动脉瘤性蛛网膜下腔出血患者认知功能影响因素研究

目的研究动脉瘤性蛛网膜下腔出血（SAH）患者认知功能的动态变化及其影响因素。方法以简易智能量表评估入院时、出院时和出院后2个月患者的认知功能;以Hunt-Hess、GCS、手术方式、GOS、年龄、性别和入院时并发症为变量,研究其与SAH患者认知功能间的关系。结果 100例动脉瘤性SAH患者认知功能损害率入院时为37%,出院时60%,出院后2个月38%;出院时认知功能损害率高于入院时（χ2=10.590,P=0.001）和出院后2个月（χ2=9.684,P=0.002）;对出院时认知功能有显著影响的因素是Hunt-Hess、GOS和手术方式,对出院后2个月认知功能有显著影响的因素是GOS。结论动脉瘤性蛛网膜下腔出血患者存在一定程度的认知功能损害,并与一定的影响因素相关;血管内治疗有助于减轻认知功能的损害。     

不同处理方式对蛛网膜下腔出血预后的影响

目的 探讨开颅动脉瘤夹闭术和血管内栓塞治疗术对动脉瘤性蛛网膜下腔出血患者预后的影响。方法 自2009年1～9月,连续入选在我院神经内科急诊就诊,发病72小时内明确诊断的动脉瘤蛛网膜下腔出血患者,分为开颅动脉瘤夹闭和血管内栓塞治疗两组,比较两组患者术后7 d的美国国立卫生院神经功能缺损评分（National Institutes of Health Stroke Scale,NIHSS）、格拉斯哥昏迷量表（Glasgow Coma Scale,GCS）评分和病死率,采用改良的Ranking量表（modified Ranking Scale,mRS）评定两组患者术后30 d预后不良率。结果 研究中共入选86例患者,其中开颅动脉瘤夹闭术51例,血管内栓塞治疗术35例。两组术后7 dNIHSS评分、GCS评分及病死率差异无统计学意义。开颅动脉瘤夹闭组治疗30 d不良预后率（mRS＞2分）高于血管内栓塞治疗组（35.3% vs 14.3%）,差异有统计学意义（P =0.031）。结论 动脉瘤性蛛网膜下腔出血后早期进行血管内栓塞治疗术的短期预后优于开颅动脉瘤夹闭术。     

前交通动脉瘤患者认知功能研究

目的研究前交通动脉瘤患者认知功能变化。方法使用简易智能量表评估67例前交通动脉瘤手术治疗患者入院时、出院时和出院后3个月的认知功能。结果 67例前交通动脉瘤患者,在入院时出现认知功能损伤为28例(41.8%),出院时42例(62.7%),出院后3个月24例(36%),患者认知功能损害率出院时高于入院时和出院后3个月时。介入栓塞组和开颅夹闭组患者入院时认知功能损害率分别是33.3%和47.5%,出院时分别为29.6%和85%,出院后3个月时分别为14.8%和50%。结论通过对不同时间段、不同治疗方式的认知功能损害率比较,在前交通动脉瘤治疗过程中选择合适的手术方式及适时早期进行有效的康复治疗措施减少前交通动脉瘤认知功能损害。     

动脉瘤性蛛网膜下腔出血患者开颅夹闭术与介入栓塞术后认知功能的对比研究

目的探讨开颅夹闭术与介入栓塞术对动脉瘤性蛛网膜下腔出血(SAH)患者认知功能的影响。方法分析2015年7月—2017年12月,行开颅夹闭术或介入栓塞术治疗的122例动脉瘤性蛛网膜下腔出血患者的临床资料。采用简易精神状态检查(MMSE)量表对所有患者的认知功能进行评定;每例患者共进行4次MMSE评分:入院时(治疗前)、术后近期(术后2周)、中期(术后2个月)、远期(术后1年)。将患者按照手术治疗方式分为开颅夹闭组(42例)和介入栓塞组(80例),分别对比两组患者术前、近期、中期和远期的MMSE评分;并对不同时期认知功能障碍发生率进行比较。结果两组患者术前MMSE评分的差异无统计学意义(P>0.05);介入栓塞组在术后早期、中期及远期的MMSE评分均明显高于开颅夹闭组(均P<0.05)。开颅夹闭组患者在术后近期及中期的认知功能障碍发生率均明显高于介入栓塞组(均P<0.05);但在术后远期,两组患者认知功能障碍发生率的差异无统计学意义(P>0.05)。结论行开颅夹闭术的动脉瘤性蛛网膜下腔出血患者,术后近期及中期的认知功能障碍发生率明显高于介入栓塞术患者。介入栓塞治疗动脉瘤有助于减轻认知功能的损害。     

