本文選題：顱內(nèi)動脈瘤　切入點：夾層動脈瘤　出處：《首都醫(yī)科大學(xué)》2017年博士論文

【摘要】：目的:通過對顱內(nèi)夾層動脈瘤患者術(shù)后臨床和影像學(xué)結(jié)果進(jìn)行隨訪,評估顱內(nèi)夾層動脈瘤血管內(nèi)治療的安全性和有效性,提出顱內(nèi)夾層動脈瘤的影像學(xué)分型,并總結(jié)出基于影像學(xué)分型的治療原則。方法:本研究分兩部分,第一部分研究對象為2010年1月至2014年6月在我院神經(jīng)介入中心接受血管內(nèi)治療的40例連續(xù)性自發(fā)性出血性顱內(nèi)椎基底夾層動脈瘤患者,對患者的術(shù)前術(shù)后的臨床資料和影像學(xué)資料進(jìn)行分析,記錄術(shù)中和術(shù)后的并發(fā)癥情況,以及術(shù)后患者的隨訪情況,評價血管內(nèi)治療對于出血性椎基底夾層動脈瘤的療效。第二部分研究對象為2010年1月至2015年12月,在我院神經(jīng)介入中心接受治療的309例連續(xù)性病例,共323個顱內(nèi)夾層動脈瘤。采集所有患者的臨床和影像學(xué)資料。所有入組患者均接受腦血管造影檢查并行血管內(nèi)治療,所有患者都進(jìn)行半年以上臨床隨訪。分析每個病變的血管壁成像特征和管腔構(gòu)型。在前人分型的基礎(chǔ)上,將顱內(nèi)夾層動脈瘤分為四型:Ⅰ型,經(jīng)典型;Ⅱ型,節(jié)段擴張型;Ⅲ型,延長擴張型;Ⅳ型,局部巨大占位型。比較每組亞型的病變臨床癥狀、治療方式、治療效果、并發(fā)癥情況以及長期預(yù)后情況。應(yīng)用多因素回歸分析尋找影響預(yù)后的危險因素。應(yīng)用SPSS22.0進(jìn)行統(tǒng)計學(xué)分析。結(jié)果:本研究第一部分,40名出血性夾層動脈瘤患者中,男性30人,女性10人,平均隨訪時間5.2個月。采用載瘤動脈閉塞治療的7名患者治療效果滿意,無明顯術(shù)中及術(shù)后并發(fā)癥,復(fù)查無影像學(xué)復(fù)發(fā);26名采用支架輔助彈簧圈栓塞的患者中,1名患者基底動脈夾層動脈瘤的患者術(shù)中支架內(nèi)血栓形成;1名患者術(shù)后出現(xiàn)腦梗死;1名患者術(shù)后發(fā)生再出血;1名患者影像學(xué)復(fù)查顯示復(fù)發(fā)。采用單純支架治療的7名患者中,2名患者出現(xiàn)再出血,其中一名死亡;1名患者影像學(xué)復(fù)查顯示復(fù)發(fā)。本研究的第二部分,309例患者中男性233名(75.4%),所有患者平均年齡為50.43±11.93歲。共發(fā)現(xiàn)323個顱內(nèi)夾層動脈瘤,其中前循環(huán)動脈瘤27個,后循環(huán)動脈瘤296個。按照改良的形態(tài)學(xué)分類,I型動脈瘤262例(81.11%),II型22例(7.12%),III型14例(4.53%),IV型25例(8.09%)。216例(66.87%)動脈瘤采用支架輔助彈簧圈栓塞治療,47例(14.55%)動脈瘤采用載瘤動脈閉塞治療,60例(18.58%)動脈瘤采用單純支架治療。共有262名(84.74%)患者(274個動脈瘤)進(jìn)行了影像學(xué)隨訪,平均隨訪時間7.10月(3-60個月)。28例行載瘤動脈閉塞的動脈瘤影像學(xué)隨訪結(jié)果滿意,未見動脈瘤復(fù)發(fā);246例采用重建性治療(使用支架輔助彈簧圈栓塞193例,使用單純支架成形治療53例)的動脈瘤中有24例動脈瘤出現(xiàn)復(fù)發(fā)(9.16%)。單因素分析顯示有兩個以上危險因素,動脈瘤大小,動脈瘤分型和治療方式的不同與臨床預(yù)后相關(guān)。多因素回歸分析顯示動脈瘤大小是預(yù)后不同的獨立危險因素(P=0.004)。與I型相比,III型預(yù)后比I型患者差(P=0.013,OR值7.091,95%可信區(qū)間1.520-3.076);IV型也比I型患者預(yù)后差(OR,6.798;95%CI,2.200-21.008;P=0.001);但是II型與I型相比預(yù)后未見明顯不同(P=0.941)。結(jié)論:如果選擇合適的治療方案,血管內(nèi)治療出血性椎基底夾層動脈瘤是安全有效的。顱內(nèi)夾層動脈瘤患者的預(yù)后和動脈瘤的大小以及動脈瘤的不同分型存在著密切關(guān)聯(lián)。本研究提出的顱內(nèi)夾層動脈瘤改良分型能評估患者的臨床預(yù)后,對臨床治療方案的選擇有較好的指導(dǎo)作用。
[Abstract]:Objective: through the follow-up of the clinical and radiographic results of intracranial aneurysm patients, treatment safety and efficacy evaluation of intracranial aneurysm endovascular, the classification of intracranial aneurysm, and summed up the principle of treatment based on imaging classification. Methods: This study is divided into two parts, the first part of the research object from January 2010 to June 2014 in our hospital received endovascular interventional Center for treatment of 40 cases of spontaneous hemorrhage of continuous intracranial vertebrobasilar dissecting aneurysm patients, the clinical data and effects of the patients with preoperative and postoperative imaging data were analyzed and recorded the complications during and after surgery, and postoperative patients the follow-up, evaluation of endovascular treatment for hemorrhage of vertebrobasilar dissecting aneurysms. The second part of the study from January 2010 to December 2015, the heart in our hospital in neurointervention 309 consecutive patients treated, 323 intracranial aneurysm. All patients collected the clinical and imaging data. All patients received cerebral angiography underwent endovascular treatment, all patients were more than half of the clinical follow-up. Analysis of each lesion blood vessel wall and lumen in the imaging features of configuration. Based on the classification, the