三维数字减影血管造影血管虚拟内镜成像在颅内动脉瘤诊治中的作用

目的探讨三维数字减影血管造影（three dimensional digital subtraction angiography,3D DSA）血管虚拟内镜成像在颅内动脉瘤诊治中的作用。方法回顾性分析53例颅内动脉瘤三维DSA血管虚拟内镜成像资料并应用三维DSA血管虚拟内镜成像随访术后载瘤血管及瘤颈残留情况。三维的旋转数字图像由脑血管造影机球管和影像增强器的同步2次240°旋转获得,应用Volume Viewer软件对原始三维图像进行重建,固定密度值并选取感兴趣区,用Navigator软件进行血管虚拟内镜成像,观察血管腔内结构。结果 53例术前三维DSA血管虚拟内镜成像清晰,共检出动脉瘤62个,其中动脉瘤体有穿支血管发出19例（15例手术证实）,动脉瘤内有血栓形成7例（4例手术证实）,载瘤动脉内有动脉粥样硬化斑块5例（3例手术证实）。术后31例3D DSA随访：28例未见瘤颈残留,2例出现载瘤动脉轻度狭窄;2例弹簧圈突入载瘤动脉血管腔内;1例动脉瘤栓塞后瘤颈复发残留,再次开颅夹闭动脉瘤。结论三维DSA血管虚拟内镜成像是一种安全有效的评估颅内动脉瘤管腔结构的方法,不仅可以用于动脉瘤的术前判断,指导手术方式的选择,也可以用于动脉瘤术后的随访,为明确术后载瘤动脉及瘤颈情况提供依据。     

平板3D-DSA在颅内动脉瘤诊断和介入治疗中的价值

目的评估平板探测器三维数字减影血管造影（3D-DSA）技术在颅内动脉瘤诊断和介入治疗中的应用价值。方法对51例蛛网膜下腔出血的患者进行常规全脑血管DSA检查后,再行旋转DSA采集数据,利用工作站进行三维重建。分析3D-DSA与常规DSA对颅内动脉瘤显示的差异,评价3D-DSA对介入栓塞治疗的指导意义。结果常规DSA检出脑动脉瘤34例,经应用旋转DSA及三维重建后检出46例,其中35例进行介入血管内栓塞治疗,栓塞效果良好,11例行手术夹闭治疗。结论3D-DSA可显著提高颅内动脉瘤的检出率,能够直观清楚地显示动脉瘤详细全面的解剖信息,指导制定治疗计划,在脑动脉瘤的诊断和介入治疗中具有重要的价值。     

三维数字血管造影在颅内动脉瘤诊治中的应用

目的探讨三维数字血管造影(3D-RA)对颅内动脉瘤诊治的应用价值及其与常规DSA检查相比的优势。方法回顾资料完整的38例40枚颅内动脉瘤患者。分析全脑血管常规DSA造影及病变血管或病变疑似血管3D-RA检查和三维重建图像。分别观察记录常规DSA及3D-RA对颅内动脉瘤提供的诊断信息。24例采用手术开颅银夹夹闭动脉瘤治疗,14例采用血管内栓塞治疗。结果38例40枚颅内动脉瘤,其中前交通动脉瘤16枚,后交通动脉瘤13枚,大脑中动脉分叉部动脉瘤5枚,颈内动脉瘤3枚,椎基底动脉瘤2枚,小脑后下动脉瘤1枚;其中小型动脉瘤(动脉瘤体直径小于5mm)12枚,中型动脉瘤(动脉瘤体直径6~10mm)20枚,大型动脉瘤(动脉瘤体直径16~25mm)6枚,巨型动脉瘤(动脉瘤体直径大于25mm)2枚;动脉瘤呈囊袋状23枚,呈哑铃形12枚,不规则形4枚,梭形1枚;颅内动脉瘤单发36例,多发2例。常规DSA诊断动脉瘤37枚,占92.5%(37/40),3D-RA诊断动脉瘤40枚,占100%(40/40)。经与手术或血管内栓塞治疗结果比较,本组DSA诊断颅内动脉瘤敏感性92.5%,特异性100%,准确率96%。3D-RA诊断颅内动脉瘤敏感性及特异性均为100%,准确率100%。结论3D-RA能较常规DSA更好的显示颅内动脉瘤的形态、大小、瘤颈部及载瘤动脉与动脉瘤的关系、动脉瘤囊腔有无重要分支发出等等。     