血管内治疗动脉瘤性蛛网膜下腔出血后认知功能损害与Claassen分级的关系

目的 探讨Claassen分级与动脉瘤性蛛网膜下腔出血(aSAH)后认知功能损害的关系.方法 对40例行血管内治疗的颅内动脉瘤破裂患者进行前瞻性研究,分析Claassen分级、动脉瘤部位、年龄与aSAH后认知功能损害的相关性.结果 多因素分析仅Claassen分级进入回归方程(P＜0.01);Classeen分级与总智商量表分存在负相关,两者Spearman相关系数为-0.398(P＜0.01);前交通动脉瘤患者与其他部位动脉瘤患者在总智商、言语智商、操作智商上差异无统计学意义(P＞0.05).结论 认知功能损害广泛存在于颅内动脉瘤破裂患者,SAH是破裂动脉瘤患者发生认知功能损害的主要原因.Claassen分级是预测患者发生认知功能损害的危险因素,分级越高认知损害发生的危险性越大;动脉瘤的部位与患者认知损害的发生及程度无明显相关性.     

动脉瘤性蛛网膜下腔出血后脑血管痉挛的治疗及临床分析

目的探讨颅内动脉瘤性蛛网膜下腔出血后脑血管痉挛的治疗方法。方法对动脉瘤性蛛网膜下腔出血71例患者的临床资料进行回顾性分析。结果71例均在出血后早期（72h内）行动脉瘤栓塞术或开颅动脉瘤夹闭术。术后均予尼莫地平,脑脊液引流,3-H疗法等治疗,共发生症状性血管痉挛22例,12例恢复良好,9例中重度残疾,1例死亡。结论尽早行开颅动脉瘤夹闭术或动脉瘤栓塞术,术后予尼莫地平、脑脊液引流、3-H疗法等是治疗和预防动脉瘤破裂后脑血管痉挛的有效方法。     

动脉瘤性蛛网膜下腔出血后认知功能损害特点

大量研究表明动脉瘤性蛛网膜下腔出血患者虽然可以达到临床上的"完全康复",但该类患者部分却遗留长期认知功能损害,程度较轻微,临床不易察觉,可使用神经心理学量表对认知功能进行全面检测,目前认为认知功能损害的发生与蛛网膜下腔出血严重程度相关性最高。本文查阅近年国内外关于动脉瘤性蛛网膜下腔出血后认知损害的文献综述如下。     

前交通动脉瘤切除术中临时血管夹闭对患者认知功能的影响

目的探讨前交通动脉(ACoA)瘤破裂引起的蛛网膜下腔出血病人手术切除动脉瘤临时血管夹闭对大脑额叶功能的影响。方法选择61例ACoA瘤破裂出血后96 h内进行早期手术的病人,所有病人手术前的Hunt-Hess评分1或2分,其中33例在切除动脉瘤时给予临时血管夹闭(A组),28例没有进行血管夹闭(B组);另选30例年龄相匹配的无神经或精神疾病的住院病人作为对照组(C组)。结果 A组病人临时血管夹闭的平均持续时间为(7.9±2.7)(6～15)min,临床或放射学检查无明显卒中,但长期随访发现有持续的认知功能缺损的表现,尤其是血管夹闭持续时间>9 min者。B组病人长期随访未发现额叶功能损害的表现。结论 ACoA瘤破裂出血后,手术切除动脉瘤进行临时血管夹闭对缺血性损害之前发生的认知改变有负性影响,强调外科医生在手术时应注意夹闭时间,以免造成永久性认知功能损害。     

