【摘要】：目的探討動脈瘤性蛛網(wǎng)膜下腔出血患者的不同手術方式,比較其預后、手術并發(fā)癥、動脈瘤殘留、復發(fā)率,并對影響療效的各種因素進行分析。方法 回顧性分析廣西醫(yī)科大學一附院神經(jīng)外科2008年1月至2013年12月間的蛛網(wǎng)膜下腔出血434例。據(jù)手術方式分為動脈瘤瘤頸夾閉組(178例)和血管內(nèi)栓塞治療組(256例)。分析其Hunt-Hess分級、Fisher分級、動脈瘤的大小、部位、瘤頸特征、血管痙攣情況、手術并發(fā)癥、動脈瘤閉塞程度、去骨瓣減壓率、腦積水發(fā)生率、出院時臨床評估、影像學和臨床隨訪結(jié)果等。對可能影響動脈瘤夾閉及栓塞效果的因素進行多因素分析。結(jié)果 本研究中出院時開顱夾閉組預后良好124例(69.66%),預后不良54例(30.33%),死亡7例(3.93%)；術后發(fā)生腦積水45例(25.28%)。動脈瘤殘留10例(5.61%),術后再出血1例(0.74%),3例動脈瘤復發(fā)(2.22%)。介入栓塞組臨床評估良好180例(70.31%),預后不良76例(29.69%),死亡8例(3.13%)；非致密栓塞47例(18.35%),術后發(fā)生腦積水79例(30.85%)；術后再出血10例(7.52%),動脈瘤復發(fā)42例(31.57%)。開顱夾閉組與介入栓塞組預后GOS無差別(P=0.884)。Hunt-Hess分級對患者GOS預后有顯著影響(P=0.000)。手術夾閉組術后再出血、動脈瘤殘留、動脈瘤復發(fā)及腦積水發(fā)生率均較介入栓塞組低。兩組共行去骨瓣減壓44例,GOS組間、Hunt-Hess分級組間、Fisher分級組間行去骨瓣減壓率差別有統(tǒng)計學意義。本研究中行開顱夾閉術后造影或CTA顯示：達到完全夾閉程度的動脈瘤168枚(94.38%),手術夾閉組術后3-6個月共隨訪到135例,術后動脈瘤殘留10例中有1例再出血(死亡),3例動脈瘤復發(fā)。單因素分析腦萎縮(P=0.899),動脈瘤的大小(P=0.156),動脈瘤部位(P=0.210),瘤頸特征(P=0.971),瘤頸穿支血管(P=0.232),顱內(nèi)動脈粥樣硬化(P=0.990),術中破裂(P=0.729),使用多枚永久動脈瘤夾(P=0.577)不是動脈瘤夾閉效果的影響因素。多因素分析顯示Fisher分級(P=0.0091)、腦脊液引流(P=0.0103)、術中臨時阻斷技術(P0.0001),術中熒光造影(P=0.0363)是顱內(nèi)動脈瘤達到完全夾閉的獨立影響因素。介入栓塞組術后即刻造影達致密栓塞的動脈瘤217枚(82.19%),非致密栓塞47枚(17.8%)。術后3-6個月隨訪到133例,其中致密栓塞86例中動脈瘤復發(fā)3例,無再出血病例。非致密栓塞47例全部獲得隨訪,動脈瘤復發(fā)39例,8例進一步血栓形成,術后再出血10例(7.52%)。單因素分析動脈瘤部位(P=0.114),血管痙攣(P=0.283),術中動脈瘤破裂(P=0.664),瘤頸特征(P=0.835),Hunt-Hess分級(P=0.106)不是動脈瘤致密栓塞的影響因素。多因素分析結(jié)果顯示小型動脈瘤(P0.001)、囊性動脈瘤(P=0.0003)、支架輔助栓塞(P=0.0046)是顱內(nèi)動脈瘤致密栓塞的獨立影響因素。結(jié)論1.兩種治療方式均有效的治療顱內(nèi)動脈瘤。兩組間GOS預后比較無統(tǒng)計學差別,對所有的臨床和形態(tài)學因素均應考慮,針對患者個性化治療。2.手術夾閉組術后再出血、瘤頸殘留、動脈瘤再通及腦積水發(fā)生率均較介入栓塞組低。3.在Hunt-Hess I-III級患者中,GOS預后均較好,在Hunt-HessIV-V級患者中GOS預后均較差。Hunt-Hess高分級常合并Fisher高分級,合并腦內(nèi)較大血腫(幕上血腫"g30ml,幕下血腫"g10m1)時,需行去骨瓣加壓或結(jié)合腦脊液外引流。4.患者腦萎縮、顱內(nèi)動脈粥樣硬化、動脈瘤大小、動脈瘤位置、瘤頸特征、瘤頸有無穿支、術中破裂與動脈瘤夾閉效果無直接影響；Fisher分級、腦脊液引流、術中臨時阻斷技術、術中熒光造影是顱內(nèi)動脈瘤達到完全夾閉的獨立影響因素。清除血腫、通暢腦脊液引流、術中臨時阻斷技術及熒光造影有利于動脈瘤完全夾閉。5.動脈瘤位置、瘤頸特征、血管痙攣、術中破裂、Hunt-Hess分級與動脈瘤栓塞程度無關；動脈瘤形態(tài)、動脈瘤大小以及栓塞治療方式是動脈瘤致密栓塞的獨立影響因素。囊性動脈瘤、小型動脈瘤、支架輔助栓塞有助于達到動脈瘤的致密栓塞。
[Abstract]:Objective To study the different operation methods of the patients with aneurysmal subarachnoid hemorrhage, to compare the prognosis, the operative complications, the residual rate of the aneurysm and the recurrence rate, and to analyze the factors that affect the curative effect. Methods 434 cases of subarachnoid hemorrhage from January 2008 to December 2013 were analyzed retrospectively. The operation was divided into the aneurysm neck clamp group (178 cases) and the endovascular embolization treatment group (256 cases). The Hunt-Hess classification, the Fisher classification, the size of the aneurysm, the location of the aneurysm, the characteristics of the neck, the conditions of the vasospasm, the surgical complications, the degree of occlusion of the aneurysm, the rate of decompression of the bone flap, the rate of hydrocephalus, the clinical evaluation at the time of discharge, the imaging and clinical follow-up results, and the like were analyzed. Multi-factor analysis of factors that might affect the clipping and embolization effects of the aneurysm. Results The outcome of the study was 124 (69.66%),54 (30.33%),7 (3.93%), and 45 (25.28%). There were 10 cases (5.61%) of aneurysm, one case (0.74%) after operation, and 3 cases of aneurysm recurrence (2.22%). The clinical evaluation of the interventional embolization group was 180 (70.31%), the prognosis was poor in 76 (29.69%), the death was 8 (3.13%), the non-dense embolism was 47 (18.35%), the postoperative hydrocephalus was 79 (30.85%), the postoperative rebleeding was 10 (7.52%), and the aneurysm recurrence was 42 (31.57%). There was no difference (P = 0.884) between the closed group of the craniotomy and the prognosis of the interventional embolization group (P = 0.884). The Hunt-Hess classification had a significant effect on the prognosis of the patients with GOS (P = 0.000). The incidence of rebleeding, aneurysm residue, aneurysm recurrence and hydrocephalus in the operation group was lower than that of the interventional embolization group. There was a significant difference in the rate of decompression of the bone flap between the two groups