本文選題：顱內(nèi)破裂動脈瘤 + 介入治療��； 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：研究背景 顱內(nèi)動脈瘤(Intracranial aneurysm)是顱內(nèi)動脈管壁的囊狀膨出,好發(fā)于腦底willis環(huán)及其主要分支,是造成蛛網(wǎng)膜下腔出血(Subarachnoid hemorrhage, SAH)的首位病因。動脈瘤好發(fā)于40～60歲中老年人,青少年相對少見。據(jù)Mayo Clinic報道,人群中動脈瘤的患病率為3.6%-6%,破裂率為1%-2%。動脈瘤破裂出血后的預(yù)后較差,破裂出血的患者中約有15%-20%因無法得到及時治療而于院外死亡,遺留有失語、失明、殘疾等嚴(yán)重神經(jīng)功能障礙的幸存者的比例高達(dá)50%。 目前,動脈瘤的治療方式主要有開顱手術(shù)和血管內(nèi)介入治療兩種方法。前者主要有動脈瘤頸夾閉術(shù)、動脈瘤包裹術(shù)及動脈瘤孤立術(shù)等手術(shù)方式；血管內(nèi)介入治療主要包括三種方法：單純彈簧圈栓塞、球囊輔助栓塞和支架輔助下彈簧圈栓塞。對于顱內(nèi)破裂動脈瘤來說,開顱夾閉手術(shù)或血管內(nèi)介入治療的目的,都是為了盡量避免復(fù)發(fā)或再出血等并發(fā)癥的發(fā)生。 國際蛛網(wǎng)膜下腔出血動脈瘤試驗(ISAT)的研究顯示,開顱夾閉術(shù)的復(fù)發(fā)率為3.8%,血管內(nèi)介入治療的復(fù)發(fā)率為17.4%。因此,血管內(nèi)介入治療動脈瘤面臨的最大問題是復(fù)發(fā)率高。有研究表明,隨著栓塞程度的提高,動脈瘤的復(fù)發(fā)率亦隨之降低,但對于寬頸或巨大動脈瘤來說,單純彈簧圈栓塞復(fù)發(fā)率仍較高。盡管支架輔助下彈簧圈栓塞術(shù)的復(fù)發(fā)率明顯低于單純彈簧圈栓塞術(shù),但仍無法完全避免栓塞術(shù)后動脈瘤的復(fù)發(fā)或再出血。雖然動脈瘤復(fù)發(fā)并不一定會導(dǎo)致動脈瘤再破裂出血,但仍會增加再出血的風(fēng)險。 顱內(nèi)破裂動脈瘤栓塞術(shù)后再次破裂出血是栓塞術(shù)后最危險的并發(fā)癥,且預(yù)后差,死亡率高,是患者致殘與致死的重要原因。術(shù)后再出血包括早期再出血與晚期再出血(遲發(fā)性再出血)。國內(nèi)外研究對于二者的時間界定尚有爭議。多數(shù)文獻(xiàn)將早期再出血的時間定義為在栓塞術(shù)后1個月以內(nèi)發(fā)生的再次破裂出血。在本研究中,我們將早期破裂再出血與遲發(fā)性再出血的時間界限定為1個月。目前,大部分的文獻(xiàn)報道術(shù)后早期再出血的發(fā)生率為0.9～3.6%,雖然術(shù)后早期再出血的發(fā)生率較低,但死亡率高,預(yù)后極差。遲發(fā)性再出血率雖小于1.0%,但是,一旦發(fā)生,仍會危及患者生命安全。 目前國內(nèi)外對于破裂動脈瘤栓塞術(shù)后再出血的研究非常少,主要集中在再出血的原因分析上,其中,不完全栓塞被認(rèn)為是導(dǎo)致顱內(nèi)動脈瘤栓塞術(shù)后再出血的主要原因。在相關(guān)危險因素的分析上,由于樣本量較小、危險因素研究不全等不足,各個報道的結(jié)論存在分歧,主要考慮可能與患者的年齡、高血壓病史、動脈瘤的大小、瘤頸寬窄及動脈瘤的栓塞程度等有關(guān)。