持续腰大池引流治疗动脉瘤性蛛网膜下腔出血46例

目的探讨持续腰大池引流治疗动脉瘤性蛛网膜下腔出血的临床效果和安全性。方法 2009年1月—2011年12月,我科对46例动脉瘤性蛛网膜下腔出血患者在其动脉瘤栓塞后进行持续腰大池引流,将该组病人作为治疗组;将2006年6月—2008年12月收治的在动脉瘤栓塞后采取常规腰椎穿刺的37例动脉瘤性蛛网下腔出血患者作为对照组,对两组患者头痛程度、脑血管痉挛程度、脑积水等有关临床资料进行回顾性分析。结果治疗组患者头痛程度、脑血管痉挛程度、脑积水发生率均明显低于对照组(P<0.05)。结论持续腰大池引流对动脉瘤性蛛网膜下腔出血的治疗是安全的,具有取材方便、操作简单、并发症少的特点,能够明显降低动脉瘤性蛛网膜下腔出血患者头痛及脑血管痉挛程度、降低脑积水的发生率。     

电解可脱式弹簧圈栓塞颅内动脉瘤的临床观察

目的　探讨电解可脱簧圈 (GDC)治疗颅内动脉瘤的介入手术指征。术前评估方法、并发症和疗效。方法　 2 0 0 0年 8月到 2 0 0 3年 11月对 10例 12枚颅内动脉瘤患者施行GDC栓塞术。其中 9例为破裂动脉瘤。 8例行急诊栓塞手术 ,在DSA动态监视下完成。术后腰椎蛛网膜下腔持续引流 ,并给予高血容量、血液稀释治疗。结果　动脉瘤完全闭塞 9例 ,1例死亡。术后随访 2～ 2 2个月 ,1例重残 ,1例有轻度神经功能异常 ,其余恢复良好。结论　短期随访结果表明 ,GDC栓塞颅内动脉具有微创、安全、效果可靠的优点。致密填塞动脉瘤疗效可靠。部分填塞可能导致动脉瘤继续扩大 ,破裂出血。破裂动脉瘤应急诊栓塞治疗 ,术后腰椎蛛网膜下腔持续引流 ,可明显提高疗效。     

术中打开Liliequist膜对动脉瘤性蛛网膜下腔出血所致慢性脑积水的预防研究

动脉瘤性蛛网膜下腔出血(SAH)后慢性脑积水是指动脉瘤破裂导致蛛网膜下腔出血2周后发生或持续存在的脑积水。慢性脑积水的发生可使患者病情加重,引起神经功能障碍,预后不良[1]。Sheehan等[2]对897例蛛网膜下腔出血的研究发现,慢性脑积水的出现概率为25%。慢性脑积水严重影响了患者的生存质量,2005-01~2012-01我们对298例前循环动脉瘤性蛛网膜下腔出血患者进行了     

联合血管内外神经介入技术治疗急性期破裂颅内动脉瘤

目的　评估联合血管内外神经介入技术治疗急性期破裂颅内动脉瘤 (aneurysm ,AN)的疗效。方法　对 4 0例急性破裂期AN采用电解脱弹簧圈栓塞 ,随后穿刺腰蛛网膜下腔 ,导丝导向的微导管在透视下插管至枕大池 ,2h后注入 10万U尿激酶 (UK)溶解血块并经微导管持续引流血性脑脊液。根据CT复查结果决定是否继续注射UK。结果　AN栓塞及枕大池插管均获成功 ,无技术相关并发症 ,术后 3～ 7d时的CT见所有患者脑池内的出血消失。除 1例有一过性症状性脑血管痉挛 (CVS)外 ,其余患者无症状性CVS、所有患者无AN再出血。结论　联合血管内外神经介入技术既闭塞了AN ,又清除了蛛网膜下腔积血 ,可防止再出血和继发性CVS的发生 ,达到了对因、对症治疗的双重目的。     

