“双容积成像”对颅内动脉瘤即刻栓塞效果评价的研究

发布时间：2018-09-13 21:49

【摘要】：研究背景颅内动脉瘤是颅内动脉管壁的异常膨出,是蛛网膜下腔出血(subarachnoid hemorrhage, SAH)的首位病因,在脑血管疾病病因中位居第3位,其死亡率和致残率约占脑血管病死亡患者的22%-25%,并呈现逐渐递增的趋势。颅内动脉瘤首次破裂出血的死亡率约为15%-20%,未及时治疗2年内的死亡率达75%-85%,50%以上的破裂动脉瘤存活者遗留不同程度的功能障碍。未破裂的动脉瘤患者常无明显不适,部分患者由于动脉瘤的占位效应,可以出现颅脑神经麻痹等局灶性症状。近年来随着介入材料和血管内治疗技术的不断发展,血管内治疗已逐渐成为颅内动脉瘤的首选治疗方法。血管内介入治疗以其微创的优点,也迅速被广大临床医师及颅内动脉瘤患者所接受。随着影像设备、微导管、微导丝和弹簧圈的性能改进以及血管内治疗技术的普遍提高,血管内治疗的安全性也获得显著提高。然而,颅内动脉瘤的血管内介入治疗作为一种微创技术,其手术风险仍然是无法避免的,总的并发症发生率可达到8%-10%,部分病人甚至出现永久性致残,甚至导致死亡。据文献报道动脉瘤血管内治疗术后仍有较高的再通率,研究结果也显示动脉瘤的再通与动脉瘤的栓塞程度密切相关,栓塞程度越高复发的机会越少。因此要提高动脉瘤的长期疗效,就必须提高动脉瘤的栓塞程度,尽可能做到致密栓塞。目前对动脉瘤血管内治疗术后栓塞结果较多采用的方法,即在动脉瘤血管内治疗结束后进行造影,根据动脉瘤是否显影及显影的程度来判断。通常采用：①文字描述：完全栓塞、“狗耳”样残留、颈残留、体部残留。②栓塞百分率表达：100%、99%～90%、90%或100%、99%～95%、95%；③将①和②两种方式结合。采用这些半定量方法评价栓塞效果时,不同的评判者可能会得出不同的结论,因此不能作为动脉瘤血管内治疗的客观的评价指标。填塞率为血管内治疗置入弹簧圈体积与动脉瘤体积比值,其作为一种作为动脉瘤栓塞效果评价的定量指标,逐渐成为研究的热点。如何对动脉瘤栓塞术后即刻栓塞效果进行准确的评价是十分必要的。目的：颅内动脉瘤即刻栓塞程度与动脉瘤术后再通有密切关系,致密栓塞可显著减少术后复发,本研究的目的是研究双容积成像对颅内动脉瘤即刻栓塞效果的评价价值,并分析影响颅内动脉瘤即刻栓塞结果的相关因素,为临床治疗提供理论依据和指导。方法：收集2013年1月-2013年6月广州军区武汉总医院神经外科收治的经血管内介入治疗的颅内囊性动脉瘤43例患者资料,每个动脉瘤作为一个独立的个体来研究,共43枚动脉瘤。采集的数据包括：患者的性别、年龄、Hunt-Hess分级、动脉瘤的大小、部位、瘤颈大小、动脉瘤体积、治疗方法、弹簧圈的体积、动脉瘤的栓塞程度(致密栓塞和非致密栓塞)等。对术后即刻的二维DSA造影(2D-DSA)和双容积成像进行分析,比较2种成像技术显示动脉瘤残留的能力。根据Raymond分级分为三类：①完全栓塞：动脉瘤瘤体及瘤颈均无造影剂充盈显影；②瘤颈残留：动脉瘤瘤颈有造影剂充盈显影而瘤体无造影剂充盈显影；③动脉瘤体残留：动脉瘤瘤体有造影剂充盈显影,被认为是动脉瘤栓塞失败。对以上数据采用多因素Spearman分析方法,分析影响动脉瘤即刻栓塞结果的相关因素。所有统计资料用SPSS13.0统计分析系统进行分析。当P0.05时差异有统计学意义。结果：共43例患者,其中女性25例,男性18例。患者平均年龄在56岁。36例为破裂动脉瘤,7例为未破裂动脉瘤。25例行支架辅助弹簧圈栓塞术,18例行单纯弹簧圈栓塞术,其中9例行双微导管栓塞。后交通动脉瘤19例,前交通动脉瘤10例,大脑中动脉瘤7例,眼动脉动脉瘤3例,床突上段动脉瘤3例,大脑前动脉A1段动脉瘤1例。动脉瘤小于5mm：20例,5mm至10mm：19例,大于10mm:4例。动脉瘤的体积从7.3mm3到2498mm3,平均190.15mm3,动脉瘤的体积小于50mm3：13例,50mm3到100mm3：10例,大于100mm320例。瘤颈大小从1.58mm到9.16mm,平均4.29mm,颈体比从1.01至2.56,平均1.39。根据颈体比分为三组：小于1.5mm：32例,1.5mm到2mm：8例,大于2mm：3例,动脉瘤的填塞率从4%-38%,平均为18.25%,小于10%：4例,10%-15%：9例,15%-20%：16例,大于20%：14例。术后即刻2D-DSA完全栓塞26例(60.5%),瘤颈残留10例(23.3%),瘤体残留7例(16.3%),术后即刻双容积成像发现完全栓塞16例(37.2%),瘤颈残留16例(37.2%),瘤体残留11例(25.6%)。2组间比较差异有统计学意义(Z=-2.009, P=0.045)。2D-DSA评价为完全栓塞组的填塞率为0.20±0.07,2D-DSA评价为非完全栓塞组填塞率为0.16±0.04,虽然完全栓塞组填塞率大于动脉瘤残留组的填塞率,但二者差异尚不具有统计学意义(t=1.918,P=0.0620.05)。双容积成像评价为完全栓塞组的填塞率为0.22±0.06,双容积成像评价为非完全栓塞组的填塞率为0.16±0.05,双容积成像完全栓塞组的填塞率显著高于非完全栓塞组的填塞率,差异有统计学意义(t=3.037P0.05)。多因素Spearman分析显示动脉瘤大小(r-0.353p=0.020)、动脉瘤体积(r-0.449p=0.003)是颅内动脉瘤致密栓塞的影响因素。结论：双容积成像能够提高动脉瘤即刻栓塞残留的检出率。双容积评价为致密栓塞的颅内动脉瘤其填塞率高。颅内动脉瘤的大小及动脉瘤的体积大小是影响动脉瘤填塞率的影响因素,且均为负相关,即动脉瘤越大、容积越大,填塞率越低。
[Abstract]:Research background