此外,對術(shù)后再出血的處理措施亦缺乏規(guī)范化的標(biāo)準(zhǔn)。因此,探討顱內(nèi)破裂動脈瘤栓塞術(shù)后早期及遲發(fā)性再出血的發(fā)生率、死亡率、危險因素及出血后的處理方法具有極為重要的臨床意義。 本研究回顧性分析本院神經(jīng)外科介入治療中心經(jīng)介入治療后發(fā)生再破裂出血的病例,分別統(tǒng)計兩者的發(fā)生率與死亡率,收集其臨床資料及影像學(xué)資料,并通過SPSS13.0統(tǒng)計分析軟件,采用Logistic回歸法進(jìn)行分析,探究栓塞術(shù)后早期及遲發(fā)性再出血的危險因素,為今后栓塞術(shù)后再出血的風(fēng)險評估提供理論依據(jù),同時為栓塞術(shù)后再出血的治療提供參考。 目的 探討顱內(nèi)破裂動脈瘤栓塞術(shù)后早期及遲發(fā)性再出血的發(fā)生率、危險因素以及出血后的處理方法,為今后術(shù)前評估術(shù)后再出血的風(fēng)險提供理論依據(jù),同時為術(shù)后再出血的治療提供參考。 方法 回顧性分析2002年1月至2014年1月南方醫(yī)科大學(xué)珠江醫(yī)院神經(jīng)外科腦血管病介入治療中心收治的顱內(nèi)破裂動脈瘤患者的資料(合并其他腦血管疾病如腦動靜脈畸形、動靜脈瘺的患者已排除)。術(shù)后早期(或遲發(fā)性)再出血的定義為：顱內(nèi)破裂動脈瘤患者在成功行血管內(nèi)介入栓塞治療后,術(shù)后1個月以內(nèi)(或1個月后)突然出現(xiàn)臨床癥狀加重或反復(fù),在排除腦梗塞、高血壓及其他原因?qū)е碌脑俪鲅?頭顱CT或MRI證實再次出現(xiàn)與已栓塞動脈瘤部位一致的新鮮出血。納入變量包括：性別、年齡、高血壓病史、動脈瘤的位置、大小、形狀、瘤頸寬窄、治療時的臨床情況、有無腦血管痙攣及其分級、動脈瘤有無鄰近顱內(nèi)血腫、動脈瘤的栓塞程度、術(shù)后有無明顯的血壓波動、有無使用支架、術(shù)后有無行抗血小板治療、栓塞術(shù)后再出血的時間、臨床預(yù)后(mRS評分)、再出血后的處理措施(介入或夾閉治療)等。統(tǒng)計栓塞術(shù)后早期或遲發(fā)性再出血的發(fā)生率與死亡率,對其臨床及影像學(xué)特點進(jìn)行分析。所有統(tǒng)計資料均采用SPSS13.0統(tǒng)計分析系統(tǒng)進(jìn)行分析。以均數(shù)±標(biāo)準(zhǔn)差表示計量資料,采用Logistic回歸法進(jìn)行多因素分析,變量入選標(biāo)準(zhǔn)基于既往報道中提示的可能引起栓塞術(shù)后再次破裂出血的危險因素(如栓塞程度、Hunt-Hess分級等),以及以往研究中得出的可能導(dǎo)致栓塞術(shù)后顱內(nèi)出血的危險因素(如高血壓等)。檢驗水準(zhǔn)取a=0.05,當(dāng)p0.05時差異有統(tǒng)計學(xué)意義。分析顱內(nèi)破裂動脈瘤栓塞術(shù)后再出血的相關(guān)危險因素,并對其發(fā)生機(jī)制進(jìn)行簡單探討,評價各項處理措施的有效性,以期降低動脈瘤栓塞術(shù)后再出血的發(fā)生率與死亡率。 