颅内破裂动脉瘤栓塞术后再出血的危险因素分析

发布时间：2018-06-26 03:56

本文选题：颅内破裂动脉瘤 + 介入治疗　；参考：《南方医科大学》2014年硕士论文

【摘要】：研究背景颅内动脉瘤(Intracranial aneurysm)是颅内动脉管壁的囊状膨出,好发于脑底willis环及其主要分支,是造成蛛网膜下腔出血(Subarachnoid hemorrhage, SAH)的首位病因。动脉瘤好发于40～60岁中老年人,青少年相对少见。据Mayo Clinic报道,人群中动脉瘤的患病率为3.6%-6%,破裂率为1%-2%。动脉瘤破裂出血后的预后较差,破裂出血的患者中约有15%-20%因无法得到及时治疗而于院外死亡,遗留有失语、失明、残疾等严重神经功能障碍的幸存者的比例高达50%。目前,动脉瘤的治疗方式主要有开颅手术和血管内介入治疗两种方法。前者主要有动脉瘤颈夹闭术、动脉瘤包裹术及动脉瘤孤立术等手术方式；血管内介入治疗主要包括三种方法：单纯弹簧圈栓塞、球囊辅助栓塞和支架辅助下弹簧圈栓塞。对于颅内破裂动脉瘤来说,开颅夹闭手术或血管内介入治疗的目的,都是为了尽量避免复发或再出血等并发症的发生。国际蛛网膜下腔出血动脉瘤试验(ISAT)的研究显示,开颅夹闭术的复发率为3.8%,血管内介入治疗的复发率为17.4%。因此,血管内介入治疗动脉瘤面临的最大问题是复发率高。有研究表明,随着栓塞程度的提高,动脉瘤的复发率亦随之降低,但对于宽颈或巨大动脉瘤来说,单纯弹簧圈栓塞复发率仍较高。尽管支架辅助下弹簧圈栓塞术的复发率明显低于单纯弹簧圈栓塞术,但仍无法完全避免栓塞术后动脉瘤的复发或再出血。虽然动脉瘤复发并不一定会导致动脉瘤再破裂出血,但仍会增加再出血的风险。颅内破裂动脉瘤栓塞术后再次破裂出血是栓塞术后最危险的并发症,且预后差,死亡率高,是患者致残与致死的重要原因。术后再出血包括早期再出血与晚期再出血(迟发性再出血)。国内外研究对于二者的时间界定尚有争议。多数文献将早期再出血的时间定义为在栓塞术后1个月以内发生的再次破裂出血。在本研究中,我们将早期破裂再出血与迟发性再出血的时间界限定为1个月。目前,大部分的文献报道术后早期再出血的发生率为0.9～3.6%,虽然术后早期再出血的发生率较低,但死亡率高,预后极差。迟发性再出血率虽小于1.0%,但是,一旦发生,仍会危及患者生命安全。目前国内外对于破裂动脉瘤栓塞术后再出血的研究非常少,主要集中在再出血的原因分析上,其中,不完全栓塞被认为是导致颅内动脉瘤栓塞术后再出血的主要原因。在相关危险因素的分析上,由于样本量较小、危险因素研究不全等不足,各个报道的结论存在分歧,主要考虑可能与患者的年龄、高血压病史、动脉瘤的大小、瘤颈宽窄及动脉瘤的栓塞程度等有关。此外,对术后再出血的处理措施亦缺乏规范化的标准。因此,探讨颅内破裂动脉瘤栓塞术后早期及迟发性再出血的发生率、死亡率、危险因素及出血后的处理方法具有极为重要的临床意义。本研究回顾性分析本院神经外科介入治疗中心经介入治疗后发生再破裂出血的病例,分别统计两者的发生率与死亡率,收集其临床资料及影像学资料,并通过SPSS13.0统计分析软件,采用Logistic回归法进行分析,探究栓塞术后早期及迟发性再出血的危险因素,为今后栓塞术后再出血的风险评估提供理论依据,同时为栓塞术后再出血的治疗提供参考。目的探讨颅内破裂动脉瘤栓塞术后早期及迟发性再出血的发生率、危险因素以及出血后的处理方法,为今后术前评估术后再出血的风险提供理论依据,同时为术后再出血的治疗提供参考。方法回顾性分析2002年1月至2014年1月南方医科大学珠江医院神经外科脑血管病介入治疗中心收治的颅内破裂动脉瘤患者的资料(合并其他脑血管疾病如脑动静脉畸形、动静脉瘘的患者已排除)。术后早期(或迟发性)再出血的定义为：颅内破裂动脉瘤患者在成功行血管内介入栓塞治疗后,术后1个月以内(或1个月后)突然出现临床症状加重或反复,在排除脑梗塞、高血压及其他原因导致的再出血后,头颅CT或MRI证实再次出现与已栓塞动脉瘤部位一致的新鲜出血。纳入变量包括：性别、年龄、高血压病史、动脉瘤的位置、大小、形状、瘤颈宽窄、治疗时的临床情况、有无脑血管痉挛及其分级、动脉瘤有无邻近颅内血肿、动脉瘤的栓塞程度、术后有无明显的血压波动、有无使用支架、术后有无行抗血小板治疗、栓塞术后再出血的时间、临床预后(mRS评分)、再出血后的处理措施(介入或夹闭治疗)等。统计栓塞术后早期或迟发性再出血的发生率与死亡率,对其临床及影像学特点进行分析。所有统计资料均采用SPSS13.0统计分析系统进行分析。