颅内破裂微小动脉瘤的治疗

发布时间：2018-07-28 15:54

【摘要】：目的：本研究拟通过回顾性临床病例分析，探究颅内破裂微小动脉瘤的治疗时机、治疗方法以及预后的的相关因素，为临床治疗颅内破裂微小动脉瘤提供参考和依据。方法： 1病例来源：回顾性分析2013年2月至2014年2月河北医科大学第二医院东院区颅内破裂动脉瘤所致蛛网膜下腔出血患者共156例，其中微小动脉瘤病历资料35例，共44个动脉瘤。住院期间未行治疗的微小动脉瘤4例（6个微小动脉瘤）。对剩余31例患者的性别、年龄、动脉瘤部位、大小、颈宽、入院时GCS评分、Hunt-Hess分级、fisher分级、高血压及冠心病病史等伴发疾病、动脉瘤处理方式、手术时机、围手术期并发症、GOS评分及术后随访等资料逐一登记，建立Access数据库。2病例纳入标准：①患者入院时根据病史、影像学资料或腰椎穿刺证实为自发性蛛网膜下腔出血；②入院后行头颅CTA或者3D-DSA证实为由动脉瘤破裂引起并排除外伤性蛛网膜下腔出血、假性动脉瘤、动静脉畸形、烟雾病或烟雾综合征、动静脉瘘等其他原因引起的SAH；③动脉瘤最大直径应≤3mm，单发或者多发可伴有除微小动脉瘤之外的脑血管疾病；④微小动脉瘤的治疗方式为显微夹闭或者介入栓塞。凡符合上述标准即可诊断为颅内破裂微小动脉瘤，均可纳入研究。3资料描述与统计：计量资料以均数±标准差(±s)表示；计数资料以构成比或率表示，两组病例分析采用Fisher确切概率法和两独立样本的非参数检验，各个因素与预后的关系采用双变量的相关分析，用SPSS13.0软件对上述临床病例资料进行统计学分析，检验水准取α=0.05。结果： 1年龄和性别：本组颅内破裂微小动脉瘤性蛛网膜下腔出血患者的年龄范围为31~77岁，平均年龄（55.19±9.81）岁，40~60岁患者18例，占58.06%，此年龄段可能是微小动脉瘤发病的高危阶段；男性9例（29.03%），女性22例（70.97%），其中15例女性(48.39%)年龄在50岁以上，提示激素水平的改变也可能一定程度上影响动脉瘤的形成。两治疗组间的年龄和性别比较均无统计学意义（P0.05）。 2动脉瘤情况及伴发疾病：颈内动脉系统33个（86.84%），椎-基底动脉系统5个（13.16%）；瘤体平均直径（2.31±0.67）mm，瘤颈平均宽度（2.06±0.82）mm；伴高血压16例（51.61%），伴糖尿病4例（12.90%），伴冠心病2例（6.45%），有吸烟饮酒等不良习惯7例（22.58%）。两治疗组间微小动脉瘤的部位、直径、瘤颈比及伴发疾病比较均无统计学意义（P0.05)。 3术前fisher及Hunt-Hess分级：术前fisher分级I~II级14例（45.16%），III~IV级17例（54.84%）；Hunt-Hess分级I~II级26例（80.65%），III~V级5例（19.35%）。采用血管内栓塞（介入组）治疗18例，显微外科夹闭（显外组）治疗13例。两治疗组间术前fisher分级及Hunt-Hess分级比较均无统计学意义（P0.05)。 4治疗时机、围手术期并发症及住院时间：发病24h内手术19例（61.29%），3d内手术21例（67.74%）,3d手术10例（32.26%）；围手术期并发症包括出血性事件4例（12.90%）、缺血性事件5例（16.13%）、迟发脑血管痉挛8例（25.81%）、MODS1例（3.23%）、颅内感染1例（3.23%）、肺部感染15例（48.39%）、低蛋白血症19例（61.29%）及癫痫发作2例（6.45%）；介入组平均住院时间（12.94±10.51）天，显外组平均住院时间（21.38±18.31）天。两治疗组间治疗时机、围手术期并发症及住院时间比较均无统计学意义（P0.05）。 5预后与随访：微小动脉瘤以1.5mm为标准，分为直径＜1.5mm组和直径1.5~3mm组，预后良好率（出院时GOS4~5分）分别是0%和76.92%，两者预后结果比较有统计学意义（P＜0.05）；以瘤颈/瘤体为1/2为标准，分为宽颈动脉瘤(瘤颈/瘤体1/2)和窄颈动脉瘤(瘤颈/瘤体＜1/2)，预后良好率（出院时GOS4~5分）分别是59.09%和66.67%，两者预后结果比较无统计学意义（P0.05）；多发动脉瘤7例（预后良好率57.14%），单发动脉瘤24例（预后良好率66.67%），两者预后比较无统计学意义（P0.05）；微小动脉瘤伴有狭窄或胚胎型大脑后动脉时，其预后比较无统计学意义（P0.05）；介入栓塞术中行支架辅助和普通栓塞的预后良好率（出院时GOS4~5分）分别为71.43%和81.82%，两者预后比较无统计学意义（P0.05）；术后即时GOS评分介入组和显外组的预后良好率（GOS4~5分）分别是72.22%和23.08%，两组治疗结果有统计学差异（P＜0.05）；出院时GOS评分介入组和显外组的预后良好率(GOS4~5分)分别是77.78%和23.08%，两组治疗结果有统计学差异（P＜0.05）；术后随访时间2~8个月，术后3个月随访19例，介入组和显外组的预后良好率(GOS4~5分）分别是80.00%和55.56%，两组病例预后无统计学意义（P0.05）；影像学随访17例，复查CTA及DSA检查均未见动脉瘤复发，头颅CT提示蛛网膜下腔出血吸收完全。 6预后相关因素：术前Hunt-Hess分级与GOS评分负相关，Rs1=-0.500（P1＜0.01），即术前Hunt-Hess分级越高，GOS评分越低，预后越差；fisher分级与GOS评分负相关，Rs2=-0.539（P2＜0.01），即术前fisher分级越高，GOS评分越低，预后越差。术前GCS评分与GOS评分正相关，Rs3=0.505（P3＜0.01），即术前GCS评分越高，GOS评分越高，预后越好。而年龄、手术时机与GOS评分无明显相关性（P0.05）。结论：本研究发现40~60岁可能是微小动脉瘤发病的高危阶段；激素水平的改变可能一定程度上影响微小动脉瘤的形成；微小动脉瘤的瘤颈宽窄、是否伴有狭窄及胚胎型大脑后动脉、是否运用支架及动脉瘤是否多发对预后无影响；微小动脉瘤直径在1.5~3.0mm之间的患者较直径1.5mm的患者预后好；介入栓塞和显微夹闭手术均适宜的情况下，尽可能选择介入栓塞治疗，其近期预后效果较好；术前fisher分级和Hunt-Hess分级越高，预后越差，术前GCS评分越高，预后越好，而年龄、手术时机与预后无明显相关性。
[Abstract]:Objective:
The purpose of this study is to explore the treatment time, treatment and prognosis of intracranial ruptured small aneurysms by retrospective clinical case analysis, and to provide reference and basis for the clinical treatment of intracranial ruptured small aneurysms.
