本文選題：手術(shù)夾閉治療 + 血管內(nèi)介入��； 參考：《新鄉(xiāng)醫(yī)學(xué)院》2014年碩士論文

【摘要】：背景顱內(nèi)動(dòng)脈瘤是顱內(nèi)動(dòng)脈壁上的異常膨出,是引起蛛網(wǎng)膜下腔出血的主要原因,其破裂出血具有很高的致殘率和死亡率。因顯微外科手術(shù)夾閉術(shù)和血管內(nèi)介入術(shù)均較易到達(dá)前循環(huán)動(dòng)脈瘤所在位置,故在臨床上選擇何種治療方式治療此類動(dòng)脈瘤成為研究熱點(diǎn)；國際蛛網(wǎng)膜下腔出血?jiǎng)用}瘤試驗(yàn)(ISAT)協(xié)作組2003年多中心隨機(jī)試驗(yàn)得出的試驗(yàn)結(jié)果顯示,對(duì)于同時(shí)適合進(jìn)行手術(shù)夾閉治療和血管內(nèi)介入治療的破裂腦動(dòng)脈瘤患者,根據(jù)治療后1年時(shí)的無殘疾存活來判斷臨床轉(zhuǎn)歸,血管內(nèi)治療組顯著優(yōu)于手術(shù)夾閉組。但近年來很多研究顯示,手術(shù)夾閉治療與血管內(nèi)介入治療術(shù)后療效差異并無統(tǒng)計(jì)學(xué)意義。目的通過對(duì)經(jīng)手術(shù)夾閉治療與血管內(nèi)介入治療的顱內(nèi)前循環(huán)動(dòng)脈瘤患者的術(shù)后主要并發(fā)癥——腦血管痙攣、腦積水發(fā)生率、術(shù)后6個(gè)月生存狀態(tài)、復(fù)發(fā)率等對(duì)比分析,比較兩種治療方式的療效。方法回顧性分析新鄉(xiāng)醫(yī)學(xué)院第一附屬醫(yī)院2009年1月至2011年6月收治的367例經(jīng)頭部CTA或全腦血管造影-DSA確診的顱內(nèi)前循環(huán)動(dòng)脈瘤患者的臨床資料。其中手術(shù)組301例,介入組66例,男性161例,女性206例,大腦前動(dòng)脈動(dòng)脈瘤150例,大腦中動(dòng)脈動(dòng)脈瘤76例,頸內(nèi)動(dòng)脈動(dòng)脈瘤141例,共計(jì)424個(gè)動(dòng)脈瘤；患者治療時(shí)機(jī)分為3個(gè)時(shí)段。(1)在顱內(nèi)動(dòng)脈瘤破裂后72小時(shí)內(nèi)行手術(shù)夾閉治療或血管內(nèi)介入治療；(2)已經(jīng)超過72小時(shí)的患者,部分患者因病情變化在4-10天之間接受治療,其余病人盡量避免在發(fā)病后4-10天的血管痙攣期進(jìn)行治療。(3)其余病人在發(fā)病10天后行手術(shù)夾閉治療或血管內(nèi)介入治療；手術(shù)夾閉治療組手術(shù)方法：患者取經(jīng)典翼點(diǎn)入路或擴(kuò)大翼點(diǎn)入路,高倍顯微鏡下仔細(xì)分離側(cè)裂,打開鄰近腦池放出腦脊液降顱壓,顯露載瘤動(dòng)脈,分離動(dòng)脈瘤頸后選取合適動(dòng)脈瘤夾將動(dòng)脈瘤夾閉。本組所有病例均采用氣管插管靜吸復(fù)合麻醉,嚴(yán)格維持血壓穩(wěn)定,根據(jù)動(dòng)脈瘤部位不同,選擇不同手術(shù)入路,高倍顯微鏡下操作行動(dòng)脈瘤頸夾閉。上夾后均對(duì)周圍穿支血管及神經(jīng)仔細(xì)探查以確定瘤夾的位置是否良好；對(duì)可能形成載瘤動(dòng)脈狹窄或夾閉不全者,術(shù)中行顯微鏡熒光造影；對(duì)于瘤體較大,可能存在壓迫癥狀者,行瘤體分離切除。對(duì)顱底粘連較重者,仔細(xì)分離粘連組織,并行終板造瘺術(shù),以降低腦積水發(fā)生幾率。術(shù)前Hunt-Hess分級(jí)低,術(shù)中腦組織水腫較輕者,嚴(yán)密縫合腦膜,骨瓣復(fù)位；術(shù)前Hunt-Hess分級(jí)高,術(shù)中腦組織水腫較重者,人工硬膜減張縫合硬腦膜,行去骨瓣減壓。血管內(nèi)介入組手術(shù)方法：在氣管插管全身麻醉并全身肝素化抗凝下,保持導(dǎo)管內(nèi)生理鹽水持續(xù)沖洗以預(yù)防血栓形成,首先經(jīng)股動(dòng)脈插管行全腦血管造影,充分了解腦血管循環(huán)情況和動(dòng)脈瘤的部位、大小、朝向、形態(tài)以及與周圍血管的關(guān)系,選擇最佳工作角度精確測(cè)量動(dòng)脈瘤直徑和瘤頸寬度,導(dǎo)引管經(jīng)患側(cè)頸內(nèi)動(dòng)脈,適當(dāng)塑形微導(dǎo)管后超選進(jìn)入動(dòng)脈瘤腔。比較兩組患者性別、年齡、動(dòng)脈瘤大小、動(dòng)脈瘤部位、術(shù)前Hunt-Hess分級(jí)；對(duì)比術(shù)后并發(fā)癥如腦血管痙攣、腦積水等的發(fā)生率：對(duì)比兩組患者術(shù)前Hunt—Hess分級(jí)與術(shù)后6個(gè)月后改良Rankin評(píng)分之間的關(guān)系；分組對(duì)比相同術(shù)前Hunt-Hess分級(jí)水平,行手術(shù)夾閉治療和血管內(nèi)介入治療病人的術(shù)后6個(gè)月改良Rankin評(píng)分：手術(shù)夾閉治療患者出院前復(fù)查頭部CTA,兩組患者術(shù)后3月均復(fù)查DSA,此后每6個(gè)月到12個(gè)月進(jìn)行隨訪,復(fù)查DSA,隨訪9個(gè)月-33個(gè)月不等,比較兩組患者術(shù)后的動(dòng)脈瘤復(fù)發(fā)率；對(duì)比兩組患者的平均住院天數(shù)。結(jié)果1.手術(shù)夾閉治療組與血管內(nèi)介入組患者術(shù)后出現(xiàn)腦血管痙攣、腦積水等主要并發(fā)癥的發(fā)生率,經(jīng)統(tǒng)計(jì)學(xué)分析無明顯差異,P0.05。2.