外伤性鼻衄的血管内介入栓塞治疗

目的：探讨外伤性鼻衄的血管内介入栓塞治疗的策略和疗效。方法对10例行血管内介入栓塞治疗的外伤性鼻衄患者的临床资料进行了回顾性分析。结果全部病例均行脑血管造影检查,3例为颈内动脉海绵窦段破裂,其中两例脑血管造影为颈内动脉海绵窦段假性动脉瘤,采用弹簧圈栓塞破口、假性动脉瘤及闭塞同侧载瘤动脉,3例一次性栓塞破口、假性动脉瘤及载瘤动脉;7例为颈外动脉颌内动脉分支破裂,4例采用明胶海绵颗粒栓塞颌内动脉,即刻造影见颌内动脉远端不显影,3例采用弹簧圈栓塞颌内动脉,其中2例即刻造影弹簧圈远端破口不显影,1例颌内动脉破口大部分消失,同侧面动脉通过远端分支动脉向破口少量供血,2周后脑血管造影随访提示破口完全消失。6例随访3个月至2年,平均1.5年,无再出血及神经功能障碍。结论血管内介入治疗外伤性鼻衄是一种安全、微创和有效的治疗方法,外伤性鼻衄应尽早进行介入栓塞治疗。     

肾动脉假性动脉瘤的栓塞治疗

目的探讨经皮肾动脉造影及栓塞治疗肾动脉假性动脉瘤的临床价值。方法 2012年1月~2014年2月15例泌尿系结石术后尿道出血,经皮肾动脉造影诊断为肾动脉假性动脉瘤,导管超选择进入载瘤动脉近端,使用弹簧圈和明胶海绵栓塞载瘤动脉。结果 15例经肾动脉造影均能清晰显示假性动脉瘤,其中位于叶间动脉11例,弓状动脉3例和小叶间动脉1例,经导管弹簧圈栓塞后尿道出血停止。1例介入栓塞术后2 d再次出现尿道出血,再次栓塞后出血停止。栓塞术后2例出现一过性肾绞痛;7例体温37.8~39.3℃,持续3~8 d。15例随访3~24个月(平均15个月),无肾功能不全和尿道出血发生。结论经皮肾动脉造影和经导管栓塞治疗肾动脉假性动脉瘤安全、有效。     

Neuroform Atlas支架在颅内动脉分叉处宽颈动脉瘤栓塞中的应用体会

目的 探讨Neuroform Atlas支架在颅内动脉分叉处宽颈动脉瘤栓塞中的价值。方法 回顾性分析2021年1～9月16例采用Neuroform Atlas支架辅助弹簧圈栓塞治疗颅内动脉分叉处宽颈动脉瘤的临床和影像学资料。动脉瘤位于大脑中动脉分叉处8例，大脑前动脉分叉处4例，大脑前、中动脉分叉处2例，大脑前动脉A2远端分叉处1例，大脑后动脉P2分叉处1例。破裂动脉瘤10例(术前Hunt-Hess分级Ⅰ级6例，Ⅱ级2例，Ⅲ级2例),未破裂动脉瘤6例。结果 均在单一Neuroform Atlas支架辅助下完成栓塞，技术成功率100%。术后即刻造影显示动脉瘤完全闭塞13例，瘤颈残留2例，瘤体残留1例。术中及围手术期未观察到介入操作相关并发症。出院前改良Rankin量表(mRS)0～1分11例，2分3例，3分2例。16例随访时间3～14个月，(7.8±3.2)月。mRS评分0～1分14例，2分1例，3分1例。9例术后3～6个月行DSA,动脉瘤完全闭塞8例，瘤颈残留1例，9例均未见载瘤动脉狭窄或支架内闭塞。结论 Neuroform Atlas支架辅助弹簧圈栓塞治疗颅内动脉分叉处宽颈动脉瘤安全，...     

