本文選題：顱內(nèi)動(dòng)脈瘤 + 后交通動(dòng)脈瘤�。� 參考：《瀘州醫(yī)學(xué)院》2014年碩士論文

【摘要】：目的：頸內(nèi)動(dòng)脈-后交通動(dòng)脈瘤是最常見(jiàn)顱內(nèi)動(dòng)脈瘤之一，盡管顯微夾閉及介入栓塞治療技術(shù)不斷改進(jìn)和提高，動(dòng)脈瘤術(shù)中破裂(Intraoperativeaneurysm rupture，IAR)仍無(wú)法完全避免。動(dòng)脈瘤術(shù)中破裂與多種因素有關(guān)，為動(dòng)脈瘤術(shù)中的突發(fā)事件，是動(dòng)脈瘤術(shù)中最大的風(fēng)險(xiǎn)，常導(dǎo)致患者術(shù)后預(yù)后不良，甚至危及生命。通過(guò)對(duì)頸內(nèi)動(dòng)脈-后交通動(dòng)脈瘤顯微夾閉及介入栓塞治療術(shù)中破裂的相關(guān)因素的分析研究，以期降低術(shù)中破裂的發(fā)生率，提高術(shù)中破裂的預(yù)防處理水平，最終改善病人預(yù)后。 方法：回顧分析瀘州醫(yī)學(xué)院附屬醫(yī)院神經(jīng)外科2004年1月至2012年12月手術(shù)治療的頸內(nèi)動(dòng)脈-后交通動(dòng)脈瘤患者發(fā)生術(shù)中破裂的63例臨床治療資料，分為顯微夾閉組和介入栓塞治療組，對(duì)比分析兩組動(dòng)脈瘤術(shù)中破裂的發(fā)生率、類型、表現(xiàn)、原因、處理要點(diǎn)，以及術(shù)中破裂對(duì)預(yù)后的影響。入院后即行頭顱CT平掃檢查，院外已行CT檢查者除外，懷疑有顱內(nèi)動(dòng)脈瘤者盡快行CTA檢查，明確診斷為頸內(nèi)動(dòng)脈-后交通動(dòng)脈瘤。積極術(shù)前準(zhǔn)備，在充分告知家屬病情的基礎(chǔ)上，除介入治療偏向選擇瘤頸較窄及夾閉手術(shù)風(fēng)險(xiǎn)較大者外，一般由家屬?zèng)Q定選擇顯微夾閉手術(shù)或介入治療。 對(duì)顯微夾閉手術(shù)，，明顯中斷、改變了手術(shù)進(jìn)程、影響手術(shù)氣氛的動(dòng)脈瘤爆裂性出血為動(dòng)脈瘤術(shù)中破裂。夾閉術(shù)中動(dòng)脈瘤破裂后通過(guò)：(1)藥物控制血壓及顱內(nèi)壓；(2)加深麻醉；(3)壓迫頸部頸總動(dòng)脈；(4)未成熟破裂者保持腦壓板位置，立即雙吸引器吸去術(shù)腔積血，必要時(shí)切除部分腦組織，顯露并阻斷載瘤動(dòng)脈，繼續(xù)解剖分離動(dòng)脈瘤頸，夾閉動(dòng)脈瘤；(5)成熟破裂者，吸引游離法(Poppen法)，壓迫止血法、雙極電凝法、調(diào)整動(dòng)脈瘤夾位置等直至夾閉滿意。(6)動(dòng)脈瘤頸撕脫者自體硬腦膜包裹術(shù)加夾閉術(shù)，夾閉頸內(nèi)動(dòng)脈行動(dòng)脈瘤孤立、動(dòng)脈瘤夾直接夾閉破裂口術(shù)等；(7)必要時(shí)內(nèi)外減壓術(shù)等處理方法。介入治療動(dòng)脈瘤術(shù)中破裂的定義：造影時(shí)發(fā)現(xiàn)造影劑外溢，微導(dǎo)管或?qū)Ыz突出瘤壁，彈簧圈突出瘤壁。介入組術(shù)中破裂的處理：(1)停用一切含有肝素的藥物；(2)立即靜脈注射魚(yú)精蛋白和肝素鈉逆轉(zhuǎn)抗凝；在術(shù)中動(dòng)脈瘤破裂時(shí)，可給予輸注血小板來(lái)迅速逆轉(zhuǎn)抗血小板效應(yīng)；(3)保持冷靜的情緒，快速填塞動(dòng)脈瘤直至對(duì)比劑不外溢；(4)如果是微導(dǎo)管頭端造成的術(shù)中破裂，此時(shí)將不能撤出微導(dǎo)管，使破口變大，可通過(guò)此微導(dǎo)管繼續(xù)栓塞，或應(yīng)用另一微導(dǎo)管進(jìn)行后續(xù)栓塞；(5)球囊暫時(shí)阻斷載瘤動(dòng)脈，為爭(zhēng)取導(dǎo)管導(dǎo)絲到位爭(zhēng)取時(shí)間；(6)栓塞困難，保留導(dǎo)管，改行開(kāi)顱手術(shù)。 術(shù)后及時(shí)復(fù)查CT和CTA檢查，所有病例在術(shù)后3月、6月、每年通過(guò)電話預(yù)約及來(lái)院復(fù)查的方式定期隨訪復(fù)查。按照GOS評(píng)分評(píng)估預(yù)后。并作統(tǒng)計(jì)分析。 結(jié)果：CT平掃發(fā)現(xiàn)自發(fā)性蛛網(wǎng)膜下腔出血51例(81.0%)(夾閉組50/56，介入組6/7)，蛛網(wǎng)膜下腔出血主要位于側(cè)裂區(qū)、鞍上池，其中15例破入腦室。單純腦內(nèi)血腫6例(9.5%)(夾閉組6/56，介入組0/7)，額葉血腫2例，顳葉血腫4例。CT-Fisher分級(jí)，Ⅰ級(jí)12例(19.0%)(夾閉組11/56，介入組1/7)，Ⅱ級(jí)21例(33.33%)(夾閉組19/56，介入組2/7)，Ⅲ級(jí)20例(31.7%)(夾閉組16/56，介入組4/7)，Ⅳ級(jí)10例(15.9%)(夾閉組10/56，介入組1/7)。DSA檢查23例(36.5%)(夾閉組16/56，介入組7/7)，MRA檢查2例(3.2%)(夾閉組1/56，介入組1/7)。CTA檢查均確診動(dòng)脈瘤，并與DSA一致，共發(fā)現(xiàn)的65個(gè)動(dòng)脈瘤，其中多發(fā)動(dòng)脈瘤2例(3.2%)。血管痙攣29例(46.0%)(夾閉組27/56，介入組2/7)，原始后交通動(dòng)脈16例(25.4%)(夾閉組14/56，介入組2/7)。 總共有63例患者的動(dòng)脈瘤發(fā)生術(shù)中破裂，其中夾閉組術(shù)中破裂56例，術(shù)中破裂率16.2%；夾閉組未成熟破裂16例(25.4%)，成熟破裂47例(74.6%)，行動(dòng)脈瘤頸夾閉43例，行動(dòng)脈瘤夾閉加包裹術(shù)5例(7.9%)，動(dòng)脈瘤夾直接夾閉破裂口2例(3.6%)，動(dòng)脈瘤孤立1例(1.6%)，術(shù)后去骨瓣減壓10例(15.9%)。