Intracranial aneurysms are the abnormal bulge of intracranial arterial wall, and the first cause of subarachnoid hemorrhage (SAH). They are the third cause of cerebrovascular diseases. The mortality and disability rate of SAH patients are about 22% - 25% of the total death rate of cerebrovascular diseases. The mortality of first rupture of intracranial aneurysms and hemorrhage is increasing gradually. The mortality rate is about 15%-20%. The mortality rate is 75%-85% in 2 years without prompt treatment. More than 50% of the survivors of ruptured aneurysms have left varying degrees of dysfunction.
In recent years, with the continuous development of interventional materials and endovascular treatment technology, endovascular treatment has gradually become the preferred treatment of intracranial aneurysms. With its advantages of minimally invasive, endovascular treatment has also been rapidly accepted by clinicians and patients with intracranial aneurysms. With the development of imaging equipment, microcatheters, microwire and coils However, as a minimally invasive technique, intravascular interventional therapy for intracranial aneurysms is still unavoidable. The overall incidence of complications can reach 8% - 10%. Some patients even suffer from permanent disability or even permanent disability. Cause death.
It is reported that the recanalization rate of aneurysms is still high after endovascular treatment. The results also show that the recanalization of aneurysms is closely related to the degree of embolization, and the higher the degree of embolization, the less the chance of recurrence. At present, embolization results after endovascular treatment of aneurysms are often used, that is, after endovascular treatment of aneurysms, angiography, according to whether the aneurysm is developed and the degree of development to judge. Usually used: 1. Written description: complete embolization, "dog ear" like residue, neck residue, body residue. 2 Embolization percentage expression: 1. 00%, 99% ~ 90%, 90% or 100%, 99% ~ 95%, 95%; 3) Combine the two methods. When using these semi-quantitative methods to evaluate the embolization effect, different judges may come to different conclusions, so they can not be used as an objective evaluation index for endovascular treatment of aneurysms. As a quantitative index for evaluating the embolization effect of aneurysms, tumor volume ratio has gradually become a research hotspot.