电解可脱性弹簧圈血管内栓塞颅内动脉瘤的技术及并发症防治

目的总结以电解可脱性弹簧圈(GDC)血管内栓塞治疗颅内动脉瘤的技术要点、并发症及其防治经验。方法采用GDC对168例颅内动脉瘤患者进行动脉瘤囊内栓塞。结果成功栓塞168个动脉瘤,其中100%闭塞的144个,95%闭塞的14个,90%闭塞的10个;全组6例死亡,死亡率3.6%。术中并发动脉瘤破裂3例,脑血管痉挛9例,脑梗死2例,术后弹簧圈末端逸出2例;3例复发者经二次补充GDC栓塞而治愈。随访5~54个月,全组术后均无再出血。结论动脉瘤的血管内治疗应根据病情进行个体化设计,并采用与之相应的栓塞技术才能最大限度的提高动脉瘤栓塞的治愈率、降低并发症。     

CT灌注成像评估颅内巨大动脉瘤患者行载瘤动脉闭塞术的脑血流动力学改变的价值

目的探讨研究CT灌注成像评估颅内巨大动脉瘤患者行载瘤动脉闭塞术的脑血流动力学改变的价值。方法将2014年1月至2016年1月入住本院22例颅内巨大动脉瘤患者作为研究对象,行载瘤动脉闭塞术后接受CT灌注成像,通过患者病侧与健侧的局部脑血容量(rCBF)、局部脑血容量(rCBV)、平均通过时间(MTT)和最大峰值时间(TTP)比值,评价疗效。结果载瘤动脉闭塞术前,CT灌注成像显示患侧大脑半球rCBF、rCBV明显下降,MTT和TTP显著延长;载瘤动脉闭塞术后,CT灌注成像显示患者脑血流灌注基本恢复正常;经治疗后,患者rCBF比值(1.02±0.33)、rCBV比值(1.01±0.33)明显高于治疗前(0.42±0.15、0.59±0.16),MTT比值(1.00±0.30)和TTP(1.34±0.34)比值明显低于治疗前(1.56±0.46、1.65±0.49),差异具有统计学意义(P0.05)。结论颅内巨大动脉瘤患者行载瘤动脉闭塞术后采用CT灌注成像,能够较为清晰的通过参数图及灌注参数比值反映患者脑血流动力学的改变情况,在临床治疗及诊断均具有一定的应用价值。     

颅内后循环动脉瘤的血管内介入治疗

目的总结颅内后循环动脉瘤的特点,探讨其血管内介入治疗的临床疗效。方法回顾性分析40例行血管内介入治疗的颅内后循环动脉瘤患者的临床和影像学资料、介入治疗过程,观察期效果及术后随访结果。结果 40例患者共发现42个后循环动脉瘤,均完成血管内介入治疗,其中8个行单纯弹簧圈栓塞,28个行支架辅助栓塞,1个行Onyx胶栓塞,5个动脉瘤及载瘤动脉同时闭塞。术后即刻DSA造影显示动脉瘤完全栓塞30个,近全栓塞6个,部分栓塞6个。术后6个月随访DSA造影显示动脉瘤完全栓塞36个,近全栓塞4个,部分栓塞1个。患者出院时行改良Rankin量表(mRS)评分,0分35例,1分3例,2分1例,1例死亡为6分;出院后3~6个月随访mRS评分0分38例,1分1例,无动脉瘤复发及新发神经功能障碍病例。结论颅内后循环动脉瘤具有特殊的临床与影像学表现,且复杂动脉瘤较为常见,对于颅内后循环动脉瘤,血管内介入治疗是一种安全有效的治疗方法。     

颅内动脉瘤囊内栓塞治疗中并发症的分析

目的 探讨颅内动脉瘤囊内治疗中并发症的发生原因及预防和处理的方法。方法 用可控性弹簧圈栓塞治疗的动脉瘤120例（125个）,其中22例（23个动脉瘤）发生并发症25例次（包括动脉瘤破裂、载瘤动脉血栓形成或其它原因所致的闭塞以及弹簧罪状脱出动脉瘤）,对其发生的原因及预防和治疗方法进行了回顾性分析。结果 22例出现并发症的动脉瘤患者中,动脉瘤破裂出血9例次,过度栓塞7例次,弹簧圈脱出7例次,血栓形成2例次,因并发症而死亡4例（3.33%),永久性神经功能障碍2例（1.67%);一过性神经功能障碍4例（3.33%)。栓塞技术、术中判断和处理的正确与否、动脉瘤和载瘤动脉的特点以及栓塞材料与并发症的发生和结局相关。结论 栓塞技术的提高,动脉瘤和载瘤动脉解剖的深入理解,术中发生情况的正确处理、栓塞材料的改进,有助于降低并发症的发生率改善其预后。     