介入組7例發(fā)生術(shù)中破裂，術(shù)中破裂率6.0%，單純藥物治療2例(28.6%)，腰大池引流2例(28.6%)，開(kāi)顱血腫清除去骨瓣減壓2例(28.6%)。兩組在年齡、性別、Hunt-Hess分級(jí)、動(dòng)脈瘤位置、動(dòng)脈瘤體頸比上比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)；而在動(dòng)脈瘤形狀和大小、術(shù)中破裂發(fā)生率上，夾閉組和介入組比較，差異有統(tǒng)計(jì)學(xué)意義(P0.05)。顯微夾閉術(shù)中破裂發(fā)生率高，以未成熟破裂多見(jiàn)，多為動(dòng)脈瘤瘤體破裂。介入栓塞術(shù)中動(dòng)脈瘤破裂發(fā)生率相對(duì)比夾閉組低，且多發(fā)生在彈簧圈栓塞過(guò)程中。此外，夾閉組術(shù)后并發(fā)癥多。術(shù)后隨訪6個(gè)月至9年，平均隨訪時(shí)間3年，動(dòng)脈瘤復(fù)發(fā)者3例(夾閉組2及介入組1例)。預(yù)后GOS評(píng)分，37例恢復(fù)良好(夾閉組34例及介入組3例)，11例中殘(夾閉組9例及介入組2例)，10例重殘(夾閉組10例)，夾閉組死亡3例，死亡率為5.4%，介入組死亡2例，死亡率為28.6%。夾閉組和介入組在殘廢率和死亡率上比較，差異有統(tǒng)計(jì)學(xué)意義(P0.05)，術(shù)中破裂發(fā)生后介入組患者死亡率較高，但存活者預(yù)后較好，夾閉組死亡率較低，但殘廢率高。結(jié)論：(1)后交通動(dòng)脈瘤夾閉術(shù)中破裂發(fā)生率高，臨時(shí)阻斷是術(shù)中破裂的保護(hù)因素。雙吸引器暴露術(shù)腔，臨時(shí)阻斷載瘤動(dòng)脈，盡快夾閉瘤頸是術(shù)中破裂搶救的重點(diǎn)。 (2)介入栓塞術(shù)中破裂發(fā)生率低，IAR發(fā)生后立即快速靜脈注射魚(yú)精蛋白中和肝素鈉逆轉(zhuǎn)抗凝,快速填塞彈簧圈栓塞動(dòng)脈瘤是介入術(shù)中動(dòng)脈瘤破裂急診救治的關(guān)鍵。 (3)術(shù)中破裂發(fā)生后介入組患者死亡率較高，但存活者預(yù)后較好，夾閉組死亡率較低，但殘廢率高
[Abstract]:Objective: the internal carotid artery posterior communicating artery aneurysm is one of the most common intracranial aneurysms. Despite the continuous improvement and improvement of the technique of microocclusion and interventional embolization, the rupture of Intraoperativeaneurysm rupture (IAR) is still not completely avoided. The rupture of the aneurysm is associated with a variety of factors and is an emergency in the operation of the aneurysm. It is the greatest risk in aneurysm surgery, which often leads to poor prognosis and even life. Through the analysis and study of the related factors of internal carotid artery posterior communicating artery aneurysm microclamping and interventional embolization in order to reduce the incidence of intraoperative rupture, improve the prevention and treatment level of intraoperative rupture, and ultimately improve the patient. Prognosis.
Methods: the clinical data of 63 cases of intraoperative rupture of internal carotid artery aneurysm operated in the Department of Neurosurgery of Affiliated Hospital of Luzhou Medical College from January 2004 to December 2012 were analyzed and analyzed. The results were divided into micro clamp group and interventional embolization therapy group. The incidence, type, manifestation, and the original rate of rupture were compared and analyzed in the two groups. The main points of treatment, and the effect of intraoperative rupture on the prognosis. CT plain scan after admission, except for CT examiners outside the hospital, suspected of intracranial aneurysm by CTA examination as soon as possible, clearly diagnosed as internal carotid artery aneurysm. Pre operation preparation, on the basis of full disclosure of the family's condition, except for interventional treatment preference selection Generally speaking, the family members decided to choose microsurgical clipping or interventional therapy.