CT血管造影指导颅内破裂动脉瘤超早期手术

目的研究单一依靠CT血管造影(CTA)资料,在超早期手术夹闭破裂颅内动脉瘤的可行性。方法从2004年6月至2007年2月,共有125例自发性蛛网膜下腔出血病人行CTA检查。其中有78例在出血后72h内完成CTA检查,并对57例患者单一依靠CTA资料急诊行超早期动脉瘤夹闭术。结果125例自发性蛛网膜下腔出血患者中,有78例在出血后72h内完成CTA检查,71例发现颅内动脉瘤,其中有57例行超早期开颅动脉瘤夹闭术。57例超早期开颅手术动脉瘤患者,多发动脉瘤4例,共61个动脉瘤,术中夹闭动脉瘤60个,动脉瘤包裹1个。CTA能很好地显示动脉瘤的大小、形态、同载瘤动脉及周边骨性结构的关系,为手术提供了足够的有用信息。结论容积重建成像CTA是一种可靠、无创的快速诊断颅内动脉瘤的方法,能为破裂动脉瘤的超早期夹闭手术提供详实的影像学资料,满足在急诊状况下开颅夹闭手术所需。     

腰大池置管外引流术在动脉瘤术后早期应用分析

目的探讨术后早期行腰大池置管外引流术对缓解动脉瘤性蛛网膜下腔出血患者头痛症状和缩短病人住院时间的影响。方法将我科2010年6月至2012年5月收治的72例动脉瘤性蛛网膜下腔出血患者分层随机分为两组：动脉瘤夹闭术后早期（24。48h）行腰大池置管外引流组（A组,39例）术后未行腰大池置管外引流分组（B组,33例）。结果A、B组患者的术后住院时间分别为（16．89±2．51）d和（21．42±2．54）d,两者相差显著（P〈0．05）。A、B组术后1周内头痛症状缓解率分别为74．36％（29／39）和15．15％（5／33）,两者相差显著（P〈0．05）。结论破裂动脉瘤夹闭术后早期（24～48h内）行腰大池置管外引流术,能够有效的减轻因蛛网膜下腔出血造成的头痛症状,缩短患者的住院时间。     

Severe cognitive impairment in aneurysmal subarachnoid hemorrhage: Predictors and relationship to functional outcome

BackgroundCognitive impairment is common after aneurysmal subarachnoid hemorrhage (SAH). However, compared to predictors of functional outcome, meaningful predictors of cognitive impairment are lacking.ObjectiveOur goal was to assess which factors during hospitalization can predict severe cognitive impairment in SAH patients, especially those who might otherwise be expected to have good functional outcomes. We hypothesized that the degree of early brain injury (EBI), vasospasm, and delayed neurological deterioration (DND) would predict worse cognitive outcomes.MethodsWe retrospectively reviewed SAH patient records from 2013 to 2019 to collect baseline information, clinical markers of EBI (Fisher, Hunt–Hess, and Glasgow Coma scores), vasospasm, and DND. Cognitive outcome was assessed by Montreal Cognitive Assessment (MoCA) and functional outcomes by modified Rankin Scale (mRS) at hospital discharge. SAH patients were compared to non-neurologic hospitalized controls. Among SAH patients, logistic regression analysis was used to identify predictors of severe cognitive impairment defined as a MoCA score <22.ResultsWe screened 288 SAH and 80 control patients. Cognitive outcomes assessed via MoCA at discharge were available in 105 SAH patients. Most of these patients had good functional outcome at discharge with a mean mRS of 1.8±1.3. Approximately 56.2% of SAH patients had MoCA scores <22 compared to 28.7% of controls. Among SAH patients, modified Fisher scale was an independent predictor of cognitive impairment after adjustment for baseline differences (OR 1.638, p=0.043). MoCA score correlated inversely with mRS (r=−0.3299, p=0.0006); however, among those with good functional outcome (mRS 0–2), 48.7% still exhibited cognitive impairment.ConclusionsSevere cognitive impairment is highly prevalent after SAH, even among patients with good functional outcome. Higher modified Fisher scale on admission is an independent risk factor for severe cognitive impairment. Cognitive screening is warranted in all SAH patients, regardless of functional outcome.     

Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study

OBJECTIVES: The debate on the timing of aneurysm surgery after subarachnoid haemorrhage (SAH) pivots on the balance of the temporal risk for fatal rebleeding versus the risk of surgical morbidity when operating early on an acutely injured brain. By following a strict management protocol for SAH, the hypothesis has been tested that in the modern arena of treatment for aneurysmal SAH the timing of surgery to secure supratentorial aneurysms does not affect surgical outcome. METHODS: Over a 6 year period, patients admitted with a diagnosis of SAH to a regional neurosurgical unit have been prospectively studied. All have been on a management protocol in which early transfer and resuscitation has been followed regardless of age and clinical condition. Angiographic investigation and surgery have been pursued in those who have been able to at least flex to pain. A total of 1168 patients (60.7% female, mean age 54.3) with proved SAH were received on median day 1 (86.4% arrived within 3 days) of the ictus. Of these, 784 (67.1%) showed aneurysms on angiography and were prepared for surgery. Those who received surgery for a supratentorial aneurysm within 21 days of the ictus were included in the final analysis (n=550). Patients with an initial negative angiogram, with posterior circulation aneurysms, or aneurysms treated by endovascular means, with aneurysms requiring emergency surgery for space occupying haematomas, with aneurysms which re-bled before surgery, and those who received very late surgery (after 21 days from ictus) were excluded. Surgical outcomes at hospital discharge and after 6 months were assessed using the Glasgow outcome score (GOS). Discharge destination and duration of stay in a neurosurgical ward were also documented. The influence of the timing of surgery (early group day 1-3 postictus, intermediate group day 4-10, or late group day 11-21) was analysed prospectively. RESULTS: 60.2% of cases fell into the early surgery group, 32.4% into the intermediate group, and 7.5% into the late operated group. Late surgery was due to delays in diagnosis, transfer, and logistic factors, but not clinical decision. The demographic characteristics, site of aneurysm, and clinical condition of the patients at the time of initial medical assessment were balanced in the three surgical timing groups. There was no significant difference in GOS between the surgical timing groups at 6 months (favourable GOS score 4 and 5: 83.2%, 80.5%, and 83.8% respectively; p=0.47, Kruskal-Wallis test). Outcome was favourable in 84% of patients under 65 years, and 70% in those over 65. The discharge destinations (home, referring hospital, nursing home, rehabilitation centre) showed no significant difference between surgical timing groups. There was no significant difference in mean time to discharge after admission to this hospital from the referring hospital (16.2, 16.2, and 14.6 days for early, intermediate, and late groups respectively; p=0.789, Analysis of variance (ANOVA)). As a result, there was reduction in the mean duration of total hospital inpatient stay in favour of the earliest operated patients (mean time 18.1, 22.0, and 28.3 days respectively; p=0.001. ANOVA showed that besides age, the only determinant of surgical outcome and duration of stay was presenting clinical grade (p<0.0005). CONCLUSION: The current management of patients presenting with SAH from anterior circulation aneurysms allows early surgery to be followed safely regardless of age. The only independent variables affecting outcome are age and clinical grade at presentation. The timing of surgery did not significantly affect surgical outcome, promoting a policy for early surgery that avoids the known risks of rebleeding and reduces inpatient stay.     