经皮血管内支架成形术在颅内血管疾病的初步应用

目的：探讨支架置入技术在治疗颅内血管疾病中的应用价值。方法：回顾性分析了13例成功置入支架的手术经验,探讨颅内支架置入的适应证、技术可行性及并发症的预防。13例颅内血管病变包括有症状的颅内血管狭窄患者7例,其中大脑中动脉狭窄3例,颈内动脉床突上段狭窄1例,椎动脉颅内段狭窄3例;颅内宽颈动脉瘤5例,包括1例基底动脉起始段宽颈动脉瘤,2例海绵窦段巨大宽颈动脉瘤以及2例颈动脉-海绵窦瘘栓塞后海绵窦段宽颈假性动脉瘤;静脉窦狭窄1例。结果：7例有症状的颅骨血管狭窄患者在支架置入后狭窄血管明显扩张,从原来平均狭窄83％下降到5％,其中1例出现了与技术有关的并发症。5例宽颈动脉瘤患者（包括2例假性动脉瘤）通过支架辅助成功地达到了囊内栓塞。横窦狭窄患者在其一侧置入支架后,颅内压力明显下降,临床症状减轻,8个月后随访症状完全消失。结论：支架置入血管内成形技术,可以成功地应用于颅内血管疾病的治疗,但对于适应证的选择和长期的疗效有待于进一步的观察确定。     

Limitations of three-dimensional reconstructed computerized tomography angiography after clip placement for intracranial aneurysms

OBJECT: The authors compared the usefulness of three-dimensional (3D) reconstructed computerized tomography (CT) angiography with 3D digital subtraction (DS) angiography in assessing intracranial aneurysms after clip placement. A retrospective review of clinical cases was performed. METHODS: Between May 2001 and May 2003, 17 patients with a total of 20 intracranial aneurysms underwent 3D CT and 3D DS angiography following clip placement. The authors assessed the presence or absence of residual aneurysm necks and stenoocclusive changes in the parent artery and the neighboring artery. The efficacy of CT angiographic visualization was also evaluated. In 12 of the 20 aneurysms, both 3D modalities similarly demonstrated the residual aneurysm neck and stenoocclusive changes in the parent artery and neighboring artery. Three-dimensional CT angiography failed to demonstrate three of the aneurysms, and the studies were not considered suitable for evaluation because of the presence of metallic artifacts. In the remaining five studies, the 3D CT angiograms did not effectively demonstrate the neighboring and parent arteries. The detectability of residual aneurysm necks was correlated with the clip material and with the number of clips applied. CONCLUSIONS: Three-dimensional DS angiography is still necessary in cases involving multiple clips or with cobalt alloy clips because the clips appear as metal artifacts on 3D CT angiography.     

Pitfalls of endovascular treatment for cerebral aneurysms]

Seventeen cases of unclippable aneurysms were treated by the endovascular balloon technique. Nine of them involved the anterior circulation, and eight involved the posterior circulation. Eleven of them were treated by parent artery occlusion with detachable balloons. Three were treated by endosaccular balloon embolization, and three cases combined with AVMs were occluded using ethylene vinyl alcohol copolymer (EVAL) including feeding arteries of the AVMs. Embolic complications occurred in one case of an IC bifurcation giant aneurysm treated by parent artery occlusion. Ischemic complications also appeared in two cases of aneurysms treated by endosaccular balloon embolization. In one case, the thrombus in the aneurysm propagated into the parent artery and occluded it later. In another case, the displaced balloon had obliterated the parent artery 6 hours after the embolization. Parent artery occlusion is a safe way to treat internal carotid giant aneurysms. However, endosaccular treatment still has some problems, i.e., 1) maintaining the balloon's position to preserve the parent artery, 2) balloon migration into the clot, 3) rupture of the aneurysm during or after treatment. Our studies indicate that endosaccular balloon embolization is still a high risk procedure and should be used only in selected cases, until new embolic agents, such as detachable coils, become available.     

