单纯弹簧圈栓塞治疗颅内破裂宽颈动脉瘤的安全性和有效性

目的 探讨颅内宽颈动脉瘤破裂后急性期使用单纯弹簧圈栓塞治疗的安全性和有效性。方法 前瞻性研究。纳入2017年6月—2018年5月首都医科大学宣武医院神经外科符合要求的颅内破裂宽颈动脉瘤60例,其中男22例、女38例,年龄38～85(57±11)岁。术前Hunt-Hess分级Ⅰ级16例,Ⅱ级23例,Ⅲ级16例,Ⅳ级4例,Ⅴ级1例;Fisher分级Ⅰ级7例,Ⅱ级36例,Ⅲ级11例,Ⅳ级6例。患者均行单纯弹簧圈栓塞治疗,观察患者术后恢复情况、手术相关并发症发生情况。术后定期随访,复查数字减影血管造影(DSA)或者CT血管成像、MR血管成像,末次随访时按照Raymond分级标准评价动脉瘤闭塞情况,采用改良Rankin量表(mRS)评价患者预后情况。结果 60例患者均顺利完成手术。术中发生动脉瘤破裂1例,因出血量较少,术后予以脑室穿刺外引流后好转。术后即刻DSA造影检查显示,Raymond Ⅰ级(动脉瘤完全闭塞)51例,Raymond Ⅱ级(动脉瘤瘤颈显影)9例。患者术后住院期间死亡2例,其中1例于术后第13天死于感染性休克,1例于术后第19天死于肺部感染后呼吸衰竭。患者出院时mRS评分0～2分47例,3分8例,4分2例,5分1例。58例患者均获随访,随访时间24～36(29.3±2.2)个月。随访期间无新发出血或缺血性卒中表现,末次随访时mRS评分0～2分者53例(53/58,91.4%),3分4例(4/58,6.9%),4分1例(1/58,1.7%);53例预后良好,5例预后不良。末次随访时,Raymond Ⅰ级53例(53/58,91.4%);Raymond Ⅱ级5例(5/58,8.6%),其中小型前交通动脉瘤2例、胚胎型大脑后动脉伴中型后交通动脉动脉瘤1例、小型大脑中动脉分叉部动脉瘤1例。结论 颅内破裂宽颈动脉瘤急性期采用单纯弹簧圈栓塞治疗,具有较高的安全性和有效性,但是需要严格把握手术适应证,且术者应具有一定的手术操作技能。

Study on the safety and efficacy of coiling alone for the treatment of ruptured intracranial wide-necked aneurysms

Objective To evaluate the safety and efficacy of coiling alone for the treatment of ruptured intracranial wide-necked aneurysms at the acute stage.Methods This prospective study was conducted from June 2017 to May 2018, and 60 patients with ruptured intracranial wide-necked aneurysm treated in the Department of Neurosurgery, Xuanwu Hospital were included. The patients included 22 males and 38 females with age 38-85(57±11)years. Pre-operative Hunt-Hess grade of class Ⅰ was designated in 16 cases, class Ⅱ in 23 cases, class Ⅲ in 16 cases, class Ⅳ in four cases, and class Ⅴ in one case. Fisher class Ⅰ was designated in seven cases, class Ⅱ in 36 cases, class Ⅲ in 11 cases, and class Ⅳ in six cases. The patients were treated with coiling embolization, and the post-operative recovery and the occurrence of surgery-related complications were observed. Regular follow-up was conducted. At the last follow-up, aneurysm occlusion was evaluated according to the Raymond classification by digital substraction angiography(DSA)/computerized tomography angiography/magnetic resonance angiography, and the prognosis was evaluated based on the modified Rankin scale(mRS).Results All 60 patients completed the operation successfully. Intra-operative rupture occurred in one case, which recovered well after extra-ventricular drainage. Post-operative DSA showed that the Raymond grade Ⅰ (aneurysm complete occlusion) in 51 cases, and Raymond grade Ⅱ (aneurysm neck remained) in nine cases. Two patients died during hospitalization, one died of septic shock 13 days after surgery, and one died of respiratory failure following pulmonary infection 19 days after surgery. The patients were evaluated with mRS at discharge, including grade 0-2 in 47 cases, grade 3 in eight cases, grade 4 in two cases, and grade 5 in one case. All 58 patients were followed up for 24-36 (29.3±2.2) months. During the follow-up period, no neurological symptoms, such as bleeding or ischemia, were observed. At the last follow-up, 53 cases were recorded with mRS score of 0-2 (53/58,91.4%), four cases with a score of 3 (4/58, 6.9%), and one case with a score of 4 (1/58, 1.7%). Moreover, 53 cases had a good prognosis, and five cases had a poor prognosis. At the last follow-up, according to the Raymond classification, 53 patients were Raymond grade Ⅰ, and 5 patients were Raymond grade Ⅱ, including 2 cases of small anterior communicating artery aneurysms, 1 case of embryonic posterior cerebral artery with medium posterior communicating artery aneurysm, and one case of small middle cerebral artery aneurysms.Conclusions The treatment of coiling alone for the treatment of ruptured intracranial wide-necked aneurysms in acute stage is relatively safe and effective, but requires rigorous selection of appropriate cases and certain surgical skills.