患者術(shù)前Hunt-Hess分級(jí)與術(shù)后6個(gè)月改良Rankin評(píng)分之間的關(guān)系：經(jīng)統(tǒng)計(jì)結(jié)果顯示,術(shù)前患者Hunt-Hess分級(jí)越低,術(shù)后6個(gè)月患者改良Rankin評(píng)分越低；當(dāng)術(shù)前患者Hunt-Hess分級(jí)增高時(shí),術(shù)后6個(gè)月患者改良Rankin評(píng)分亦增高,P值0.05。3.分組對(duì)比相同術(shù)前Hunt-Hess分級(jí)水平,行手術(shù)夾閉治療和血管內(nèi)介入治療病人的術(shù)后6個(gè)月改良Rankin評(píng)分；結(jié)果顯示在相同術(shù)前Hunt-Hess分級(jí)水平對(duì)比時(shí),兩組患者改良Rankin評(píng)分經(jīng)統(tǒng)計(jì)學(xué)分析P值分別為Ⅰ級(jí)(P=0.21)、Ⅱ級(jí)(P=0.79)、Ⅲ級(jí)(P＝0.99),均大于0.05,表明兩組患者治療后改良Rankin評(píng)分差異無統(tǒng)計(jì)學(xué)意義。4.手術(shù)夾閉組與血管內(nèi)介入組術(shù)后行門診復(fù)查隨訪9-33個(gè)月,平均為17個(gè)月,動(dòng)脈瘤復(fù)發(fā)患者12個(gè)；其中,開顱夾閉組術(shù)后有1個(gè)復(fù)發(fā)(由于夾閉不全),復(fù)發(fā)率0.3%；血管內(nèi)介入組術(shù)后11個(gè)復(fù)發(fā),復(fù)發(fā)率16.70%。手術(shù)夾閉組與血管內(nèi)介入組兩組復(fù)發(fā)率之間的差異應(yīng)用χ2檢驗(yàn),手術(shù)夾閉組術(shù)后復(fù)發(fā)率明顯低于血管內(nèi)介入組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。5.手術(shù)夾閉治療組患者平均住院天數(shù)為17.4±3.8天,血管內(nèi)介入治療組患者平均住院天數(shù)為12.8+2.9天,血管內(nèi)介入組小于手術(shù)夾閉組,結(jié)果差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論1.手術(shù)夾閉治療與血管內(nèi)介入治療術(shù)中動(dòng)脈瘤破裂幾率均低,兩種療法對(duì)術(shù)后腦血管痙攣的發(fā)生率、腦積水發(fā)生率的影響無明顯差別。2.手術(shù)夾閉治療和血管內(nèi)介入治療對(duì)患者預(yù)后的影響無明顯差別。術(shù)前Hunt-Hess分級(jí)對(duì)患者預(yù)后影響明顯。3.手術(shù)夾閉治療動(dòng)脈瘤較血管內(nèi)介入有較低復(fù)發(fā)率,而血管內(nèi)介入治療可縮短患者住院時(shí)間。4.顱內(nèi)前循環(huán)動(dòng)脈瘤患者,年輕者,身體狀態(tài)好的,建議選擇手術(shù)夾閉治療,以求更確切的療效；老年患者,年齡大于65歲者,身體條件差的,建議選擇血管內(nèi)介入治療,以降低術(shù)后臥床并發(fā)癥風(fēng)險(xiǎn)。
[Abstract]:Background Intracranial aneurysm is an abnormal swelling in the wall of intracranial artery , which is the main cause of hemorrhage of subarachnoid hemorrhage .
The clinical data of 367 patients with ruptured cerebral aneurysms diagnosed with head CTA or all - cerebral angiography - DSA were retrospectively analyzed .
The patients were divided into three periods : ( 1 ) within 72 hours after ruptured intracranial aneurysm , operation clipping or endovascular interventional therapy was performed ;
( 2 ) In patients with more than 72 hours , some patients received treatment between 4 and 10 days due to the change of the condition , and the rest of the patients had to avoid the treatment during the 4 - 10 days after the onset of the disease . ( 3 ) The rest of the patients underwent surgical clipping or endovascular interventional therapy after 10 days of onset ;
The operation method of surgical clipping treatment group : The patients take classical wing - point approach or enlarge the wing - point approach , carefully separate the lateral fissure under the microscope , open the adjacent brain pool to release cerebrospinal fluid to reduce the cranial pressure , reveal the tumor - carrying artery , separate the aneurysm neck and select the appropriate aneurysm clip to clamp the aneurysm .