影像融合技术在颅内多发动脉瘤破裂出血后责任动脉瘤判断中的应用

目的 探讨影像融合技术在颅内多发动脉瘤破裂出血后责任动脉瘤判断中应用效果。方法 2016年1月至2020年8月前瞻性收治颅内多发动脉瘤破裂出血57例,术前将CT及CTA扫描DICOM格式原始数据导入3D Slicer软件进行影像融合,判断出血责任动脉瘤,并与开颅手术记录进行对比。结果 融合影像可以精确地显示蛛网膜下腔血肿与动脉瘤的关系。57例中,54例（94.7%）融合影像判断责任动脉瘤与手术记录一致,3例不一致（1例出血量小、2例出血量过多,无法根据血肿与动脉瘤的空间关系判定责任动脉瘤）。结论 颅内多发动脉瘤破裂出血病人,应用3D Slicer软件将CT与CTA数据进行影像融合,可以精确显示血肿与动脉瘤的空间关系,有助于判断破裂出血的责任动脉瘤。     

动脉瘤病人术后并发认知机能障碍的影响因素

目的 认知机能障碍是动脉瘤破裂后使病人失能的常见后遗症，故探讨动脉瘤破裂病人术后出现认知机能障碍原因及影响因素。方法 回顾性研究动脉瘤破裂手术治疗病人22例。参考病人术前Hunt—Hess分级，SAH Fisher评分及动脉瘤部位，探讨其与病人发生认知机能障碍的关系。结果 并发认知障碍8例；其中前交通动脉瘤表现为5例，左侧后交通动脉瘤2例，左侧大脑中动脉瘤1例。SAH Fisher评分3分6例，2分2例。发病时间：术后8～10d出现5例，14～16d2例，1例病人术后18d发病（已出院）。结论 结果表明，动脉瘤破裂手术病人并发认知功能障碍由多种综合因素导致。临床应早期重视病人术后认知功能障碍的防治，降低病人持久性认知机能障碍发病率，促进病人生活自理和社会活动参与能力。     

Angiogram-negative subarachnoid hemorrhage in the era of three dimensional rotational angiography.

BACKGROUND: Three dimensional rotational angiography (3DRA) is a powerful method for depicting intracranial vascular lesions because of its 3D imaging capability. The purpose of this study was to analyse if 3DRA had reduced the incidence of angiogram-negative subarchnoid haemorrhage (SAH) and which type of aneurysm tended to be overlooked with conventional digital subtraction angiography. METHOD: Angiogram-negative SAH was defined as present in those patients with SAH who had no demonstrable lesion revealed by more than two adequate cerebral angiograms. From January 1, 1992, to December 31, 2004, angiography was performed on 247 patients at the Yamaguchi University Hospital. Digital subtraction angiography (DSA) alone was used for 105 patients (DSA group) from 1992 to 2000. After the technology of 3DRA was introduced to our hospital in 2000, 142 patients were evaluated by 3DRA and DSA together (3DRA group). FINDINGS: The incidence of angiogram-negative SAH was 9/105 (8.6%) in the DSA group and 6/142 (4.2%) in the 3DRA group. 3DRA revealed six aneurysms not depicted by the conventional DSA, including a basilar tip aneurysm, anterior cerebral artery aneurysm and a basilar tip aneurysm originating from a previously clipped aneurysm. CONCLUSION: Three dimensional RA is more sensitive in detecting aneurysms, but in our study still produced a 4.2% rate of angiogram-negative SAH. Three dimensional RA has some advantages for evaluation, especially of complicated sites and previously clipped aneurysms because of its three dimensional imaging capability.     

Reducing length of stay in aneurysmal subarachnoid hemorrhage: A three year institutional experience

Hospital length of stay is a common metric of excellence in health care. With limited data evaluating hospital length of stay (LOS) and cost in subarachnoid hemorrhage (SAH), in this study we explore multiple prognostic factors and present our institutional experience in shortening LOS. 345 SAH patients were reviewed over a three year period. Patient demographics, hemorrhage grade, hospital course, hospital costs, and LOS were reviewed. Angiogram-negative SAH, Hunt and Hess (HH) Grade 5, and early mortalities were excluded. During this period a physician-led daily multidisciplinary huddle was established to identify and expedite patient discharge needs. 174 patients met inclusion criteria. Significant predictors of increased hospital LOS on univariate analysis included higher HH grade, hydrocephalus, need for ventriculostomy or ventriculoperitoneal shunt, clinical vasospasm, pneumonia, respiratory failure, deep venous thrombosis, and urinary tract infection. Need for shunt, clinical vasospasm, and pneumonia remained significant on multivariate analysis. Mean LOS times decreased to less than those cited in earlier studies, with mean hospital LOS dropping from 21.6 days to 14.1. Total hospital costs per SAH patient decreased from $328K to $269K. Readmission rate and breakdown by patient discharge site remained unchanged. Need for ventriculoperitoneal shunt, clinical vasospasm, and pneumonia were found predictive of longer LOS in SAH patients. A physician-led daily multidisciplinary huddle is a potentially valuable tool to identify patient discharge needs and lower LOS and cost in SAH patients.     