intracranial aneurysm were divided into four types: the first type of classic; type II, Section III, extend the expansion; expansion; type IV, local huge occupying type. The clinical symptoms of lesions in each subtype, treatment, therapeutic effect and complications and the long-term prognosis. The application of multiple factors regression analysis for the risk factors influencing the prognosis. The application of SPSS22.0 for statistical analysis. Results: the first part of this study, 40 hemorrhagic dissecting aneurysm patients, male 30, female 10, average follow-up Time for 5.2 months. The parent artery occlusion in 7 patients, treatment satisfaction, no intraoperative and postoperative complications, follow-up imaging shadowless recurrence; 26 with stent assisted coil embolization in patients with stent thrombosis in 1 patients with basilar artery dissection in patients with cerebral infarction; 1 patients developed postoperative rebleeding; 1 patients after surgery; 1 patients with postoperative imaging showed recurrence. 7 patients treated with single stent, then bleeding occurred in 2 patients, one died; 1 patients with postoperative imaging showed recurrence. The second part of this study, 309 cases in 233 male patients (75.4%), all patients with an average age of 50.43 + 11.93 years. There were 323 intracranial aneurysm, including 27 anterior circulation aneurysms, 296 aneurysms of posterior circulation. According to the morphological classification of the modified type I aneurysm in 262 cases (81.11%), II 22 (7.12% cases), 14 cases of type III (4.53%), 25 cases of type IV (8.09%).216 (66.87% cases) treated by stent assisted coil embolization of aneurysm, 47 cases (14.55% aneurysms) with parent artery occlusion, 60 cases (18.58%) with stent in the treatment of aneurysms with a total of 262. A (84.74%) patients (274 aneurysms) were imaging follow-up, the mean follow-up time was 7.10 months (3-60 months) aneurysm in.28 cases of parent artery occlusion. The follow-up results were satisfactory, no aneurysm recurrence; 246 cases treated by reconstruction (using stent assisted coil embolization in 193 cases, the use of simple stent treatment of 53 cases of aneurysms) in 24 cases of aneurysm recurrence (9.16%). Univariate analysis showed that there are two or more risk factors, the size of the aneurysm, aneurysm type and the different ways of treatment and clinical prognosis. Multivariate regression analysis showed that the size of the aneurysm is a different prognosis Independent risk factors (P=0.004). Compared with I type, III type I patients with poor prognosis than type (P=0.013 = 7.091,95% CI OR, 1.520-3.076); type IV than type I patients with poor prognosis (OR, 6.798; 95%CI, 2.200-21.008; P=0.001); but the II type compared with I type was significantly different prognosis (P=0.941). Conclusion: if the choice of appropriate treatment, endovascular treatment of hemorrhagic vertebrobasilar dissecting aneurysms is safe and effective. Patients with intracranial aneurysm prognosis and the size of aneurysms and aneurysms of different types are closely related. Improvement of intracranial aneurysm dissection the typing to assess the prognosis of the patients, has good guidance for clinical treatment.

【學(xué)位授予單位】：首都醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R651.12

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