The operation process was obviously interrupted and the operation process was obviously interrupted and the operation process was changed. The aneurysm burst bleeding affected the operation atmosphere. The aneurysm was ruptured during the operation. (1) the drug controlled the blood pressure and intracranial pressure; (2) the deepening anaesthesia; (3) the compression of the neck and neck common artery; (4) the unripe ruptured person kept the position of the brain pressure plate, immediately The double suction apparatus sucked the blood of the cavity, removed part of the brain tissue, exposed and blocked the aneurysm arteries, continued dissecting the aneurysm neck and clipping the aneurysm; (5) the mature ruptured, the free method (Poppen), the compression hemostasis method, the bipolar electrocoagulation, the adjustment of the position of the aneurysm clip were satisfied. (6) the autologous brain of the aneurysm neck avulsion was in the autologous brain. Membrane encapsulation and clipping, clamping internal carotid artery aneurysm isolated, aneurysm clipping and rupture, and so on; (7) internal and external decompression, such as necessary treatment. Interventional treatment of aneurysm rupture definition: contrast medium spillover, micro catheter or filaments out of the tumor wall, coils protruding the tumor wall. Intraoperative rupture of the interventional group. Treatment: (1) discontinuation of all drugs containing heparin; (2) immediate intravenous injection of protamine and heparin sodium to reverse anticoagulation; when intraoperative aneurysm ruptures, infusion of platelets can be given to quickly reverse the antiplatelet effect; (3) keep calm and quickly fill the vein tumor until the contrast agent does not spilt; (4) if it is the head end of the micro catheter In the case of intraoperative rupture, the microcatheter could not be withdrawn at this time to make the breach larger, and the microcatheter could be embolized by this microcatheter or the other microcatheter was used for subsequent embolization; (5) the balloon was temporarily blocked by the balloon to strive for the time of the catheter guide in place; (6) the catheter was retained and the catheter was retained, and a craniotomy was performed.