以均数±标准差表示计量资料,采用Logistic回归法进行多因素分析,变量入选标准基于既往报道中提示的可能引起栓塞术后再次破裂出血的危险因素(如栓塞程度、Hunt-Hess分级等),以及以往研究中得出的可能导致栓塞术后颅内出血的危险因素(如高血压等)。检验水准取a=0.05,当p0.05时差异有统计学意义。分析颅内破裂动脉瘤栓塞术后再出血的相关危险因素,并对其发生机制进行简单探讨,评价各项处理措施的有效性,以期降低动脉瘤栓塞术后再出血的发生率与死亡率。结果栓塞术后早期再出血：从2002年1月至2014年1月期间,共有1455例颅内破裂动脉瘤患者在南方医科大学珠江医院神经外科脑血管病介入治疗中心接受血管内介入治疗并被纳入本研究。所有1455例破裂动脉瘤患者中,共有18例发生早期再出血,发生率为1.24%,死亡10例,死亡率为55.6%。早期再出血的平均时间为4.3±3.3天。在18例再出血的患者中,2例行保守治疗；3例再次行血管内栓塞治疗；2例行动脉瘤夹闭术；2例行双侧侧脑室外引流术；1例行血肿清除十脑室外引流术；6例行血肿清除+去骨瓣减压术；2例行去骨瓣减压+脑室外引流术。最终预后良好3例,中度残疾2例,重度残疾3例,死亡10例。经Logistic逐步回归分析得出：既往高血压病史、前交通动脉瘤、动脉瘤邻近颅内血肿、影像学明显脑血管痉挛(2-3级)、栓塞前的临床情况差(Hunt-Hess3-5级)及不完全栓塞是栓塞术后早期再出血的独立危险因素。栓塞术后迟发性再出血：在上述1455例颅内破裂动脉瘤患者中,有503例(34.6%)失随访,共有952例(65.4%)患者有完整随访资料。所有952例颅内破裂动脉瘤患者中,共有6例发生栓塞术后迟发性再出血,发生率为0.63%,死亡0例,死亡率为0%。栓塞术后迟发性再出血的平均时间为39.8±16.9个月。6例患者均再次接受血管内介入治疗并获得良好预后。经Logistic逐步回归分析,得到栓塞术后迟发性再出血的独立危险因素为：既往高血压病史、初次不完全栓塞以及动脉瘤复发。结论破裂动脉瘤栓塞术后早期再出血是血管内介入治疗最严重的并发症。本研究结果显示,颅内破裂动脉瘤栓塞术后早期再出血的发生率较低,但预后差,死亡率高,迟发性再出血的发生率较低,且预后较好。早期再出血的独立危险因素为既往高血压病史、前交通动脉瘤、影像学明显脑血管痉挛(2-3级)、动脉瘤邻近颅内血肿、治疗时的临床情况差(Hunt-Hess3-5级)及不完全栓塞。迟发性再出血的独立危险因素为既往高血压病史、不完全栓塞以及动脉瘤复发。栓塞术中尽量致密栓塞动脉瘤,术后予镇静、通便等处理,防治因用力排便或其他可引起血压骤升而导致的再次破裂出血；栓塞术后在安全的前提下尽早行腰椎穿刺术释放血性脑脊液,在有条件的情况下,还可行腰大池置管术,加速血性脑脊液的释放,减轻对脑血管的刺激,防止脑血管痉挛引起继发性的缺血性脑损害。在颅内再出血的处理方法上,如果脑实质出血量较少、无中线明显偏移或无脑疝迹象时可以尽早行DSA,明确动脉瘤栓塞情况,若有复发,可再次行栓塞术；一旦出血量较大或临床表现较严重时应立即行血肿清除术,最好能同期行动脉瘤夹闭术,避免再次破裂出血,还可根据情况实施去骨瓣减压术。
[Abstract]:Background of the study

Intracranial aneurysm ( aneurysm ) is a saccular expansion of the wall of the intracranial artery . It is the first cause of subarachnoid hemorrhage ( SAH ) . The incidence of aneurysm is 3.6 % -6 % , and the rate of rupture is 1 % -2 % . According to Mayo Clinic , about 15 % -20 % of patients with ruptured intracranial aneurysms died outside the hospital due to lack of timely treatment . The proportion of survivors with severe neurological disorders such as aphasia , blindness and disability is up to 50 % .