Objective: Immediate embolization of intracranial aneurysms is closely related to the recanalization of aneurysms. Compact embolization can significantly reduce postoperative recurrence. The purpose of this study is to study the value of dual-volume imaging in evaluating the effect of immediate embolization of intracranial aneurysms, and to analyze the related factors affecting the results of immediate embolization of intracranial aneurysms, so as to provide clinical treatment. For theoretical basis and guidance.
METHODS: The data of 43 patients with intracranial cystic aneurysms treated by endovascular interventional therapy in the Department of Neurosurgery, Wuhan General Hospital of Guangzhou Military Region from January 2013 to June 2013 were collected. Each aneurysm was studied as an independent individual with 43 aneurysms. The size, location, neck size, aneurysm volume, treatment method, coil volume, embolization degree of aneurysm (dense embolism and non-dense embolism) were analyzed. The two imaging techniques, two-dimensional DSA (two-dimensional DSA) and two-volume imaging (two-dimensional DSA) were compared to show the residual aneurysm ability. Complete embolization: Neither aneurysm nor neck had contrast agent filling imaging; Neck residue: Neck of aneurysm had contrast agent filling imaging but no contrast agent filling imaging; Neck of aneurysm residue: Neck of aneurysm had contrast agent filling imaging; Neck of aneurysm residue: Neck of aneurysm had contrast agent filling imaging, which was considered aneurysm embolization failure. All statistical data were analyzed by SPSS13.0 statistical analysis system. The difference was statistically significant when P 0.05.
Results: A total of 43 patients, including 25 females and 18 males, had an average age of 56.36 with ruptured aneurysms, 7 with unruptured aneurysms, 25 with stent-assisted coil embolization, 18 with simple coil embolization, 9 with dual-microcatheter embolization, 19 with posterior communicating aneurysms, 10 with anterior communicating aneurysms, and 7 with middle cerebral artery. There were 7 aneurysms, 3 ophthalmic aneurysms, 3 superior clinoid aneurysms, 1 anterior cerebral artery A1 aneurysm, 19 aneurysms less than 5 mm: 20, 5 mm to 10 mm: 19, more than 10 mm: 4. The aneurysms ranged in size from 7.3 mm3 to 2498 mm3, with an average of 190.15 mm3, the aneurysms less than 50 mm3 to 100 mm3: 13, 50 mm3 to 100 mm3: 10, and more than 100 mm320 aneurysms. From 1.58 mm to 9.16 mm, average 4.29 mm, neck-body ratio from 1.01 to 2.56, average 1.39. According to neck-body ratio, they were divided into three groups: less than 1.5 mm: 32 cases, 1.5 mm to 2 mm: 8 cases, more than 2 mm: 3 cases, aneurysm tamponade rate from 4% to 38%, average 18.25%, less than 10% - 15%: 9 cases, 15% - 20%: 16 cases, more than 20%: 14 cases. There were 16 cases (37.2%) with complete embolization, 16 cases (37.2%) with residual tumor neck and 11 cases (25.6%) with residual tumor neck. There were significant differences between the two groups (Z = - 2.009, P = 0.045). The packing rate of complete embolization group was 0.20 [0.07], and non-embolization group was evaluated by 2D-DSA. The filling rate of complete embolization group was 0.16 [0.04]. Although the filling rate of complete embolization group was higher than that of residual aneurysm group, there was no significant difference between the two groups (t = 1.918, P = 0.0620.05). The filling rate of complete embolization group was 0.22 [0.06], and that of incomplete embolization group was 0.16 [0.05] by dual volume imaging. The filling rate of complete embolization group was significantly higher than that of incomplete embolization group (t = 3.037 P 0.05). Multivariate Spearman analysis showed that the size of aneurysm (r-0.353 P = 0.020) and the volume of aneurysm (r-0.449 P = 0.003) were the influencing factors of intracranial aneurysm compact embolization.
Conclusion: Dual-volume imaging can improve the detection rate of aneurysm embolization residual immediately. Dual-volume evaluation of dense embolization of intracranial aneurysms has a high rate of tamponade. Low.
【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

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