結(jié)果 栓塞術(shù)后早期再出血：從2002年1月至2014年1月期間,共有1455例顱內(nèi)破裂動脈瘤患者在南方醫(yī)科大學(xué)珠江醫(yī)院神經(jīng)外科腦血管病介入治療中心接受血管內(nèi)介入治療并被納入本研究。所有1455例破裂動脈瘤患者中,共有18例發(fā)生早期再出血,發(fā)生率為1.24%,死亡10例,死亡率為55.6%。早期再出血的平均時間為4.3±3.3天。在18例再出血的患者中,2例行保守治療；3例再次行血管內(nèi)栓塞治療；2例行動脈瘤夾閉術(shù)；2例行雙側(cè)側(cè)腦室外引流術(shù)；1例行血腫清除十腦室外引流術(shù)；6例行血腫清除+去骨瓣減壓術(shù)；2例行去骨瓣減壓+腦室外引流術(shù)。最終預(yù)后良好3例,中度殘疾2例,重度殘疾3例,死亡10例。經(jīng)Logistic逐步回歸分析得出：既往高血壓病史、前交通動脈瘤、動脈瘤鄰近顱內(nèi)血腫、影像學(xué)明顯腦血管痙攣(2-3級)、栓塞前的臨床情況差(Hunt-Hess3-5級)及不完全栓塞是栓塞術(shù)后早期再出血的獨立危險因素。栓塞術(shù)后遲發(fā)性再出血：在上述1455例顱內(nèi)破裂動脈瘤患者中,有503例(34.6%)失隨訪,共有952例(65.4%)患者有完整隨訪資料。所有952例顱內(nèi)破裂動脈瘤患者中,共有6例發(fā)生栓塞術(shù)后遲發(fā)性再出血,發(fā)生率為0.63%,死亡0例,死亡率為0%。栓塞術(shù)后遲發(fā)性再出血的平均時間為39.8±16.9個月。6例患者均再次接受血管內(nèi)介入治療并獲得良好預(yù)后。經(jīng)Logistic逐步回歸分析,得到栓塞術(shù)后遲發(fā)性再出血的獨立危險因素為：既往高血壓病史、初次不完全栓塞以及動脈瘤復(fù)發(fā)。 結(jié)論 破裂動脈瘤栓塞術(shù)后早期再出血是血管內(nèi)介入治療最嚴(yán)重的并發(fā)癥。本研究結(jié)果顯示,顱內(nèi)破裂動脈瘤栓塞術(shù)后早期再出血的發(fā)生率較低,但預(yù)后差,死亡率高,遲發(fā)性再出血的發(fā)生率較低,且預(yù)后較好。早期再出血的獨立危險因素為既往高血壓病史、前交通動脈瘤、影像學(xué)明顯腦血管痙攣(2-3級)、動脈瘤鄰近顱內(nèi)血腫、治療時的臨床情況差(Hunt-Hess3-5級)及不完全栓塞。遲發(fā)性再出血的獨立危險因素為既往高血壓病史、不完全栓塞以及動脈瘤復(fù)發(fā)。栓塞術(shù)中盡量致密栓塞動脈瘤,術(shù)后予鎮(zhèn)靜、通便等處理,防治因用力排便或其他可引起血壓驟升而導(dǎo)致的再次破裂出血；栓塞術(shù)后在安全的前提下盡早行腰椎穿刺術(shù)釋放血性腦脊液,在有條件的情況下,還可行腰大池置管術(shù),加速血性腦脊液的釋放,減輕對腦血管的刺激,防止腦血管痙攣引起繼發(fā)性的缺血性腦損害。在顱內(nèi)再出血的處理方法上,如果腦實質(zhì)出血量較少、無中線明顯偏移或無腦疝跡象時可以盡早行DSA,明確動脈瘤栓塞情況,若有復(fù)發(fā),可再次行栓塞術(shù)；一旦出血量較大或臨床表現(xiàn)較嚴(yán)重時應(yīng)立即行血腫清除術(shù),最好能同期行動脈瘤夾閉術(shù),避免再次破裂出血,還可根據(jù)情況實施去骨瓣減壓術(shù)。
[Abstract]:Background of the study

