颅内动脉瘤治疗方式选择及疗效影响因素分析—单中心434例病例回顾性分析

发布时间：2019-06-25 00:13

【摘要】：目的探讨动脉瘤性蛛网膜下腔出血患者的不同手术方式,比较其预后、手术并发症、动脉瘤残留、复发率,并对影响疗效的各种因素进行分析。方法回顾性分析广西医科大学一附院神经外科2008年1月至2013年12月间的蛛网膜下腔出血434例。据手术方式分为动脉瘤瘤颈夹闭组(178例)和血管内栓塞治疗组(256例)。分析其Hunt-Hess分级、Fisher分级、动脉瘤的大小、部位、瘤颈特征、血管痉挛情况、手术并发症、动脉瘤闭塞程度、去骨瓣减压率、脑积水发生率、出院时临床评估、影像学和临床随访结果等。对可能影响动脉瘤夹闭及栓塞效果的因素进行多因素分析。结果本研究中出院时开颅夹闭组预后良好124例(69.66%),预后不良54例(30.33%),死亡7例(3.93%)；术后发生脑积水45例(25.28%)。动脉瘤残留10例(5.61%),术后再出血1例(0.74%),3例动脉瘤复发(2.22%)。介入栓塞组临床评估良好180例(70.31%),预后不良76例(29.69%),死亡8例(3.13%)；非致密栓塞47例(18.35%),术后发生脑积水79例(30.85%)；术后再出血10例(7.52%),动脉瘤复发42例(31.57%)。开颅夹闭组与介入栓塞组预后GOS无差别(P=0.884)。Hunt-Hess分级对患者GOS预后有显著影响(P=0.000)。手术夹闭组术后再出血、动脉瘤残留、动脉瘤复发及脑积水发生率均较介入栓塞组低。两组共行去骨瓣减压44例,GOS组间、Hunt-Hess分级组间、Fisher分级组间行去骨瓣减压率差别有统计学意义。本研究中行开颅夹闭术后造影或CTA显示：达到完全夹闭程度的动脉瘤168枚(94.38%),手术夹闭组术后3-6个月共随访到135例,术后动脉瘤残留10例中有1例再出血(死亡),3例动脉瘤复发。单因素分析脑萎缩(P=0.899),动脉瘤的大小(P=0.156),动脉瘤部位(P=0.210),瘤颈特征(P=0.971),瘤颈穿支血管(P=0.232),颅内动脉粥样硬化(P=0.990),术中破裂(P=0.729),使用多枚永久动脉瘤夹(P=0.577)不是动脉瘤夹闭效果的影响因素。多因素分析显示Fisher分级(P=0.0091)、脑脊液引流(P=0.0103)、术中临时阻断技术(P0.0001),术中荧光造影(P=0.0363)是颅内动脉瘤达到完全夹闭的独立影响因素。介入栓塞组术后即刻造影达致密栓塞的动脉瘤217枚(82.19%),非致密栓塞47枚(17.8%)。术后3-6个月随访到133例,其中致密栓塞86例中动脉瘤复发3例,无再出血病例。非致密栓塞47例全部获得随访,动脉瘤复发39例,8例进一步血栓形成,术后再出血10例(7.52%)。单因素分析动脉瘤部位(P=0.114),血管痉挛(P=0.283),术中动脉瘤破裂(P=0.664),瘤颈特征(P=0.835),Hunt-Hess分级(P=0.106)不是动脉瘤致密栓塞的影响因素。多因素分析结果显示小型动脉瘤(P0.001)、囊性动脉瘤(P=0.0003)、支架辅助栓塞(P=0.0046)是颅内动脉瘤致密栓塞的独立影响因素。结论1.两种治疗方式均有效的治疗颅内动脉瘤。两组间GOS预后比较无统计学差别,对所有的临床和形态学因素均应考虑,针对患者个性化治疗。2.手术夹闭组术后再出血、瘤颈残留、动脉瘤再通及脑积水发生率均较介入栓塞组低。3.在Hunt-Hess I-III级患者中,GOS预后均较好,在Hunt-HessIV-V级患者中GOS预后均较差。Hunt-Hess高分级常合并Fisher高分级,合并脑内较大血肿(幕上血肿"g30ml,幕下血肿"g10m1)时,需行去骨瓣加压或结合脑脊液外引流。4.患者脑萎缩、颅内动脉粥样硬化、动脉瘤大小、动脉瘤位置、瘤颈特征、瘤颈有无穿支、术中破裂与动脉瘤夹闭效果无直接影响；Fisher分级、脑脊液引流、术中临时阻断技术、术中荧光造影是颅内动脉瘤达到完全夹闭的独立影响因素。清除血肿、通畅脑脊液引流、术中临时阻断技术及荧光造影有利于动脉瘤完全夹闭。5.动脉瘤位置、瘤颈特征、血管痉挛、术中破裂、Hunt-Hess分级与动脉瘤栓塞程度无关；动脉瘤形态、动脉瘤大小以及栓塞治疗方式是动脉瘤致密栓塞的独立影响因素。囊性动脉瘤、小型动脉瘤、支架辅助栓塞有助于达到动脉瘤的致密栓塞。
[Abstract]:Objective To study the different operation methods of the patients with aneurysmal subarachnoid hemorrhage, to compare the prognosis, the operative complications, the residual rate of the aneurysm and the recurrence rate, and to analyze the factors that affect the curative effect. Methods 434 cases of subarachnoid hemorrhage from January 2008 to December 2013 were analyzed retrospectively. The operation was divided into the aneurysm neck clamp group (178 cases) and the endovascular embolization treatment group (256 cases). The Hunt-Hess classification, the Fisher classification, the size of the aneurysm, the location of the aneurysm, the characteristics of the neck, the conditions of the vasospasm, the surgical complications, the degree of occlusion of the aneurysm, the rate of decompression of the bone flap, the rate of hydrocephalus, the clinical evaluation at the time of discharge, the imaging and clinical follow-up results, and the like were analyzed. Multi-factor analysis of factors that might affect the clipping and embolization effects of the aneurysm. Results The outcome of the study was 124 (69.66%),54 (30.33%),7 (3.93%), and 45 (25.28%). There were 10 cases (5.61%) of aneurysm, one case (0.74%) after operation, and 3 cases of aneurysm recurrence (2.22%). The clinical evaluation of the interventional embolization group was 180 (70.31%), the prognosis was poor in 76 (29.69%), the death was 8 (3.13%), the non-dense embolism was 47 (18.35%), the postoperative hydrocephalus was 79 (30.85%), the postoperative rebleeding was 10 (7.52%), and the aneurysm recurrence was 42 (31.57%). There was no difference (P = 0.884) between the closed group of the craniotomy and the prognosis of the interventional embolization group (P = 0.884). The Hunt-Hess classification had a significant effect on the prognosis of the patients with GOS (P = 0.000). The incidence of rebleeding, aneurysm residue, aneurysm recurrence and hydrocephalus in the operation group was lower than that of the interventional embolization group. There was a significant difference in the rate of decompression of the bone flap between the two groups in 44 patients, the GOS group, the Hunt-Hess classification