【摘要】：目的： 本研究擬通過回顧性臨床病例分析，探究顱內(nèi)破裂微小動(dòng)脈瘤的治療時(shí)機(jī)、治療方法以及預(yù)后的的相關(guān)因素，為臨床治療顱內(nèi)破裂微小動(dòng)脈瘤提供參考和依據(jù)。 方法： 1病例來源：回顧性分析2013年2月至2014年2月河北醫(yī)科大學(xué)第二醫(yī)院東院區(qū)顱內(nèi)破裂動(dòng)脈瘤所致蛛網(wǎng)膜下腔出血患者共156例，其中微小動(dòng)脈瘤病歷資料35例，共44個(gè)動(dòng)脈瘤。住院期間未行治療的微小動(dòng)脈瘤4例（6個(gè)微小動(dòng)脈瘤）。對(duì)剩余31例患者的性別、年齡、動(dòng)脈瘤部位、大小、頸寬、入院時(shí)GCS評(píng)分、Hunt-Hess分級(jí)、fisher分級(jí)、高血壓及冠心病病史等伴發(fā)疾病、動(dòng)脈瘤處理方式、手術(shù)時(shí)機(jī)、圍手術(shù)期并發(fā)癥、GOS評(píng)分及術(shù)后隨訪等資料逐一登記，建立Access數(shù)據(jù)庫。2病例納入標(biāo)準(zhǔn)：①患者入院時(shí)根據(jù)病史、影像學(xué)資料或腰椎穿刺證實(shí)為自發(fā)性蛛網(wǎng)膜下腔出血；②入院后行頭顱CTA或者3D-DSA證實(shí)為由動(dòng)脈瘤破裂引起并排除外傷性蛛網(wǎng)膜下腔出血、假性動(dòng)脈瘤、動(dòng)靜脈畸形、煙霧病或煙霧綜合征、動(dòng)靜脈瘺等其他原因引起的SAH；③動(dòng)脈瘤最大直徑應(yīng)≤3mm，單發(fā)或者多發(fā)可伴有除微小動(dòng)脈瘤之外的腦血管疾��；④微小動(dòng)脈瘤的治療方式為顯微夾閉或者介入栓塞。凡符合上述標(biāo)準(zhǔn)即可診斷為顱內(nèi)破裂微小動(dòng)脈瘤，均可納入研究。3資料描述與統(tǒng)計(jì)：計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(±s)表示；計(jì)數(shù)資料以構(gòu)成比或率表示，兩組病例分析采用Fisher確切概率法和兩獨(dú)立樣本的非參數(shù)檢驗(yàn)，各個(gè)因素與預(yù)后的關(guān)系采用雙變量的相關(guān)分析，用SPSS13.0軟件對(duì)上述臨床病例資料進(jìn)行統(tǒng)計(jì)學(xué)分析，檢驗(yàn)水準(zhǔn)取α=0.05。 結(jié)果： 1年齡和性別：本組顱內(nèi)破裂微小動(dòng)脈瘤性蛛網(wǎng)膜下腔出血患者的年齡范圍為31~77歲，平均年齡（55.19±9.81）歲，40~60歲患者18例，占58.06%，此年齡段可能是微小動(dòng)脈瘤發(fā)病的高危階段；男性9例（29.03%），女性22例（70.97%），其中15例女性(48.39%)年齡在50歲以上，提示激素水平的改變也可能一定程度上影響動(dòng)脈瘤的形成。兩治療組間的年齡和性別比較均無統(tǒng)計(jì)學(xué)意義（P0.05）。 2動(dòng)脈瘤情況及伴發(fā)疾病：頸內(nèi)動(dòng)脈系統(tǒng)33個(gè)（86.84%），椎-基底動(dòng)脈系統(tǒng)5個(gè)（13.16%）；瘤體平均直徑（2.31±0.67）mm，瘤頸平均寬度（2.06±0.82）mm；伴高血壓16例（51.61%），伴糖尿病4例（12.90%），伴冠心病2例（6.45%），有吸煙飲酒等不良習(xí)慣7例（22.58%）。兩治療組間微小動(dòng)脈瘤的部位、直徑、瘤頸比及伴發(fā)疾病比較均無統(tǒng)計(jì)學(xué)意義（P0.05)。 3術(shù)前fisher及Hunt-Hess分級(jí)：術(shù)前fisher分級(jí)I~II級(jí)14例（45.16%），III~IV級(jí)17例（54.84%）；Hunt-Hess分級(jí)I~II級(jí)26例（80.65%），III~V級(jí)5例（19.35%）。采用血管內(nèi)栓塞（介入組）治療18例，顯微外科夾閉（顯外組）治療13例。兩治療組間術(shù)前fisher分級(jí)及Hunt-Hess分級(jí)比較均無統(tǒng)計(jì)學(xué)意義（P0.05)。 4治療時(shí)機(jī)、圍手術(shù)期并發(fā)癥及住院時(shí)間：發(fā)病24h內(nèi)手術(shù)19例（61.29%），3d內(nèi)手術(shù)21例（67.74%）,3d手術(shù)10例（32.26%）；圍手術(shù)期并發(fā)癥包括出血性事件4例（12.90%）、缺血性事件5例（16.13%）、遲發(fā)腦血管痙攣8例（25.81%）、MODS1例（3.23%）、顱內(nèi)感染1例（3.23%）、肺部感染15例（48.39%）、低蛋白血癥19例（61.29%）及癲癇發(fā)作2例（6.45%）；介入組平均住院時(shí)間（12.94±10.51）天，顯外組平均住院時(shí)間（21.38±18.31）天。兩治療組間治療時(shí)機(jī)、圍手術(shù)期并發(fā)癥及住院時(shí)間比較均無統(tǒng)計(jì)學(xué)意義（P0.05）。 