Intracranial aneurysm ( aneurysm ) is a saccular expansion of the wall of the intracranial artery . It is the first cause of subarachnoid hemorrhage ( SAH ) . The incidence of aneurysm is 3.6 % -6 % , and the rate of rupture is 1 % -2 % . According to Mayo Clinic , about 15 % -20 % of patients with ruptured intracranial aneurysms died outside the hospital due to lack of timely treatment . The proportion of survivors with severe neurological disorders such as aphasia , blindness and disability is up to 50 % .

At present , there are two methods for the treatment of aneurysm , such as aneurysm neck clamping , aneurysm wrapping and aneurysm isolation .
Endovascular interventional therapy mainly includes three methods : single coil embolization , balloon - assisted embolization , and stent - assisted lower coil embolization . For intracranial ruptured aneurysms , the purpose of open - skull clipping surgery or endovascular interventional therapy is to avoid the occurrence of complications such as recurrence or rebleeding .

The study of international subarachnoid hemorrhage ( ISAT ) showed that the recurrence rate of intracranial aneurysms was 3.8 % , and the recurrence rate of endovascular intervention was 17.4 % .

Rebleeding after embolization of ruptured intracranial aneurysms is the most dangerous complication after embolization , and the prognosis is poor and death rate is high . It is an important cause of disability and death in patients . At present , most of the literatures define the time limit of early rebleeding and late re - bleeding . Most of the literatures report that the incidence of early rebleeding is 0.9 - 3.6 % . In the present study , the incidence of early re - bleeding is 0 . 9 - 3.6 % .

At present , there is very little study on the re - bleeding after embolization of ruptured aneurysm , which is mainly focused on the causes of re - bleeding . In the analysis of the relevant risk factors , there are some differences in the analysis of the relevant risk factors . The main consideration may be related to the age of the patient , the history of hypertension , the size of the aneurysm , the width of the neck and the degree of embolization of the aneurysm .

This study retrospectively analyzed the incidence and mortality of the interventional therapy center in our hospital after interventional therapy , collected the clinical data and image data , analyzed the risk factors of early and delayed rebleeding after embolization , provided the theoretical basis for the risk assessment of postoperative hemorrhage after embolization , and provided a reference for the treatment of re - bleeding after embolization .

Purpose

To study the incidence , risk factors and treatment methods of early and delayed rebleeding after embolization of ruptured intracranial aneurysms , and to provide a theoretical basis for the risk of postoperative rebleeding before operation , and to provide a reference for the treatment of postoperative rebleeding .

method

Retrospective analysis of the data of patients with ruptured intracranial aneurysms treated by the interventional therapy center of the Pearl River Hospital of the South Medical University from January 2002 to January 2014 ( the patients with other cerebrovascular diseases such as cerebral arteriovenous malformations and arteriovenous fistula have been excluded ) . All the statistical data were analyzed by SPSS 13.0 statistical analysis system . All the statistical data were analyzed by SPSS 13.0 statistical analysis system .

Results

Early re - bleeding after embolization : From January 2002 to January 2014 , a total of 1,950 patients with ruptured intracranial aneurysms received intravascular interventional therapy at the interventional therapy center of the Pearl River Hospital of the South Medical University . Among all the patients with ruptured aneurysms , 18 patients experienced early re - bleeding , the incidence rate was 1.24 % , the mortality was 10 cases , the mortality rate was 55.6 % . The average time of early re - bleeding was 4.3 鹵 3.3 days . Of the 18 patients with rebleeding , 2 cases had conservative treatment ;
3 cases were treated with endovascular embolization .
2 patients underwent aneurysm clipping ;
2 cases of bilateral lateral ventricle drainage ;
1 routine hematoma evacuation was performed in 10 cases of external drainage ;
6 cases of hematoma were removed + debone flap decompression ;
In all 952 patients with ruptured intracranial aneurysms , there were 3 cases with moderate disability , 2 cases with moderate disability , 3 cases with severe disability and 10 cases of death .

Conclusion

Early re - bleeding after ruptured aneurysm embolization is the most serious complication of endovascular interventional therapy . The results show that the incidence of early re - bleeding after embolization of ruptured intracranial aneurysms is low , but the prognosis is worse . The independent risk factors of early re - bleeding are the history of hypertension , anterior communicating aneurysm , clinical condition difference of imaging ( Hunt - Hess3 - 5 ) and incomplete embolization .
The hemorrhagic cerebrospinal fluid can be released as early as possible under the precondition of safety . Under the condition of the condition , it is feasible to set up the spinal canal , accelerate the release of the hemorrhagic cerebral spinal fluid , reduce the irritation to the cerebral vessels and prevent the secondary ischemic brain damage caused by cerebral vascular spasm .
When the bleeding amount is large or the clinical manifestation is serious , the hematoma removal operation should be carried out immediately , and it is preferable that the aneurysm clipping procedure be performed in the same period , so that the bleeding can be avoided again , and the decompression of the bone flap can be performed according to the circumstances .
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R739.41

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