本文選題：顱內(nèi)動脈瘤　切入點：術(shù)中破裂　出處：《大連醫(yī)科大學》2014年碩士論文　論文類型：學位論文

【摘要】：目的：顱內(nèi)動脈瘤的外科治療過程中,動脈瘤術(shù)中破裂十分兇險,是最為嚴重的并發(fā)癥,致殘率、致死率高,對患者家屬造成沉重的傷害。顱內(nèi)動脈瘤血管內(nèi)治療起步較開顱夾閉晚,但效果令人滿意,對多發(fā)性動脈瘤、未破裂動脈瘤或合并血管畸形的動脈瘤等更更具有優(yōu)勢。本文通過對介入治療術(shù)中顱內(nèi)動脈瘤破裂的經(jīng)驗總結(jié),著重探討血管內(nèi)介入治療術(shù)中動脈瘤破裂的危險因素、發(fā)生機制、預防及處理方法,為臨床治療提供幫助。 方法：通過對2009年7月至2014年3月期間在大連醫(yī)科大學附屬第一醫(yī)院神經(jīng)外科住院的行介入治療的顱內(nèi)動脈瘤患者進行回顧分析,其中9例患者發(fā)生術(shù)中動脈瘤破裂,男4例,女5例,年齡47歲-68歲,平均年齡58.4歲,Hent-Hess分級Ⅰ-Ⅳ級。動脈瘤均為單發(fā),其中前交通動脈瘤3例,2例大腦中動脈瘤,基底動脈頂端動脈瘤1例,后交通動脈瘤3例(其中1例行支架系統(tǒng)輔助彈簧圈栓塞)。術(shù)前均常規(guī)應用苯巴比妥、阿托品作為術(shù)前用藥,術(shù)中均采用靜脈麻醉,氣管插管輔助通氣。術(shù)前患者均行頭CT檢查明確診斷為蛛網(wǎng)膜下腔出血,均行頭CTA或DSA檢查明確診斷為動脈瘤。上述患者均在發(fā)病3天內(nèi)行血管內(nèi)介入治療。所有患者均在全身麻醉下行經(jīng)股動脈應用Seldinger技術(shù)置入6F動脈短鞘,全身肝素化下進行,手術(shù)均由神經(jīng)外科醫(yī)師(副教授以上)按常規(guī)介入手術(shù)操作。 結(jié)果：顱內(nèi)動脈瘤介入治療術(shù)中動脈瘤破裂的9例患者,1例發(fā)生在支架系統(tǒng)成功置入后再次填塞彈簧圈過程中,2例發(fā)生在輸送微導絲過程中,3例發(fā)生在置入微導管后,3例發(fā)生在填充彈簧圈過程中。術(shù)后6例患者進入我科重癥監(jiān)護室(Intensive Care Unit ICU),其中術(shù)后4例患者術(shù)后完全恢復,1例患者遺留言語障礙(術(shù)后3個月后復查,患者可與家人簡單言語交流),1例患者遺留一側(cè)肢體偏癱(術(shù)后3個月復查,患者可借助器械行走),其中3例患者轉(zhuǎn)入重癥監(jiān)護室(Intensive Care Unit ICU)病房,呼吸機輔助通氣,1例患者家屬主動放棄治療,術(shù)后當夜1例患者死于呼吸心跳驟停,術(shù)后第三日1例患者于呼吸衰竭死亡。 結(jié)論：顱內(nèi)動脈瘤介入治療術(shù)中破裂的患者致殘率、死亡率高；導絲、導管、彈簧圈穿通動脈瘤是最常見的術(shù)中破裂原因；及時正確的處理顱內(nèi)動脈瘤術(shù)中破裂(Intraoperative aneurysmal rupture IAR),需要神經(jīng)外科醫(yī)師掌握顱內(nèi)動脈瘤的病因、術(shù)前患者狀態(tài)、破裂原因、治療措施、預防等相關(guān)問題,并做出最適當?shù)闹委煷胧�。術(shù)中動脈瘤破裂后,神經(jīng)外科醫(yī)師需妥善處理有關(guān)問題,在同一時間內(nèi),術(shù)后治療是患者康復的關(guān)鍵。
[Abstract]:Objective: in the course of surgical treatment of intracranial aneurysms, the rupture of aneurysms during operation is very dangerous, and it is the most serious complication, the rate of disability is high, and the fatality rate is high. Endovascular treatment of intracranial aneurysms started later than open clipping, but the effect was satisfactory. This article summarized the experience of intracranial aneurysm rupture during interventional therapy, and discussed the risk factors of aneurysm rupture in intravascular interventional therapy. The mechanism of occurrence, prevention and treatment are helpful for clinical treatment. Methods: from July 2009 to March 2014, interventional treatment of intracranial aneurysms was performed in the first affiliated Hospital of Dalian Medical University. Among them, 9 patients suffered from ruptured aneurysms during operation. There were 4 males and 5 females, aged from 47 to 68 years, with an average age of 58.4 years. The aneurysms were all single, including 3 cases of anterior communicating artery aneurysms and 2 cases of middle cerebral artery aneurysms, and 1 case of aneurysms at the top of the basilar artery. 3 cases of posterior communicating aneurysm (including 1 case with stent-assisted coils embolization) were treated with phenobarbital and atropine before operation. All patients were diagnosed as subarachnoid hemorrhage by CT. All the patients were diagnosed as aneurysms by CTA or DSA. All the patients were treated with intravascular interventional therapy within 3 days after onset. All the patients were placed 6F artery short sheath via femoral artery under general anesthesia, and heparin was used in the whole body. The operation is performed by neurosurgeon (associate professor or above) according to routine interventional operation. Results: during interventional treatment of intracranial aneurysms, one patient with ruptured aneurysm occurred in 2 cases of intracranial aneurysm rupture during the successful placement of stent system and the re-filling of coils. 3 cases occurred in the process of microguide wire delivery. 3 cases occurred in microimplantation. After operation, 6 patients entered intensive Care Unit ICUU, and 4 patients recovered completely after operation. The patient could communicate with his family in simple words. One patient had left one side of hemiplegia. After 3 months of operation, the patient could walk with instruments. Among them, 3 patients were transferred to intensive Care Unit ICUU. One patient died of respiratory and cardiac arrest at night and one died of respiratory failure on the third day of operation. Conclusion: the rate of disability and mortality in patients with ruptured intracranial aneurysms during interventional treatment are high, the most common causes of rupture are wire guide, catheter and coil perforating aneurysm. Timely and correct treatment of intracranial aneurysm rupture during operation requires neurosurgeon to know the cause of intracranial aneurysm, preoperative condition, cause of rupture, treatment measures, prevention and so on. After rupture of aneurysm, neurosurgeon should deal with the related problems properly. At the same time, postoperative treatment is the key to the recovery of patients.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R739.41

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