5預(yù)后與隨訪：微小動(dòng)脈瘤以1.5mm為標(biāo)準(zhǔn)，分為直徑＜1.5mm組和直徑1.5~3mm組，預(yù)后良好率（出院時(shí)GOS4~5分）分別是0%和76.92%，兩者預(yù)后結(jié)果比較有統(tǒng)計(jì)學(xué)意義（P＜0.05）；以瘤頸/瘤體為1/2為標(biāo)準(zhǔn)，分為寬頸動(dòng)脈瘤(瘤頸/瘤體1/2)和窄頸動(dòng)脈瘤(瘤頸/瘤體＜1/2)，預(yù)后良好率（出院時(shí)GOS4~5分）分別是59.09%和66.67%，兩者預(yù)后結(jié)果比較無統(tǒng)計(jì)學(xué)意義（P0.05）；多發(fā)動(dòng)脈瘤7例（預(yù)后良好率57.14%），單發(fā)動(dòng)脈瘤24例（預(yù)后良好率66.67%），兩者預(yù)后比較無統(tǒng)計(jì)學(xué)意義（P0.05）；微小動(dòng)脈瘤伴有狹窄或胚胎型大腦后動(dòng)脈時(shí)，其預(yù)后比較無統(tǒng)計(jì)學(xué)意義（P0.05）；介入栓塞術(shù)中行支架輔助和普通栓塞的預(yù)后良好率（出院時(shí)GOS4~5分）分別為71.43%和81.82%，兩者預(yù)后比較無統(tǒng)計(jì)學(xué)意義（P0.05）；術(shù)后即時(shí)GOS評(píng)分介入組和顯外組的預(yù)后良好率（GOS4~5分）分別是72.22%和23.08%，兩組治療結(jié)果有統(tǒng)計(jì)學(xué)差異（P＜0.05）；出院時(shí)GOS評(píng)分介入組和顯外組的預(yù)后良好率(GOS4~5分)分別是77.78%和23.08%，兩組治療結(jié)果有統(tǒng)計(jì)學(xué)差異（P＜0.05）；術(shù)后隨訪時(shí)間2~8個(gè)月，術(shù)后3個(gè)月隨訪19例，介入組和顯外組的預(yù)后良好率(GOS4~5分）分別是80.00%和55.56%，兩組病例預(yù)后無統(tǒng)計(jì)學(xué)意義（P0.05）；影像學(xué)隨訪17例，復(fù)查CTA及DSA檢查均未見動(dòng)脈瘤復(fù)發(fā)，頭顱CT提示蛛網(wǎng)膜下腔出血吸收完全。 6預(yù)后相關(guān)因素：術(shù)前Hunt-Hess分級(jí)與GOS評(píng)分負(fù)相關(guān)，Rs1=-0.500（P1＜0.01），即術(shù)前Hunt-Hess分級(jí)越高，GOS評(píng)分越低，預(yù)后越差；fisher分級(jí)與GOS評(píng)分負(fù)相關(guān)，Rs2=-0.539（P2＜0.01），即術(shù)前fisher分級(jí)越高，GOS評(píng)分越低，預(yù)后越差。術(shù)前GCS評(píng)分與GOS評(píng)分正相關(guān)，Rs3=0.505（P3＜0.01），即術(shù)前GCS評(píng)分越高，GOS評(píng)分越高，預(yù)后越好。而年齡、手術(shù)時(shí)機(jī)與GOS評(píng)分無明顯相關(guān)性（P0.05）。 結(jié)論： 本研究發(fā)現(xiàn)40~60歲可能是微小動(dòng)脈瘤發(fā)病的高危階段；激素水平的改變可能一定程度上影響微小動(dòng)脈瘤的形成；微小動(dòng)脈瘤的瘤頸寬窄、是否伴有狹窄及胚胎型大腦后動(dòng)脈、是否運(yùn)用支架及動(dòng)脈瘤是否多發(fā)對(duì)預(yù)后無影響；微小動(dòng)脈瘤直徑在1.5~3.0mm之間的患者較直徑1.5mm的患者預(yù)后好；介入栓塞和顯微夾閉手術(shù)均適宜的情況下，盡可能選擇介入栓塞治療，其近期預(yù)后效果較好；術(shù)前fisher分級(jí)和Hunt-Hess分級(jí)越高，預(yù)后越差，術(shù)前GCS評(píng)分越高，預(yù)后越好，而年齡、手術(shù)時(shí)機(jī)與預(yù)后無明顯相關(guān)性。
[Abstract]:Objective:
The purpose of this study is to explore the treatment time, treatment and prognosis of intracranial ruptured small aneurysms by retrospective clinical case analysis, and to provide reference and basis for the clinical treatment of intracranial ruptured small aneurysms.
Method:
1 source of cases: a retrospective analysis of 156 cases of subarachnoid hemorrhage caused by aneurysm of intracranial aneurysm in the Eastern Hospital of the second hospital of Hebei Medical University from February 2013 to February 2014, including 35 cases of small aneurysm records, 44 aneurysms. 4 cases of minor aneurysms (6 tiny aneurysms) were not treated during hospitalization. The remaining 31 cases were in the remaining 31 cases. The sex, age, age, aneurysm site, size, neck width, GCS score at admission, Hunt-Hess classification, Fisher classification, hypertension and coronary heart disease history and other associated diseases, aneurysm treatment methods, operation timing, perioperative