脑动脉瘤显微手术治疗及脑血管痉挛的综合防治

目的探讨脑动脉瘤破裂出血后的最佳手术时机和方法,分析影响脑动脉瘤患者预后的因素,探讨防治脑血管痉挛的最佳措施.方法回顾性分析412例脑动脉瘤患者的临床资料,着重探讨不同时期开颅手术的效果和急性期锁孔手术的相对适应证,分析影响颅内动脉瘤患者预后的因素,比较各种防治脑血管痉挛措施的效果.结果使用常规开颅显微手术治疗361例,其中急性期手术222例,92%动脉瘤夹闭成功;发病后4～14d手术63例;延期手术76例.非急性期手术患者在等待手术期间发生动脉瘤再破裂出血27例(27/139).经眉眶上锁孔入路动脉瘤夹闭31例.未行手术治疗20例.术后脑血管痉挛的总发生率为45.5%,其中静脉联合使用尼莫同加硫酸镁组为32.7%;尼莫同加环孢菌素-A组为33.3%.术后3个月时预后良好333例,中残29例,重残及植物人15例,死亡23例,自动出院12例.病程中有意识障碍、癫痫发作、动脉瘤多次破裂的预后较差.结论脑动脉瘤一旦发现应积极争取早期手术治疗,锁孔手术同样适合急性期手术.病程中有意识障碍、癫痫发作、病情危重及动脉瘤多次破裂是影响患者预后的重要因素.静脉联合使用尼莫同加硫酸镁或尼莫同加环孢菌素-A是防治脑血管痉挛的较好方法.

Microsurgery of cerebral aneurysms and combined prevention of cerebral vasospasm

Objective To explore the best timing and method of t reating ruptured cerebral aneurysms and analyze prognostic factors of patients w ith ruptured cerebral aneurysms, and to investigate the best method to prevent cerebral vasospasm.Methods The clinical data of 412 cases wi th cerebral aneurysms were retrospectively analyzed. The craniotomic operat ive effects during different periods and relative indication of key hole operati on in acute stage were investigated, while the prognostic factors of patients we re analyzed and many methods of preventing cerebral vasospasm were compared. Results A total of 361 cases underwent microsurgery by regular craniotomy, including 222 cases were operated during acute period and 92% of an eurysms were successfully clipped, 63 cases were operated from 4 days to 14 days and 76 cases were operated after 14 days postaneusymal rupture. Rerupture happe ned in 27 cases without operation in acute stage.Thirty-one cases were operated during acute stage via supraorbital key hole. Twenty cases were not operated.Th e total incidence of cerebral vasospasm was 45.5%. The incidence of cerebral vas ospasm was 32.7% in group of those treated with nimotop and magnesium sulpha te and was 33.3% in group of those treated with nimotop and cyclosporine A. Good recovery happened in 333 cases, middle morbidity in 29 cases, severe morbid ity in 15 cases and death in 23 cases. The patients with coma, epilepsy, reruptu re or poor hunt's grade had poor outcome.Conclusion The early operation should be performed once the aneurysm was found.The key hole operation is also suitable to be done during acute stage. The following factors, such as coma, epilepsy, rerupture and poor hunt's grade, are very important to patient s' outcomes. It is a better method that nimotop and magnesium sulphate or nimo top and cyclosporine are used to prevent cerebral vasospasm.