颅内动脉瘤破裂早期介入治疗的临床价值

目的探讨颅内动脉瘤破裂后早期行数字减影血管造影(DSA)诊断价值并介入栓塞治疗的临床价值。方法对在我院治疗的38例自发性蛛网膜下腔出血患者行头颅CT扫描及早期DSA检查,并行血管内微弹簧圈栓塞治疗及或手术夹闭,包括GDC34例,手术夹闭4例。38例患者按Hunt-Hess分级:Ⅰ级30例、Ⅱ级6例、Ⅲ级1例、Ⅳ级1例,所有病例均行DSA造影及CT扫描。结果 CT扫描均提示不同程度的自发性蛛网膜下腔出血;脑血管DSA造影诊断:前交通动脉瘤13例,后交通动脉瘤16例,大脑中动脉瘤7例,颈内动脉分叉部2例。介入栓塞及手术夹闭成功36例,占94.7%。36例随访3～35个月无再次出血,全部病例CT复查显示弹簧圈形态、位置无改变,30例6个月后复查DSA未见动脉瘤复发。2例后交通复杂动脉瘤介入栓塞失败,家属不愿手术治疗,他们分别于术后1周及1月后死亡。结论对颅内动脉瘤破裂患者需尽早行数字减影血管造影(DSA)作出早期诊断,早期进行弹簧圈血管内栓塞治疗;DSA在诊断,治疗及患者随访中均发挥非常重要的作用。     

电解可脱弹簧圈栓塞治疗H&HⅣ级和Ⅴ级的动脉瘤

目的　 对于蛛网膜下腔出血H&HⅣ级和Ⅴ级动脉瘤患者的治疗时机和方法一直是有争论的。很多文献报告手术治疗改进了临床预后、降低了病死率。也有很多H&HⅣ级和Ⅴ级动脉瘤患者被排除在治疗外。目前动脉瘤的血管内治疗日益增多 ,本文探讨H&HⅣ级和Ⅴ级动脉瘤患者的超早期电解可脱弹簧圈栓塞治疗方法和评估疗效。方法　H&HⅣ级和Ⅴ级的动脉瘤患者 2 6例 ,共 2 8个动脉瘤。动脉瘤破裂后 2 4h内行超选GDC或EDC栓塞 ,有脑室铸形或脑积水栓塞后行脑室外引流 9例 ,3例行开颅单纯去骨瓣减压术 ,术后“三高”治疗。结果　H&HⅣ级 18例 ,占 6 9.2 % ;H&HⅤ级 8例 ,占 30 .8%。动脉瘤完全栓塞 10 0 %为 18枚 (6 4 .3% )。术后GOSⅠ级和Ⅱ级 14例 (6 1.1%Ⅳ级 11例 ,Ⅴ级 3例 37.5 % )占 5 3.8% ,2例严重神经功障碍 ,死亡 10例 (38.5 % )。随访 2个月～ 4年 ,无动脉瘤再出血。结论　H&HⅣ级和Ⅴ级动脉瘤患者虽然临床状况差 ,血管痉挛发生率高 ,但超早期通常都能顺利进行动脉瘤的栓塞治疗 ,辅助行脑室外引流等微侵袭治疗方法。虽然仍有较高的致残和病死率 ,但多数患者取得了满意的疗效。     

64排CT灌注及血管成像对蛛网膜下腔出血后脑血管痉挛的诊断价值

目的：探讨64排CT脑血流灌注（ CTP）联合CT脑血管成像（ CTA）在判断蛛网膜下腔出血患者脑血管痉挛诊断中的价值。方法收集蛛网膜下腔出血患者37例,通过64排螺旋CTP及CTA检查,检出脑动脉瘤,同时以灌注参数评估蛛网膜下腔出血后脑血管痉挛的变化情况。结果研究中37例患者,CTA检出动脉瘤35例38个,CTP联合CTA检查,共检出血管痉挛23例,出血后急性期（3天）,检出血管痉挛5例,其余为出血后4～10天检出,其中有7例轻度脑血管痉挛,8例患者为中度脑血管痉挛,8例显示为重度脑血管痉挛,未检出血管痉挛14例中,发生局部脑低灌注者6例。结论 CTA联合CTP检查不仅能够诊断SAH原因,并能同时显示SAH后脑血管痉挛的情况,有助于对SAH患者预后的判断,同时给临床治疗提供指导。     