Surgery for giant intracranial aneurysms using advanced technology

PURPOSE: Outcome of surgery for giant intracranial aneurysms is still unsatisfactory. The reason for complications is occlusion of perforators or parent arteries by the aneurysmal clipping itself or temporary occlusion of the main arteries. We report the surgical outcome of treatment of giant aneurysms using several advanced techniques which we devised to prevent these complications. MATERIALS AND METHODS: The subjects were eight patients with giant intracranial aneurysms who underwent surgery during the recent five years. Six patients had ruptured and two had unruptured aneurysms. Aneurysms were located at the ICA in five and the MCA in three patients. Aneurysmal sizes ranged from 25 to 50 mm. Preoperative 3DCTA was performed to investigate the aneurysm and the surrounding vessels in all cases. Patients with unruptured aneurysms at the ICA underwent balloon occlusion tests to check the potential for safe temporary occlusion of the parent artery, with SEP monitoring and Xe-SPECT. Intraoperative angiography and neuroendoscopes were used to prevent problems and complications which might be caused by aneurysmal clipping. RESULTS: In seven of eight cases, the aneurysmal neck was completely obliterated with clips and in one case the aneurysm was trapped with STA-MCA anastomosis. Glasgow Outcome Scale of the patients showed good recovery in six, moderately disabled (MD) in one and dead in one. The patient demonstrating MD developed hemiparesis due to vasospasm. One patient died from rebleeding of the aneurysm caused by slippage of the aneurysmal clip despite the confirmation of complete obliteration by intraoperative angiography. CONCLUSIONS: A better surgical outcome of treatment for giant aneurysms was obtained by temporary clips whose placement was based on the results of balloon occlusion test, as well as the use of intraoperative angiography and neuroendoscopes.     

126例前交通动脉瘤的介入治疗

目的：探讨前交通动脉瘤介入治疗的特点,以提高临床疗效。方法：经血管内途径,采用可脱性弹簧圈对126例前交通动脉瘤患者行栓塞治疗,未能栓塞者多数行手术治疗。结果：成功栓塞109例,其中100％闭塞97例,95％－98％闭塞12例。17例栓塞未成功者,行外科手术治疗15例,2例因脑血管痉挛而未进行处理。123例患者治疗后痊愈;1例死亡;2例栓塞失败后未进行治疗的患者,分别随访5个月及1年,动脉瘤自愈。本组32例治疗后获随访3周－30个月,行脑血管造影,30例动脉瘤未见显影;2例复发,经再次栓塞后治愈。结论：多数前交通动脉瘤可经血管内栓塞治愈,不能行血管内治疗的可行外科手术治疗,极少数病例可自愈,但远期效果仍需行长期随访观察。     

电解可脱式铂金弹簧圈栓塞治疗颅内动脉瘤

目的报告使用电解可脱式铂金弹簧圈（ｇｕｇｌｉｅｌｍｉｄｅｔａｃｈａｂｌｅｃｏｉｌ,ＧＤＣ）治疗颅内动脉瘤的情况。方法气管内插管全麻和肝素抗凝下,经Ｔｒａｃｋｅｒ微导管放置ＧＤＣ栓塞颅内动脉瘤,必要时辅以重塑技术（ｒｅｍｏｄｅｌｉｎｇｔｅｃｈｎｉｑｕｅ,ＲＴ）。结果成功栓塞８例动脉瘤,其中５例为１００％栓塞,２例为９５％,１例为９０％。有４例既往用机械可脱式铂金弹簧圈（ＭＤＳ）无法安全栓塞或Ｍａｇ３Ｆ或２Ｆ微导管插管失败。无并发症。结论ＧＤＣ栓塞颅内动脉瘤安全可靠,效果良好,并可使部分ＭＤＳ无法栓塞或栓塞危险性较大的动脉瘤得以治疗。     