complications, GOS score and postoperative follow-up were registered one by one, and Access database.2 cases were included in the standard: (1) patients: (1) The patients were admitted to spontaneous subarachnoid hemorrhage according to medical history, imaging data or lumbar puncture; 2. After admission, the head CTA or 3D-DSA proved to be caused by aneurysm rupture and excluded from traumatic subarachnoid hemorrhage, pseudoaneurysm, arteriovenous malformation, moyamoya disease, smoke syndrome, arteriovenous fistula and other causes. SAH; (3) the maximum diameter of the aneurysm should be less than 3mm. Single or multiple hair can be accompanied by cerebral vascular diseases other than small aneurysms. (4) the treatment of small aneurysms is microscopic occlusion or interventional embolization. All of these can be diagnosed as intracranial rupture microaneurysms, which can be included in the study of.3 data and Statistics: measurement capital The material was expressed with mean standard deviation (+ s), and the count data were expressed by the ratio or rate of composition. The two groups of cases were analyzed by the exact probability method of Fisher and the nonparametric test of the two independent samples. The relationship between the factors and the prognosis was analyzed by the bivariate correlation analysis. The data of the above clinical cases were statistically analyzed with SPSS13.0 software, and the test level was tested. Alpha =0.05.
Result:
1 age and sex: the age range of the group of intracranial ruptured small aneurysmal subarachnoid hemorrhage in this group was 31~77 years, the average age (55.19 + 9.81) years, and 18 cases of 40~60 years old, accounting for 58.06%. This age segment may be the high risk stage of the onset of small aneurysms; 9 cases (29.03%) and 22 women (70.97%), 15 women (48.39%) age. At the age of 50, the changes in the level of hormone may also affect the formation of the aneurysm to some extent. There is no statistically significant difference in age and sex between the two groups (P0.05).
2 aneurysms and associated diseases: the internal carotid artery system 33 (86.84%), the vertebral basilar artery system 5 (13.16%), the average diameter of the tumor (2.31 + 0.67) mm, the average width of the tumor neck (2.06 + 0.82), 16 cases (51.61%) with hypertension, diabetes 4 cases (12.90%), coronary heart disease and unhealthy habits, such as smoking and drinking. There was no significant difference in the location, diameter, tumor neck ratio and accompanying diseases between the groups (P0.05).