in 44 patients, the GOS group, the Hunt-Hess classification group and the Fisher classification group. In this study, a total of 168 (94.38%) aneurysms were observed after the operation, and in the operation group, a total of 135 aneurysms (94.38%) were observed, and 135 cases were followed up 3-6 months after the operation, and one case of rebleeding (death) was found in 10 cases of the postoperative aneurysm, and 3 cases of the aneurysm recurrence. One factor analysis of the brain atrophy (P = 0.899), the size of the aneurysm (P = 0.156), the aneurysm site (P = 0.210), the neck of the aneurysm (P = 0.971), the neck of the tumor (P = 0.232), the intracranial atherosclerosis (P = 0.990), the intraoperative rupture (P = 0.729), The use of multiple permanent aneurysm clips (P = 0.577) is not a factor in the effect of aneurysm clipping. The multi-factor analysis showed Fisher's classification (P = 0.0091), cerebrospinal fluid drainage (P = 0.0103), and temporary blocking in the operation (P = 0.0001), and intraoperative fluorescence (P = 0.0363) was an independent factor of the complete clamp closure of the intracranial aneurysm. There were 217 aneurysms (82.19%) and non-dense embolism (17.8%). The 3-6-month follow-up was followed up to 133 cases, of which there were 3 cases of aneurysm recurrence and no re-bleeding in 86 cases of dense embolism. The follow-up was obtained in 47 cases of non-dense embolism,39 cases of aneurysm recurrence,8 cases of further thrombosis and 10 cases of rebleeding after operation (7.52%). Single factor analysis of aneurysm site (P = 0.114), vasospasm (P = 0.283), intraoperative aneurysm rupture (P = 0.664), neck feature (P = 0.835), Hunt-Hess grade (P = 0.106) was not an influence factor for aneurysm dense embolization. The multi-factor analysis showed that the small aneurysm (P0.001), the cystic aneurysm (P = 0.0003), the stent-assisted embolization (P = 0.0046) were the independent factors of the tight embolization of the intracranial aneurysm. Conclusion 1. Both treatments were effective in the treatment of intracranial aneurysms. There was no statistical difference between the two groups of GOS, and all the clinical and morphological factors should be considered. The incidence of rebleeding, neck, aneurysm and hydrocephalus in the surgical clip group was lower than that of the interventional embolization group. In the Hunt-Hess I-III patients, the GOS prognosis was better and the GOS prognosis was poor in the Hunt-Hess IV-V patients. The Hunt-Hess high grade was often combined with Fisher's high grade and combined with a large hematoma in the brain (supratentorial hematomas "g30ml, subside hematomas" g10m1), to which the bone flap was to be pressurized or combined with the external drainage of the CSF. The patient's brain atrophy, the intracranial atherosclerosis, the size of the aneurysm, the location of the aneurysm, the characteristics of the neck of the tumor, the presence or absence of a penetrating branch in the neck of the aneurysm, no direct effect on the effect of the rupture of the aneurysm and the clipping of the aneurysm, the Fisher classification, the drainage of the cerebrospinal fluid, the temporary blocking technique in the operation, Intraoperative fluorography was an independent factor in the complete clamp closure of the intracranial aneurysm. The removal of the hematoma, the smooth drainage of the cerebrospinal fluid, the temporary blocking technique during the operation and the fluorescence contrast are beneficial to the complete occlusion of the aneurysm. The location of the aneurysm, the neck of the neck, the vasospasm, the intraoperative rupture, the Hunt-Hess classification were not related to the degree of aneurysm embolization; the morphology of the aneurysm, the size of the aneurysm, and the way of embolization were the independent factors of the embolization of the aneurysm. Cystic aneurysms, small aneurysms, and stent-assisted embolization help to achieve a tight embolization of the aneurysm.
【學位授予單位】：廣西醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R651.1

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