Familial Intracranial Aneurysms

Objective

Numerous studies have compared the characteristics of familial intracranial aneurysms with those of non-familial aneurysms. To better understand familial subarachnoid hemorrhage (SAH), we studied a series of patients with SAH who had at least one first-degree relative with SAH, and compared our results with those of previous studies.

Methods

We identified patients treated for SAH at our hospital between January 1993 and October 2006 and analyzed those patients with one or more first-degree relatives with SAH. We retrospectively collected data from patients with a family history and searched for patients who had relatives with aneurysms or who had been treated at other hospitals for SAH.

Results

We identified 12 patients from six families with at least two first-degree relatives with SAH. All patients had affected first-degree relatives; in five families, they were siblings. The mean age at the time of rupture was 49.75 years; in four families, the age difference was within 5 years. In five patients (42%), the aneurysm was located in the middle cerebral artery. Only one patient had an aneurysm in the anterior communicating artery.

Conclusion

In agreement with previous studies, our results showed that familial aneurysms, in comparison with non-familiar aneurysms, ruptured at a younger age and smaller size, had a high incidence in the middle cerebral artery, and were underrepresented in the anterior communicating artery. Interestingly, the age at the time of rupture was similar between relatives. Screening should be considered in the fifth or sixth decade for those who have a sibling with SAH.     

Aneurysmal SAH: cognitive outcome and structural damage after clipping or coiling.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) and surgical clipping of intracranial aneurysms are associated with substantial morbidity and mortality. OBJECTIVE: To compare cognitive outcome and structural damage in patients with aneurysmal SAH treated with surgical clipping or endovascular coiling. METHODS: Forty case-matched pairs of patients with aneurysmal SAH treated by surgical clipping or endovascular coiling were prospectively assessed by use of a battery of cognitive tests. Twenty-three case-matched pairs underwent MRI 1 year after the procedure. Matching was based on grade of SAH on admission, location of aneurysm, age, and premorbid IQ. RESULTS: Both groups were impaired in all cognitive domains when compared with age-matched healthy control subjects. Comparison of cognitive outcome between the two groups indicated an overall trend toward a poorer cognitive outcome in the surgical group, which achieved significance in four tests. MRI showed focal encephalomalacia exclusively in the surgical group. This group also had a significantly higher incidence of single or multiple small infarcts within the vascular territory of the aneurysm, but both groups had similar incidence of large infarcts and global ischemic damage. CONCLUSION: Endovascular treatment may cause less structural brain damage than surgery and have a more favorable cognitive outcome. However, cognitive outcome appears to be dictated primarily by the complications of SAH.     

动脉瘤性蛛网膜下腔出血患者脑脊液中一氧化氮浓度的动态变化

目的探讨蛛网膜下腔出血后脑脊液中一氧化氮浓度的动态变化及其与脑血管痉挛的关系。方法采集57例动脉瘤性蛛网膜下腔出血(aSAH)患者脑脊液标本(采集时间为入院后即刻,出血后第3、5、7、10、14天),采用镉粒还原法检测脑脊液中NO浓度。结果出血后第3天脑脊液中NO浓度即有明显降低(P<0.05),在出血后第7～10天达到最低(P<0.01),而后逐渐升高。症状性脑血管痉挛患者NO浓度明显低于未痉挛者及无症状的脑血管痉挛患者。结论症状性脑血管痉挛的发生与脑脊液中NO浓度降低有一定相关性。