in that case of stenosis or clipping of the artery which may form the tumor - bearing artery , the intraoperative microscopic fluorescence angiography is performed ;
For the larger tumor volume , there may be compression symptoms , and the tumor body can be separated and removed . For the greater adhesion of the skull base , the adhesion structure and the parallel terminal plate ostomy are carefully separated , so as to reduce the incidence of hydrocephalus .
Preoperative Hunt - Hess grade was high , the brain edema was more severe in the operation , the hard dura mater was sutured with the artificial dura mater and the decompression of the bone flap was performed . The procedure of the endovascular intervention group was as follows : After the endotracheal intubation general anesthesia and the whole body heparinized anti - coagulation , the saline was kept in the catheter for continuous flushing to prevent thrombosis . The diameter of the aneurysm and the width of the aneurysm were measured accurately through the femoral artery cannula . The diameter of the aneurysm and the width of the aneurysm neck were measured accurately .
The incidence of postoperative complications such as cerebrovascular spasm , hydrocephalus , etc . was compared : the relationship between preoperative Hunt - Hess grade and modified Rankin score after 6 months after operation was compared between the two groups .
The modified Rankin score of patients with preoperative Hunt - Hess classification , operation clipping treatment and intravascular interventional therapy was compared with that of the patients after operation . The DSA was re - examined every 6 months to 12 months . The DSA was re - examined and the follow - up period was 9 months to 33 months , and the recurrence rate of aneurysm was compared between the two groups .
Results 1 . There was no significant difference in the incidence of cerebrovascular spasm , hydrocephalus and other major complications between treatment group and intra - vascular interventional group after operation . The relationship between the preoperative Hunt - Hess grade and the modified Rankin score of 6 months after operation was statistically analyzed .
The Rankin score was also increased in patients with preoperative Hunt - Hess ( P = 0 . 05 . 3 ) .
The results showed that the modified Rankin score of the two groups was significantly higher than that of group 鈪，

本文編號(hào)：1949314