At present , there are two methods for the treatment of aneurysm , such as aneurysm neck clamping , aneurysm wrapping and aneurysm isolation .
Endovascular interventional therapy mainly includes three methods : single coil embolization , balloon - assisted embolization , and stent - assisted lower coil embolization . For intracranial ruptured aneurysms , the purpose of open - skull clipping surgery or endovascular interventional therapy is to avoid the occurrence of complications such as recurrence or rebleeding .

The study of international subarachnoid hemorrhage ( ISAT ) showed that the recurrence rate of intracranial aneurysms was 3.8 % , and the recurrence rate of endovascular intervention was 17.4 % .

Rebleeding after embolization of ruptured intracranial aneurysms is the most dangerous complication after embolization , and the prognosis is poor and death rate is high . It is an important cause of disability and death in patients . At present , most of the literatures define the time limit of early rebleeding and late re - bleeding . Most of the literatures report that the incidence of early rebleeding is 0.9 - 3.6 % . In the present study , the incidence of early re - bleeding is 0 . 9 - 3.6 % .

At present , there is very little study on the re - bleeding after embolization of ruptured aneurysm , which is mainly focused on the causes of re - bleeding . In the analysis of the relevant risk factors , there are some differences in the analysis of the relevant risk factors . The main consideration may be related to the age of the patient , the history of hypertension , the size of the aneurysm , the width of the neck and the degree of embolization of the aneurysm .

This study retrospectively analyzed the incidence and mortality of the interventional therapy center in our hospital after interventional therapy , collected the clinical data and image data , analyzed the risk factors of early and delayed rebleeding after embolization , provided the theoretical basis for the risk assessment of postoperative hemorrhage after embolization , and provided a reference for the treatment of re - bleeding after embolization .

Purpose

To study the incidence , risk factors and treatment methods of early and delayed rebleeding after embolization of ruptured intracranial aneurysms , and to provide a theoretical basis for the risk of postoperative rebleeding before operation , and to provide a reference for the treatment of postoperative rebleeding .

method

Retrospective analysis of the data of patients with ruptured intracranial aneurysms treated by the interventional therapy center of the Pearl River Hospital of the South Medical University from January 2002 to January 2014 ( the patients with other cerebrovascular diseases such as cerebral arteriovenous malformations and arteriovenous fistula have been excluded ) . All the statistical data were analyzed by SPSS 13.0 statistical analysis system . All the statistical data were analyzed by SPSS 13.0 statistical analysis system .

Results

Early re - bleeding after embolization : From January 2002 to January 2014 , a total of 1,950 patients with ruptured intracranial aneurysms received intravascular interventional therapy at the interventional therapy center of the Pearl River Hospital of the South Medical University . Among all the patients with ruptured aneurysms , 18 patients experienced early re - bleeding , the incidence rate was 1.24 % , the mortality was 10 cases , the mortality rate was 55.6 % . The average time of early re - bleeding was 4.3 卤 3.3 days . Of the 18 patients with rebleeding , 2 cases had conservative treatment ;
3 cases were treated with endovascular embolization .
2 patients underwent aneurysm clipping ;
2 cases of bilateral lateral ventricle drainage ;
1 routine hematoma evacuation was performed in 10 cases of external drainage ;
6 cases of hematoma were removed + debone flap decompression ;
In all 952 patients with ruptured intracranial aneurysms , there were 3 cases with moderate disability , 2 cases with moderate disability , 3 cases with severe disability and 10 cases of death .

Conclusion

Early re - bleeding after ruptured aneurysm embolization is the most serious complication of endovascular interventional therapy . The results show that the incidence of early re - bleeding after embolization of ruptured intracranial aneurysms is low , but the prognosis is worse . The independent risk factors of early re - bleeding are the history of hypertension , anterior communicating aneurysm , clinical condition difference of imaging ( Hunt - Hess3 - 5 ) and incomplete embolization .
The hemorrhagic cerebrospinal fluid can be released as early as possible under the precondition of safety . Under the condition of the condition , it is feasible to set up the spinal canal , accelerate the release of the hemorrhagic cerebral spinal fluid , reduce the irritation to the cerebral vessels and prevent the secondary ischemic brain damage caused by cerebral vascular spasm .
When the bleeding amount is large or the clinical manifestation is serious , the hematoma removal operation should be carried out immediately , and it is preferable that the aneurysm clipping procedure be performed in the same period , so that the bleeding can be avoided again , and the decompression of the bone flap can be performed according to the circumstances .
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.41

【参考文献】