本文選題：顱內(nèi)多發(fā)動(dòng)脈瘤　切入點(diǎn)：蛛網(wǎng)膜下腔出血　出處：《天津醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：目的基于三維腦血管造影,通過對顱內(nèi)多發(fā)囊性動(dòng)脈瘤合并蛛網(wǎng)膜下腔出血患者中破裂動(dòng)脈瘤與未破裂動(dòng)脈瘤三維重建影像的對比分析,減少患者個(gè)體差異對動(dòng)脈瘤破裂的影響及測量誤差,探討動(dòng)脈瘤形態(tài)學(xué)特征相關(guān)指標(biāo)與動(dòng)脈瘤破裂風(fēng)險(xiǎn)的關(guān)系,從而探尋預(yù)測動(dòng)脈瘤破裂風(fēng)險(xiǎn)的形態(tài)學(xué)因素,為更好的制定未破裂動(dòng)脈瘤的臨床決策提供依據(jù)。 方法回顧性分析天津市環(huán)湖醫(yī)院自2011年09月至2013年12月收治的94例發(fā)生蛛網(wǎng)膜下腔出血的顱內(nèi)多發(fā)囊性動(dòng)脈瘤患者的病例資料,對其中有完整臨床資料及本院三維腦血管造影資料且能明確責(zé)任動(dòng)脈瘤的61例患者中的61個(gè)破裂動(dòng)脈瘤與78個(gè)未破裂動(dòng)脈瘤進(jìn)行對比分析。在三維腦血管造影影像上,分析多發(fā)動(dòng)脈瘤患者中破裂動(dòng)脈瘤部位、大小、形狀分布特征,測量破裂與未破裂動(dòng)脈瘤的瘤頸寬度(Wneck)、瘤體高度(H)、瘤體長徑(L)、瘤體寬徑(W)、載瘤動(dòng)脈直徑(Dv)一維形態(tài)學(xué)參數(shù),計(jì)算瘤體高度與瘤頸寬度的比值(AR)、瘤體高度與瘤體寬徑的比值(HWR)、瘤體寬徑與瘤頸寬度的比值(BN)、瘤體長徑與載瘤動(dòng)脈直徑的比值(SR)二維形態(tài)學(xué)參數(shù)。對以上9項(xiàng)參數(shù)進(jìn)行單因素分析,探討其與動(dòng)脈瘤破裂風(fēng)險(xiǎn)的關(guān)系,并對各參數(shù)進(jìn)行受試者工作(ROC)曲線分析,以確定其曲線下面積及最佳臨界值。將單因素分析中有意義各變量進(jìn)行多因素logistic回歸分析。為便于比較不同形態(tài)學(xué)指標(biāo)與動(dòng)脈瘤破裂相關(guān)程度,在進(jìn)行多因素分析之前,將各連續(xù)變量轉(zhuǎn)換為0-10的范圍,使轉(zhuǎn)換后的變量每增加1個(gè)單位對應(yīng)其原變量10%的變化。 結(jié)果①顱內(nèi)多發(fā)動(dòng)脈瘤患者中破裂動(dòng)脈瘤最常見于頸內(nèi)動(dòng)脈后交通段,但前交通動(dòng)脈瘤及大腦前動(dòng)脈瘤破裂率明顯高于顱內(nèi)其他位置的動(dòng)脈瘤(P0.05)。②顱內(nèi)多發(fā)動(dòng)脈瘤患者中破裂動(dòng)脈瘤最大徑為(5.94±3.32)mm,大于未破裂動(dòng)脈瘤(3.83±2.89)mm,二者具有統(tǒng)計(jì)學(xué)意義(P0.05),但6例(9.83%)患者中破裂動(dòng)脈瘤并不是最大的那一個(gè)。最大徑≤3mm、3mm但≤7mm、7mm者動(dòng)脈瘤破裂率依次增高,分別為20.0%、58.5%、81.0%,具有統(tǒng)計(jì)學(xué)差異(P0.05),但61個(gè)破裂動(dòng)脈瘤中,最大徑≤3mm者13個(gè)(21.3%),最大徑3mm但≤7mm者31個(gè)(50.8%),僅有17個(gè)(27.9%)動(dòng)脈瘤最大徑7mm,且各部位破裂動(dòng)脈瘤中最大徑7mm者所占比例均不超過1/3。③動(dòng)脈瘤破裂的形態(tài)學(xué)因素研究中,單因素分析顯示破裂與未破裂動(dòng)脈瘤間Wneck、H、L、AR、BN、SR6項(xiàng)指標(biāo)差異有統(tǒng)計(jì)學(xué)意義(P0.05),而W、Dv、HWR3項(xiàng)指標(biāo)差異無統(tǒng)計(jì)學(xué)意義(P0.05)；多因素分析顯示,只有AR、SR與動(dòng)脈瘤破裂具有獨(dú)立相關(guān)性,當(dāng)AR、SR值增加10%,動(dòng)脈瘤破裂風(fēng)險(xiǎn)性分別為原來的1.34、1.45倍。ROC曲線分析顯示AR、SR具有較高的曲線下面積(分別為0.78、0.81),其最佳臨界值分別為1.36、1.81。 結(jié)論①顱內(nèi)多發(fā)動(dòng)脈瘤中的破裂和未破裂動(dòng)脈瘤可以作為研究動(dòng)脈瘤形態(tài)學(xué)特征與破裂風(fēng)險(xiǎn)關(guān)系的理想模型,在一定程度上解決病例選擇偏倚的影響。②微小動(dòng)脈瘤在顱內(nèi)破裂動(dòng)脈瘤中占有一定的比例,蛛網(wǎng)膜下腔出血患者應(yīng)當(dāng)在經(jīng)驗(yàn)豐富的腦血管病診療中心接受診治。③顱內(nèi)動(dòng)脈瘤的破裂與動(dòng)脈瘤位置、大小有關(guān),但僅以此預(yù)測動(dòng)脈瘤破裂風(fēng)險(xiǎn)不能完全反映動(dòng)脈瘤的形態(tài)學(xué)及血流動(dòng)力學(xué)特征。④動(dòng)脈瘤AR、SR值是反映顱內(nèi)動(dòng)脈瘤幾何特征和瘤內(nèi)血流動(dòng)力學(xué)的良好形態(tài)學(xué)指標(biāo),可作為評估動(dòng)脈瘤破裂風(fēng)險(xiǎn)的參數(shù),其數(shù)值越大,動(dòng)脈瘤破裂的風(fēng)險(xiǎn)性越高,但目前預(yù)測動(dòng)脈瘤破裂的AR、SR可靠的臨界值尚無定論。在今后動(dòng)脈瘤形態(tài)學(xué)特征與破裂風(fēng)險(xiǎn)關(guān)系的研究中,需要大樣本前瞻性和長期隨訪的研究,這樣才能在臨床診治中更好地運(yùn)用相關(guān)形態(tài)學(xué)參數(shù),準(zhǔn)確預(yù)測動(dòng)脈瘤發(fā)生破裂的危險(xiǎn)程度,為未破裂顱內(nèi)動(dòng)脈瘤患者提供更加完善的術(shù)前評估,以做出更恰當(dāng)?shù)呐R床決策。