经旋转3D-DSA测量实验动脉瘤弹簧圈致密填塞的栓塞容积比率

目的：探讨致密填塞情况下,应用旋转三给数字减影血管造影（three dimension digital subtraction angiography,3D-DSA）的容积测量功能,测量实验性动脉瘤栓塞容积比率的可行性。方法：家养普通大白兔6只,体重3－4kg,应用显微外科技术在兔颈总动脉处建立实验性分叉动脉瘤6个,2周后行旋转血管造影,应用3D－DSA表面遮盖法（surfaceshaded display,SSD)三维重建动脉瘤并测量其容积,每个动脉瘤连续测量3次,计算其平均值,该平均值经球囊校正法线图校正后即为最终该动脉瘤的容积,用弹簧圈致密填塞动脉瘤,计算填塞所用弹簧圈的体积,该体积与所测动脉瘤的容积之比即为栓塞容积比率（volume embolization ration,VER）,结论：3D－DSA SSD法测量的VER范围在23．5％－32．5％之间,平均为27．4％,结论：实验性动脉瘤在弹簧圈密填塞时其最小栓塞容积比率为23．5％。     

Detachable balloon embolization therapy of posterior circulation intracranial aneurysms

Treatment of complex and surgically difficult intracranial aneurysms of the posterior circulation is now being performed with intravascular detachable balloon embolization techniques. The procedure is carried out under local anesthesia from a transfemoral arterial approach, which allows continuous neurological monitoring. Under fluoroscopic guidance, the balloon is propelled by blood flow through the intracranial circulation and in most cases, can be guided directly into the aneurysm, thus preserving the parent vessel. If an aneurysm neck is not present, test occlusion of the parent vessel is performed and, if tolerated, the balloon is detached. Twenty-six aneurysms in 25 patients have been treated by this technique. The aneurysms have involved the distal vertebral artery (five cases), the mid-basilar artery (six cases), the basilar artery (11 cases), and the posterior cerebral artery (four cases). The aneurysms varied in size and included three small (less than 12 mm), 15 large (12 to 25 mm), and eight giant (greater than 25 mm). Fifteen patients (60%) presented with hemorrhage and 10 patients (40%) with mass effect. In 17 cases (65%) direct balloon embolization of the aneurysm was achieved with preservation of the parent artery. In nine cases (35%), because of aneurysm location and size, occlusion of the parent vessel was performed. Complications from therapy included three cases of transient cerebral ischemia which resolved, three cases of stroke, and five deaths due to immediate or delayed aneurysm rupture. The follow-up period has ranged from 2 months to 43 months (mean 22.5 months). In cases where posterior circulation aneurysms have been difficult to treat by conventional neurosurgical techniques, intravascular detachable balloon embolization may offer an alternative therapeutic option.     

Computerized tomography angiography in patients with subarachnoid hemorrhage: from aneurysm detection to treatment without conventional angiography.

OBJECT: The purpose of this study was to determine prospectively whether and to what extent computerized tomography (CT) angiography can serve as the sole imaging method for a preoperative workup in patients with ruptured intracranial aneurysms. METHODS: During a 1-year period, all patients who presented to the authors' hospital with subarachnoid hemorrhage demonstrated by unenhanced CT scanning or lumbar puncture underwent CT angiography. Two radiologists evaluated the CT angiography source images and maximum intensity projection slabs and arrived at a consensus. They categorized the quality of the CT angiography as adequate or inadequate and classified aneurysms that were detected as definitely or possibly present. The parent artery of anterior communicating artery aneurysms was identified by asymmetrical anterior cerebral artery size and asymmetrical aneurysm location. The parent artery was indicated by the larger A1 segment in cases of asymmetrical A1 size. Only CT angiograms of adequate quality that revealed aneurysms classified as definitely present and with an unequivocal parent artery were presented to the neurosurgeons, who decided whether preoperative digital subtraction (DS) angiography should still be performed. Forty-nine of the 100 studied patients did not undergo surgery because of poor clinical condition, nonaneurysmal cause of the hemorrhage, or endovascular treatment of the ruptured aneurysm. Of the 51 patients who underwent surgery, radiologists required DS angiography in 17 patients; the imaging technique provided greater certainty in 13 instances. The neurosurgeons required DS angiography 11 times; this provided additional information in two instances. Twenty-three (45%) of the 51 patients were surgically treated successfully on the basis of CT angiography findings alone. CONCLUSIONS: Computerized tomography angiography can replace DS angiography as the preoperative neuroimaging technique in a substantial proportion of patients with ruptured intracranial aneurysms.