Background Intracranial aneurysm is an abnormal swelling in the wall of intracranial artery , which is the main cause of hemorrhage of subarachnoid hemorrhage .
The clinical data of 367 patients with ruptured cerebral aneurysms diagnosed with head CTA or all - cerebral angiography - DSA were retrospectively analyzed .
The patients were divided into three periods : ( 1 ) within 72 hours after ruptured intracranial aneurysm , operation clipping or endovascular interventional therapy was performed ;
( 2 ) In patients with more than 72 hours , some patients received treatment between 4 and 10 days due to the change of the condition , and the rest of the patients had to avoid the treatment during the 4 - 10 days after the onset of the disease . ( 3 ) The rest of the patients underwent surgical clipping or endovascular interventional therapy after 10 days of onset ;
The operation method of surgical clipping treatment group : The patients take classical wing - point approach or enlarge the wing - point approach , carefully separate the lateral fissure under the microscope , open the adjacent brain pool to release cerebrospinal fluid to reduce the cranial pressure , reveal the tumor - carrying artery , separate the aneurysm neck and select the appropriate aneurysm clip to clamp the aneurysm .
in that case of stenosis or clipping of the artery which may form the tumor - bearing artery , the intraoperative microscopic fluorescence angiography is performed ;
For the larger tumor volume , there may be compression symptoms , and the tumor body can be separated and removed . For the greater adhesion of the skull base , the adhesion structure and the parallel terminal plate ostomy are carefully separated , so as to reduce the incidence of hydrocephalus .
Preoperative Hunt - Hess grade was high , the brain edema was more severe in the operation , the hard dura mater was sutured with the artificial dura mater and the decompression of the bone flap was performed . The procedure of the endovascular intervention group was as follows : After the endotracheal intubation general anesthesia and the whole body heparinized anti - coagulation , the saline was kept in the catheter for continuous flushing to prevent thrombosis . The diameter of the aneurysm and the width of the aneurysm were measured accurately through the femoral artery cannula . The diameter of the aneurysm and the width of the aneurysm neck were measured accurately .
The incidence of postoperative complications such as cerebrovascular spasm , hydrocephalus , etc . was compared : the relationship between preoperative Hunt - Hess grade and modified Rankin score after 6 months after operation was compared between the two groups .
The modified Rankin score of patients with preoperative Hunt - Hess classification , operation clipping treatment and intravascular interventional therapy was compared with that of the patients after operation . The DSA was re - examined every 6 months to 12 months . The DSA was re - examined and the follow - up period was 9 months to 33 months , and the recurrence rate of aneurysm was compared between the two groups .
Results 1 . There was no significant difference in the incidence of cerebrovascular spasm , hydrocephalus and other major complications between treatment group and intra - vascular interventional group after operation . The relationship between the preoperative Hunt - Hess grade and the modified Rankin score of 6 months after operation was statistically analyzed .
The Rankin score was also increased in patients with preoperative Hunt - Hess ( P = 0 . 05 . 3 ) .
The results showed that the modified Rankin score of the two groups was significantly higher than that of group 鈪，

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