Method:
1 source of cases: a retrospective analysis of 156 cases of subarachnoid hemorrhage caused by aneurysm of intracranial aneurysm in the Eastern Hospital of the second hospital of Hebei Medical University from February 2013 to February 2014, including 35 cases of small aneurysm records, 44 aneurysms. 4 cases of minor aneurysms (6 tiny aneurysms) were not treated during hospitalization. The remaining 31 cases were in the remaining 31 cases. The sex, age, age, aneurysm site, size, neck width, GCS score at admission, Hunt-Hess classification, Fisher classification, hypertension and coronary heart disease history and other associated diseases, aneurysm treatment methods, operation timing, perioperative complications, GOS score and postoperative follow-up were registered one by one, and Access database.2 cases were included in the standard: (1) patients: (1) The patients were admitted to spontaneous subarachnoid hemorrhage according to medical history, imaging data or lumbar puncture; 2. After admission, the head CTA or 3D-DSA proved to be caused by aneurysm rupture and excluded from traumatic subarachnoid hemorrhage, pseudoaneurysm, arteriovenous malformation, moyamoya disease, smoke syndrome, arteriovenous fistula and other causes. SAH; (3) the maximum diameter of the aneurysm should be less than 3mm. Single or multiple hair can be accompanied by cerebral vascular diseases other than small aneurysms. (4) the treatment of small aneurysms is microscopic occlusion or interventional embolization. All of these can be diagnosed as intracranial rupture microaneurysms, which can be included in the study of.3 data and Statistics: measurement capital The material was expressed with mean standard deviation (+ s), and the count data were expressed by the ratio or rate of composition. The two groups of cases were analyzed by the exact probability method of Fisher and the nonparametric test of the two independent samples. The relationship between the factors and the prognosis was analyzed by the bivariate correlation analysis. The data of the above clinical cases were statistically analyzed with SPSS13.0 software, and the test level was tested. Alpha =0.05.
Result:
1 age and sex: the age range of the group of intracranial ruptured small aneurysmal subarachnoid hemorrhage in this group was 31~77 years, the average age (55.19 + 9.81) years, and 18 cases of 40~60 years old, accounting for 58.06%. This age segment may be the high risk stage of the onset of small aneurysms; 9 cases (29.03%) and 22 women (70.97%), 15 women (48.39%) age. At the age of 50, the changes in the level of hormone may also affect the formation of the aneurysm to some extent. There is no statistically significant difference in age and sex between the two groups (P0.05).