旋转DSA及三维重建技术在颅内动脉瘤介入治疗中的价值

目的 :分析旋转DSA及三维重建技术对颅内动脉瘤栓塞治疗和手术治疗的价值。方法 :10 0例蛛网膜下腔出血的患者除进行常规全脑血管造影外 ,对颅内的双侧椎动脉、颈内动脉进行旋转DSA图像采集及三维重建 ;对 82例经旋转DSA及三维重建证实为颅内动脉瘤的病例进行介入栓塞治疗或手术夹闭治疗 ,术后行旋转DSA检查及图像的三维重建 ,评价介入栓塞治疗或手术夹闭治疗的效果。结果 :10 0例蛛网膜下腔出血患者中 ,全脑血管造影检出动脉瘤 76例 ;经旋转DSA采集及图像三维重建后 ,检出动脉瘤 82例。其中 71例行GDC或EDC介入栓塞治疗 ,11例行手术夹闭治疗。术后经旋转DSA及三维重建证实 ,71例介入栓塞的病例中 ,67例全部栓塞 ,4例 90 %栓塞。 11例手术夹闭病例均完全夹闭。结论 :旋转DSA及三维重建技术可以明显提高颅内动脉瘤的检出率 ;能够多角度立体观察、直观清晰地显示动脉瘤的大小、形态、瘤颈的宽度及与载瘤动脉的关系 ;为介入栓塞治疗或手术夹闭治疗提供精确的数据 ;评价动脉瘤介入栓塞治疗或手术夹闭治疗的效果。     

Hunt-Hess Ⅳ～Ⅴ级蛛网膜下腔出血的早期病因诊断及治疗

目的：探讨Hunt-HessⅣ～Ⅴ级蛛网膜下腔出血（SAH）的早期病因诊断方法及治疗原则，并客观评价其治疗效果。方法：对31例SAH患者发病后7d内进行CT及DSA检查，寻找SAH的原因，明确SAH均为脑动脉瘤破裂所致。明确病因后，即刻采用电解可脱性弹簧圈（GDC）进行动脉瘤囊内栓塞，术后早期处理出血并行有效的对症治疗。对于动脉瘤直径和瘤颈宽度不同患者的疗效和病死率进行比较，结果经X^2检验。结果：31例患者经CT、DSA检查，均明确诊断。SAH均为脑动脉瘤破裂所致，所有动脉瘤均经栓塞治疗。其中动脉瘤腔100％闭塞26例、95％闭塞者3例、90％闭塞者2例。术中并发脑血管痉挛5例，1例动脉瘤复发并经第2次补充GDC栓塞而治愈。29．0％（9／31）出现与SAH有关的永久性后遗症。治疗结果根据Glasgow预后评分：Ⅰ级6例、Ⅱ级9例、Ⅲ级4例、Ⅳ级2例、Ⅴ级10例；病死率32．3％（10／31）。术后随访3～68个月均无再出血。动脉瘤直径11～25mm组7例，死亡5例；5～10mm组21例，死亡4例，2组比较差异有统计学意义（r=6．60，P〈0．05）。瘤颈≤4mm组24例，动脉瘤完全栓塞23例，死亡5例；瘤颈〉4mm组7例，动脉瘤完全栓塞3例，死亡5例，2组动脉瘤完全栓塞率和病死率差异均有统计学意义（分别X^2=11．24、P〈0．01，X^2=6．35、P〈0．05）。结论：CT及DSA可对Hunt-HessⅣ～Ⅴ级SAH进行早期病因诊断；对已破裂的动脉瘤早期采用电解可脱性弹簧圈囊内栓塞，术后早期处理出血并有效的对症治疗，是提高动脉瘤性SAH治愈率和降低病死率及致残率的有效方法。     

破裂出血动脉瘤的早期栓塞治疗与脑血管痉挛

目的　分析血管内栓塞治疗急性破裂出血动脉瘤脑血管痉挛的发生及治疗。方法　Hunt HessⅠ～Ⅲ级并在发病后 72h内进行介入治疗的动脉瘤患者 32 9例 ,症状性血管痉挛的诊断根据迟发性神经功能损害 ,并有TCD和 (或 )脑血管造影的证据。结果　共发生症状性血管痉挛 6 2例 (18.2 % ) ,血管痉挛的发生率和Hunt Hess分级及Fisher分级有显著的相关关系 ,6 2例发生症状性脑血管痉挛患者中恢复良好 4 1例 ,中度致残 13例 ,重度致残 6例 ,死亡 2例。结论　GDC栓塞治疗动脉瘤后症状性血管痉挛的发生率并不高于常规手术治疗 ;放置腰椎蛛网膜下腔持续引流可能对降低症状性脑血管痉挛的发生有积极意义。     

Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils

BACKGROUND AND PURPOSE: Middle cerebral artery (MCA) aneurysms often have an unfavorable aneurysm geometry that might limit endovascular therapy. Our purpose was to analyze the feasibility, safety, and efficacy of coil embolization in a consecutive series of MCA aneurysms chosen for endovascular treatment. PATIENTS AND TECHNIQUES: Of 235 MCA aneurysms seen at our institution during the past 5 years, 36 patients harboring 38 MCA aneurysms were primarily selected for coil embolization: 18 patients had an acute subarachnoid hemorrhage (SAH), 16 of which were due to a ruptured MCA aneurysm. SAH was classified according to Hunt and Hess grade: I (5), II (7), III (5), IV (0), and V (1). RESULTS: Complete occlusion could be achieved in 33 of 38 aneurysms. In 5 aneurysms, coil embolization was not performed because of an unfavorable aneurysm geometry with a wide neck or incorporation of adjacent branches (3) or failed because of insecure coil placement (1) or severe vasospasm (1). Procedural complications included coil protrusion into the parent artery (1), and thromboembolic M2 occlusion (5), with recanalization in 4 of 5 cases. Of 8 aneurysms with initial subtotal occlusion, 3 progressed to total occlusion during follow-up. Three aneurysms had to be retreated, and no patient rebled. Glasgow Outcome Scale at 6 months for the patients with SAH (17/18) was good recovery (12), moderate disability (4), severe disability (0), persistent vegetative state (0), and death (1); outcomes for patients with an incidental aneurysm (17/18) were good recovery (16) and moderate disability (1). CONCLUSION: Endovascular coil embolization can be performed safely and effectively in selected MCA aneurysms. Initial subtotal aneurysm occlusion might progress to total occlusion.     

Combined endovascular treatment for both intracranial aneurysm and symptomatic vasospasm

BACKGROUND AND PURPOSE: The best strategy for treatment of subarachnoid hemorrhage due to ruptured cerebral aneurysm is obliteration of the aneurysm as soon as possible. Early surgery is desirable if the patient does not develop severe vasospasm or is clinically stable. However, if the patient has already developed severe vasospasm on admission, surgery may carry the risk of increasing the severity. We evaluated the safety and effectiveness of combined Guglielmi detachable coil (GDC) embolization and angioplasty in a single session for the treatment of ruptured aneurysms associated with symptomatic vasospasm. METHODS: From January 1992 to January 2001, 12 consecutive patients with ruptured aneurysms associated with symptomatic vasospasm were treated. Patients were classified as Hunt and Hess grade 2 (n = 1), 3 (n = 6), 4 (n = 4), or 5 (n = 1) and Fisher CT group 2 (n = 1), 3 (n = 10), or 4 (n = 1). They underwent GDC aneurysm occlusion and balloon angioplasty (n = 6), intraarterial papaverine infusion (n = 2), or both (n = 4) in a single session. In nine patients, aneurysm coil occlusion was performed first. RESULTS: Complete GDC occlusion was achieved in eight patients, a small neck remnant persisted in three, and embolization was incomplete in one patient. In all patients, angiographic improvement of vasospasm was obtained. In one patient, a thromboembolic complication occurred and was treated with urokinase. Clinical outcomes at discharge were good recovery in six, moderate disability in two, severe disability in three, or death in one. CONCLUSION: Endovascular treatment can be the first therapeutic option for ruptured aneurysms associated with severe vasospasm on admission. It offers some advantages over surgery in this setting, but these are balanced by the risk of thromboembolism.     

全脑血管CT血管成像 数字减影血管造影检查和介入栓塞治疗在颅内动脉瘤中的诊断和治疗价值

目的探讨全脑血管CT血管成像（CTA）、数字减影血管造影（DSA）检查及介入栓塞治疗在颅内动脉瘤中的诊断和治疗价值。方法回顾性分析我院26例颅内动脉瘤病例的CTA与DSA资料,其中14例接受颅内动脉瘤的介入栓塞治疗。结果 CTA和DSA在颅内动脉瘤检出情况无明显差异;就显示动脉瘤大小,形态及其载瘤动脉和周围血管方面DSA检查优于CTA检查。14例动脉瘤介入栓塞治疗患者中无1例死亡,术后行DSA血管造影显示动脉瘤完全栓塞;2例术中出现血管痉挛,使用药物后缓解。结论CTA可以作为筛选颅内动脉瘤的首选检查方法,DSA在观察动脉瘤附近重要的穿支动脉血管方面明显优于CTA;介入栓塞治疗颅内动脉瘤是安全有效的,可以明显减少动脉瘤再次破裂出血,改善预后。     