3 preoperative Fisher and Hunt-Hess classification: preoperative Fisher grade I~II level 14 cases (45.16%), III~IV Class 17 cases (54.84%); Hunt-Hess grading I~II class 26 cases (80.65%), III~V grade 5 cases (19.35%). 18 cases were treated by intravascular embolization (interventional group) and 13 cases were treated with microsurgical clipping (external group). The preoperative Fisher classification and Hunt-Hess grading comparison between the two treatment groups were compared. There was no statistical significance (P0.05).
4 the timing of treatment, perioperative complications and hospitalization time: 19 cases in 24h (61.29%), 21 cases (67.74%) and 10 3D surgery (32.26%); perioperative complications including hemorrhagic events 4 cases (12.90%), 5 cases (16.13%) of ischemic events, 61.29% cases of delayed cerebral vasospasm (25.81%), MODS1 cases, intracranial infection cases, lungs There were 15 cases (48.39%), 19 cases of hypoproteinemia (61.29%) and 2 cases of epileptic seizures (6.45%), the average hospitalization time (12.94 + 10.51) days in the intervention group (12.94 + 10.51) days, and the average time of admission (21.38 + 18.31) days (21.38 + 18.31) days. There was no significant difference between the perioperative complications and the time of hospitalization (P0.05).
5 the prognosis and follow-up: the small aneurysm was divided into group 1.5mm and 1.5~3mm in diameter with 1.5mm as the standard. The good prognosis (GOS4~5 score at discharge) was 0% and 76.92%, respectively, and the prognosis was statistically significant (P < 0.05). The tumor neck / tumor body was the standard, and it was divided into wide neck aneurysm (tumor neck / tumor 1/2) and narrow neck aneurysm (tumor). The prognosis was 59.09% and 66.67%, respectively, and the prognosis was 59.09% and 66.67% respectively. The prognosis was not statistically significant (P0.05), 7 cases of multiple aneurysms (good prognosis rate 57.14%), 24 cases of single aneurysm (good prognosis rate 66.67%), the prognosis was not statistically significant (P0.05), small aneurysm accompanied by stenosis or embryo. The prognosis of the posterior cerebral artery was not statistically significant (P0.05). The good prognosis of stent assisted and common embolization (GOS4~5 scores at discharge) in interventional embolization was 71.43% and 81.82%, respectively, and there was no statistical significance (P0.05), and the prognosis of the intervention group and the exter group (GOS4~5 score) after the operation were respectively. The results were 72.22% and 23.08% in the two groups (P < 0.05); the prognosis of the GOS score in the intervention group and the exo group was 77.78% and 23.08%, respectively, and the two groups were statistically different (P < 0.05); the follow-up time was 2~8 months after the operation, 19 patients were followed up for 3 months, and the prognosis of the intervention group and the exo group was good. The rate (GOS4~5 score) was 80% and 55.56% respectively. The prognosis of the two groups was not statistically significant (P0.05); 17 cases were followed up by imaging, and no recurrence of aneurysm was found in CTA and DSA examination. The skull CT showed that the subarachnoid hemorrhage was absorbed completely.
6 prognostic factors: preoperative Hunt-Hess grading was negatively correlated with GOS score, Rs1=-0.500 (P1 < 0.01), that is, the higher the Hunt-Hess grading before operation, the lower the GOS score, the worse the prognosis; the Fisher classification is negatively correlated with GOS score, Rs2=-0.539 (P2 < 0.01), that is, the higher the preoperative Fisher classification, the lower the GOS score and the worse the prognosis. Rs3=0.505 (P3 < 0.01), that is, the higher the preoperative GCS score and the higher the GOS score, the better the prognosis. There was no significant correlation between age, operation time and GOS score (P0.05).
Conclusion:
This study found that 40~60 years may be a high risk stage for the onset of small aneurysms; changes in hormone levels may affect the formation of small aneurysms to some extent; the narrowing of the neck of the small aneurysm, the complication of the stenosis and the embryonic posterior cerebral artery, whether or not the stent and aneurysms have no effect on the prognosis; small arteries The patients with a diameter of 1.5~3.0mm had better prognosis than those in the diameter 1.5mm. Interventional embolization and microsurgical clipping were all suitable for the treatment of interventional embolization. The prognosis was better in the near future. The higher the Fisher grading and Hunt-Hess classification before operation, the worse the prognosis, the higher the preoperative GCS score, the better the prognosis, and the age and operation. There was no significant correlation between the timing and prognosis.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R739.41

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