2 aneurysms and associated diseases: the internal carotid artery system 33 (86.84%), the vertebral basilar artery system 5 (13.16%), the average diameter of the tumor (2.31 + 0.67) mm, the average width of the tumor neck (2.06 + 0.82), 16 cases (51.61%) with hypertension, diabetes 4 cases (12.90%), coronary heart disease and unhealthy habits, such as smoking and drinking. There was no significant difference in the location, diameter, tumor neck ratio and accompanying diseases between the groups (P0.05).
3 preoperative Fisher and Hunt-Hess classification: preoperative Fisher grade I~II level 14 cases (45.16%), III~IV Class 17 cases (54.84%); Hunt-Hess grading I~II class 26 cases (80.65%), III~V grade 5 cases (19.35%). 18 cases were treated by intravascular embolization (interventional group) and 13 cases were treated with microsurgical clipping (external group). The preoperative Fisher classification and Hunt-Hess grading comparison between the two treatment groups were compared. There was no statistical significance (P0.05).
4 the timing of treatment, perioperative complications and hospitalization time: 19 cases in 24h (61.29%), 21 cases (67.74%) and 10 3D surgery (32.26%); perioperative complications including hemorrhagic events 4 cases (12.90%), 5 cases (16.13%) of ischemic events, 61.29% cases of delayed cerebral vasospasm (25.81%), MODS1 cases, intracranial infection cases, lungs There were 15 cases (48.39%), 19 cases of hypoproteinemia (61.29%) and 2 cases of epileptic seizures (6.45%), the average hospitalization time (12.94 + 10.51) days in the intervention group (12.94 + 10.51) days, and the average time of admission (21.38 + 18.31) days (21.38 + 18.31) days. There was no significant difference between the perioperative complications and the time of hospitalization (P0.05).
5 the prognosis and follow-up: the small aneurysm was divided into group 1.5mm and 1.5~3mm in diameter with 1.5mm as the standard. The good prognosis (GOS4~5 score at discharge) was 0% and 76.92%, respectively, and the prognosis was statistically significant (P < 0.05). The tumor neck / tumor body was the standard, and it was divided into wide neck aneurysm (tumor neck / tumor 1/2) and narrow neck aneurysm (tumor). The prognosis was 59.09% and 66.67%, respectively, and the prognosis was 59.09% and 66.67% respectively. The prognosis was not statistically significant (P0.05), 7 cases of multiple aneurysms (good prognosis rate 57.14%), 24 cases of single aneurysm (good prognosis rate 66.67%), the prognosis was not statistically significant (P0.05), small aneurysm accompanied by stenosis or embryo. The prognosis of the posterior cerebral artery was not statistically significant (P0.05). The good prognosis of stent assisted and common embolization (GOS4~5 scores at discharge) in interventional embolization was 71.43% and 81.82%, respectively, and there was no statistical significance (P0.05), and the prognosis of the intervention group and the exter group (GOS4~5 score) after the operation were respectively. The results were 72.22% and 23.08% in the two groups (P < 0.05); the prognosis of the GOS score in the intervention group and the exo group was 77.78% and 23.08%, respectively, and the two groups were statistically different (P < 0.05); the follow-up time was 2~8 months after the operation, 19 patients were followed up for 3 months, and the prognosis of the intervention group and the exo group was good. The rate (GOS4~5 score) was 80% and 55.56% respectively. The prognosis of the two groups was not statistically significant (P0.05); 17 cases were followed up by imaging, and no recurrence of aneurysm was found in CTA and DSA examination. The skull CT showed that the subarachnoid hemorrhage was absorbed completely.
6 prognostic factors: preoperative Hunt-Hess grading was negatively correlated with GOS score, Rs1=-0.500 (P1 < 0.01), that is, the higher the Hunt-Hess grading before operation, the lower the GOS score, the worse the prognosis; the Fisher classification is negatively correlated with GOS score, Rs2=-0.539 (P2 < 0.01), that is, the higher the preoperative Fisher classification, the lower the GOS score and the worse the prognosis. Rs3=0.505 (P3 < 0.01), that is, the higher the preoperative GCS score and the higher the GOS score, the better the prognosis. There was no significant correlation between age, operation time and GOS score (P0.05).
Conclusion:
This study found that 40~60 years may be a high risk stage for the onset of small aneurysms; changes in hormone levels may affect the formation of small aneurysms to some extent; the narrowing of the neck of the small aneurysm, the complication of the stenosis and the embryonic posterior cerebral artery, whether or not the stent and aneurysms have no effect on the prognosis; small arteries The patients with a diameter of 1.5~3.0mm had better prognosis than those in the diameter 1.5mm. Interventional embolization and microsurgical clipping were all suitable for the treatment of interventional embolization. The prognosis was better in the near future. The higher the Fisher grading and Hunt-Hess classification before operation, the worse the prognosis, the higher the preoperative GCS score, the better the prognosis, and the age and operation. There was no significant correlation between the timing and prognosis.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.41

【参考文献】