肾医源性出血的介入治疗

目的：探讨肾医源性出血介入治疗的可行性。方法：7例患者中2例为肾穿刺活检术,5例为肾微创外科治疗导致肾出血,DSA诊断明确后行血管内栓塞治疗。结果：DSA诊断为肾假性动脉瘤5例,动静脉瘘（arteriovenous fistula,AVF）2例,均行一次栓塞治疗后血尿停止,无严重并发症发生,随诊6～12个月,肾功能检查无异常。结论：血管内栓塞治疗肾医源性出血是一种安全、有效的治疗方法,在临床应用时应为首选的治疗方法。     

经颅多普勒在前循环动脉瘤破裂致脑血管痉挛中的应用价值

目的探讨经颅多普勒(TCD)在前循环动脉瘤破裂致症状性脑血管痉挛中的应用价值。方法回顾性分析我院神经外科2010年4月~2020年4月收治的前循环动脉瘤性蛛网膜下腔出血,诊断为症状性脑血管痉挛的患者62例,所有患者在发病后连续每天行TCD检查,连续观察大脑中动脉血流速度,诊断为症状性脑血管痉挛后行脑血管造影检查(DSA),并行选择性脑动脉内盐酸法舒地尔灌注治疗,治疗后继续每日TCD监测;以DSA结果为标准,对比分析TCD诊断脑血管痉挛的准确性,分析TCD与DSA诊断痉挛程度的一致性。结果62例症状性脑血管痉挛患者,男性26例,女性36例,平均年龄(57.7±7.5)岁,其中前交通动脉瘤9例,大脑中动脉瘤21例,后交通动脉瘤32例;临床诊断症状性脑血管痉挛后,TCD诊断脑血管痉挛57例,行DSA检查,61例证实血管痉挛;TCD检出率93.4%(57/61)。选择性脑血管灌注法舒地尔前后,TCD测量M1平均血流速度,轻度痉挛组分别是(130.8±6.4)cm/s、(83.8±14.6)cm/s,中度痉挛组分别是(171.3±12.8)cm/s、(82.3±8.5)cm/s,灌注治疗效果明显,TCD血流速度有明显差异。术后TCD继续监测,4例患者在TCD血流速度再次升高后复查DSA,证实并治疗。结论针对前循环动脉瘤破裂所致症状性脑血管痉挛,TCD筛查检出率高;选择性脑血管内灌注治疗前后TCD血流速度有明显差异,可预测和指导下一步的动脉内治疗,并可作为治疗后的复查手段。TCD检查是症状性脑血管痉挛安全、有效、便捷的筛查手段。     

A Less Invasive Approach for Ruptured Aneurysm with Intracranial Hematoma: Coil Embolization Followed by Clot Evacuation

Objective

The presence of an intracerebral hematoma from a ruptured aneurysm is a negative predictive factor and it is associated with high morbidity and mortality rates even though clot evacuation followed by the neck clipping is performed. Endovascular coil embolization is a useful alternative procedure to reduce the surgical morbidity and mortality rates. We report here on our experiences with the alternative option of endovascular coil placement followed by craniotomy for clot evacuation.

Materials and Methods

Among 312 patients who were admitted with intracerebral subarachnoid hemorrhage during the recent three years, 119 cases were treated via the endovascular approach. Nine cases were suspected to show aneurysmal intracerebral hemorrhage (ICH) on CT scan and they underwent emergency cerebral angiograms. We performed immediate coil embolization at the same session of angiographic examination, and this was followed by clot evacuation.

Results

Seven cases showed to have ruptured middle cerebral artery (MCA) aneurysms and two cases had internal carotid artery aneurysms. The clinical status on admission was Hunt-Hess grade (HHG) IV in seven patients and HHG III in two. Surgical evacuation of the clot was done immediately after the endovascular coil placement. The treatment results were a Glasgow Outcome Scale score of good recovery and moderate disability in six patients (66.7%). No mortality was recorded and no procedural morbidity was incurred by both the endovascular and direct craniotomy procedures.

Conclusion

The results indicate that the coil embolization followed by clot evacuation for the patients with aneurysmal ICH may be a less invasive and quite a valuable alternative treatment for this patient group, and this warrants further investigation.