[Abstract]:The purpose of 3D DSA based, through comparison and analysis of the aneurysms and aneurysms rupture in patients with three-dimensional reconstruction of multiple intracranial aneurysms with subarachnoid hemorrhage, reduce the impact of individual differences in patients with rupture of the aneurysm and measurement errors, to explore the relationship between the risk of rupture related indicators of aneurysm morphology and aneurysm the morphological factors in order to explore the prediction of aneurysm rupture risk, provide the basis for clinical decision making better unruptured aneurysms.
Methods a retrospective analysis of Tianjin Huanhu Hospital from 2011 09 to December 2013 were 94 cases of subarachnoid hemorrhage patients with multiple intracranial saccular aneurysm cases with complete clinical data and the 3D angiographic data of 61 aneurysms and 61 cases of clear responsibility aneurysm in patients with 78 unruptured aneurysms were analyzed. In the 3D cerebral angiography image analysis, location of aneurysm rupture were multiple aneurysms in size, shape distribution, measurement of ruptured and unruptured aneurysm neck width (Wneck), the tumor body height (H), tumor size (L), tumor diameter (W), the parent artery diameter (Dv) one dimensional morphological parameters, calculation of the ratio of tumor body height and neck width (AR), the ratio of height and width of tumor tumor diameter (HWR), the ratio of tumor body width and neck width (BN), tumor the body length and diameter The ratio of parent artery diameter (SR) parameters of two-dimensional morphology. Single factor analysis of the above 9 parameters, and to explore the relationship between aneurysm rupture risk, and the subjects of each parameter (ROC) curve analysis, to determine the area under the curve and the optimal critical value. Single factor analysis logistic multi factor regression analysis of each variable. In order to compare different morphological indexes related with aneurysm rupture, before the multi factor analysis, the continuous transformation of each variable to 0-10 range, the conversion of the variable changes each increase of 1 single bits corresponding to the original 10% variables.
緇撴灉鈶犻鍐呭鍙戝姩鑴夌槫鎮(zhèn)ｈ，

本文編號：1629845