CT and CTA were reviewed in time after operation. All cases were reviewed in March and June after the operation. The prognosis was evaluated according to the GOS score.
Results: 51 cases of spontaneous subarachnoid hemorrhage (50/56, 6/7) were found in 51 cases of spontaneous subarachnoid hemorrhage (50/56, 6/7). Subarachnoid hemorrhage was mainly located in the lateral fissure area, in which 15 cases were broken into the ventricle, 6 cases of intracerebral hematoma (9.5%) (6/56, 0/7), 2 cases of frontal hematoma, 4 cases of temporal lobe hematoma, 12 cases (19%) (19%) (19%). 11/56, interventional group 1/7), 21 cases (33.33%) of grade II (19/56 in clipping group, 2/7 in interventional group), 20 cases (31.7%) of grade III (4/7 in clipping group, 4/7), 10 cases (15.9%) of grade IV (10/56 in clipping group, 1/7) in 23 cases (36.5%) (clipping group 16/ 56, 7/7 in intervention group), 2 cases of MRA examination (3.2%) (interlocking group, interventional group) examination all confirmed arteries 65 aneurysms were found in common with DSA, including 2 cases (3.2%) of multiple aneurysms, 29 cases of vasospasm (46%) (27/56 in clipping group, 2/7 in interventional group), 16 cases of primary posterior communicating artery (25.4%) (14/56 in clipping group and 2/7 in interventional group).
A total of 63 cases of aneurysm occurred intraoperative rupture, of which 56 cases were ruptured in the clipping group and 16.2% in the intraoperative rupture rate; 16 cases of unripe rupture (25.4%), 47 mature rupture (74.6%), 43 cases of aneurysm neck clipping, 5 cases of aneurysm clipping plus parcels (7.9%), aneurysm clips 2 cases (3.6%) and aneurysm isolating 1. Cases (1.6%), postoperative bone flap decompression in 10 cases (15.9%). 7 cases occurred intraoperative rupture, 6% of intraoperative rupture, 2 cases of pure drug therapy (28.6%), 2 cases (28.6%), craniotomy hematoma removal of 2 cases (28.6%). The difference was not statistically significant in age, sex, Hunt-Hess classification, aneurysm position and comparison of aneurysm neck ratio. Significance (P0.05), but in the shape and size of aneurysm and the incidence of intraoperative rupture, the difference between the clipping group and the interventional group was statistically significant (P0.05). The incidence of rupture was high in the microsurgical clipping, most of which were ruptured with unripe ruptures and most of the aneurysm rupture. The incidence of aneurysm rupture in interventional embolization was relatively lower than that in the clipping group. In addition, in the process of coiling embolism, there were more complications in the clipping group. The follow-up period was 6 months to 9 years, the average follow-up time was 3 years, 3 cases of aneurysm recurrence (2 and 1 cases in the intervention group). The prognosis was GOS score, 37 cases were recovered well (34 cases in the clipping group and 3 cases in the intervention group), 11 cases were disabled (9 in clipping group and 2 cases), and 10 cases were severely disabled (10 cases in clipping group) In the clipping group, 3 cases died, the mortality rate was 5.4% and the intervention group died in 2 cases. The mortality rate was compared with the 28.6%. clipping group and the intervention group, the difference was statistically significant (P0.05). The mortality of the patients in the intervention group was higher after the intraoperative rupture, but the survival rate was better, the mortality rate was lower in the clipping group, but the residual rate was high. Conclusion: (1) after (1) The incidence of rupture is high during the operation of aneurysm clipping. Temporary occlusion is a protective factor for intraoperative rupture. Double suction apparatus exposes the operation cavity, temporarily blocks the aneurysm of the aneurysm, and clips the neck of the tumor as soon as possible.
(2) the incidence of ruptured embolization in interventional embolization is low. Immediately after IAR, protamine and heparin sodium are quickly injected to reverse the anticoagulation. The key to emergency treatment of aneurysm rupture during interventional procedure is to plug the aneurysm quickly by filling the coils.
(3) the mortality rate of the intervention group was higher after the rupture of the operation, but the prognosis of the survivors was better, and the mortality of the clipping group was lower, but the disability rate was high.

【學(xué)位授予單位】：瀘州醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R651.12

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