group and the Fisher classification group. In this study, a total of 168 (94.38%) aneurysms were observed after the operation, and in the operation group, a total of 135 aneurysms (94.38%) were observed, and 135 cases were followed up 3-6 months after the operation, and one case of rebleeding (death) was found in 10 cases of the postoperative aneurysm, and 3 cases of the aneurysm recurrence. One factor analysis of the brain atrophy (P = 0.899), the size of the aneurysm (P = 0.156), the aneurysm site (P = 0.210), the neck of the aneurysm (P = 0.971), the neck of the tumor (P = 0.232), the intracranial atherosclerosis (P = 0.990), the intraoperative rupture (P = 0.729), The use of multiple permanent aneurysm clips (P = 0.577) is not a factor in the effect of aneurysm clipping. The multi-factor analysis showed Fisher's classification (P = 0.0091), cerebrospinal fluid drainage (P = 0.0103), and temporary blocking in the operation (P = 0.0001), and intraoperative fluorescence (P = 0.0363) was an independent factor of the complete clamp closure of the intracranial aneurysm. There were 217 aneurysms (82.19%) and non-dense embolism (17.8%). The 3-6-month follow-up was followed up to 133 cases, of which there were 3 cases of aneurysm recurrence and no re-bleeding in 86 cases of dense embolism. The follow-up was obtained in 47 cases of non-dense embolism,39 cases of aneurysm recurrence,8 cases of further thrombosis and 10 cases of rebleeding after operation (7.52%). Single factor analysis of aneurysm site (P = 0.114), vasospasm (P = 0.283), intraoperative aneurysm rupture (P = 0.664), neck feature (P = 0.835), Hunt-Hess grade (P = 0.106) was not an influence factor for aneurysm dense embolization. The multi-factor analysis showed that the small aneurysm (P0.001), the cystic aneurysm (P = 0.0003), the stent-assisted embolization (P = 0.0046) were the independent factors of the tight embolization of the intracranial aneurysm. Conclusion 1. Both treatments were effective in the treatment of intracranial aneurysms. There was no statistical difference between the two groups of GOS, and all the clinical and morphological factors should be considered. The incidence of rebleeding, neck, aneurysm and hydrocephalus in the surgical clip group was lower than that of the interventional embolization group. In the Hunt-Hess I-III patients, the GOS prognosis was better and the GOS prognosis was poor in the Hunt-Hess IV-V patients. The Hunt-Hess high grade was often combined with Fisher's high grade and combined with a large hematoma in the brain (supratentorial hematomas "g30ml, subside hematomas" g10m1), to which the bone flap was to be pressurized or combined with the external drainage of the CSF. The patient's brain atrophy, the intracranial atherosclerosis, the size of the aneurysm, the location of the aneurysm, the characteristics of the neck of the tumor, the presence or absence of a penetrating branch in the neck of the aneurysm, no direct effect on the effect of the rupture of the aneurysm and the clipping of the aneurysm, the Fisher classification, the drainage of the cerebrospinal fluid, the temporary blocking technique in the operation, Intraoperative fluorography was an independent factor in the complete clamp closure of the intracranial aneurysm. The removal of the hematoma, the smooth drainage of the cerebrospinal fluid, the temporary blocking technique during the operation and the fluorescence contrast are beneficial to the complete occlusion of the aneurysm. The location of the aneurysm, the neck of the neck, the vasospasm, the intraoperative rupture, the Hunt-Hess classification were not related to the degree of aneurysm embolization; the morphology of the aneurysm, the size of the aneurysm, and the way of embolization were the independent factors of the embolization of the aneurysm. Cystic aneurysms, small aneurysms, and stent-assisted embolization help to achieve a tight embolization of the aneurysm.
【学位授予单位】：广西医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R651.1

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