颅内动-静脉畸形治疗面临的困境与挑战

正颅内动-静脉畸形(AVM)是临床最常见的颅内血管发育异常导致的疾病,由于其病残率和病死率高、自然病程不确定、血管结构复杂,长期以来一直是临床治疗的重点和难点。颅内动-静脉畸形的治疗主要包括保守治疗、手术切除、血管内介入治疗和立体定向放射治疗(SRT),不同治疗方式组合、不同动-静脉畸形分级、不同临床表现、不同高危因素,使我们难以在复杂的临床实践中整理出所谓的"颅内动-静脉畸形治疗规范",而且面临更多的是颅内     

万古霉素脑室内注射治疗成人中枢神经系统感染的研究进展

中枢神经系统(CNS)周围的屏障以及多重耐药菌的出现对有效治疗CNS感染提出了治疗挑战。万古霉素是一种糖肽类抗生素，用于治疗和预防由革兰阳性菌引起的各种细菌感染，包括耐甲氧西林金黄色葡萄球菌(MRSA)。它也用于肠球菌、链球菌和甲氧西林敏感的金黄色葡萄球菌(MSSA)等引起的感染。万古霉素被推荐作为颅内感染的一线治疗药物。然而，通过静脉(IV)输注给药时，万古霉素在脑脊液(CSF)中的渗透是有限的。万古霉素通过脑室内(IVT)给药可绕过血脑屏障直接到达目标部位，实现高浓度以获得更好的杀菌作用。万古霉素IVT给药的适应症主要包括对IV抗生素反应较差的脑膜炎、脑室炎、颅内装置感染和脑脓肿。本文综述了成人万古霉素IVT给药的研究现状，旨在为临床实践提供参考。根据现有证据，使用万古霉素IVT给药治疗CNS感染是安全有效的。万古霉素IVT给药的最佳给药方案需要考虑到不同患者CNS的病理生理学特点并根据具体情况进行临床判断。     

周口市暗娼人群艾滋病相关知识和行为调查分析

目的 了解周口市暗娼人群艾滋病防治知识的知晓情况及相关行为特征,为制定干预措施提供科学依据.方法 2010年对周口市艾滋病疫情较高的4个县的暗娼人群进行问卷调查.结果 调查421人,艾滋病知识总体知晓率为88.84％;最近一次发生商业性行为时安全套使用率为91.69％;最近的3个月发生商业性行为时均使用安全套的比率为...     

Willis覆膜支架与弹簧圈栓塞治疗颅段颈内动脉瘤效果的比较

目的 比较Willis覆膜支架和弹簧圈栓塞治疗颅段颈内动脉瘤的临床效果.方法 89例经皮动脉穿刺行全脑选择性血管造影术证实的颅段颈内动脉瘤患者,根据其意愿分为A组43例,行Willis覆膜支架治疗;B组46例,行弹簧圈治疗.术后3、6、12个月及之后每年1次进行脑血管造影及临床随访,搜集血管造影及临床资料进行分析.对2组患者的手术成功率及并发症发生率进行x2检验,对即刻血管造影结果、手术时间、住院时间进行独立样本t检验.结果 A组患者支架成功置入42例,失败1例;B组46例弹簧圈栓塞均获成功,2组差异无统计学意义(Fisher精确概率法,P=0.999).即刻肭血管造影显示A组34例动脉瘤完全闭塞(81%),B组24例完全闭塞(52%);平均手术时间A组(103±13)min,B组(143±39)min,2组间差异有统计学意义(t=6.20,P＜0.01＝.并发症A组6例,B组8例,2组差异无统计学意义(x2=0.20,P＞0.05).A组41例随访6～41个月,脑血管造影显示39例动脉瘤完全闭塞(95%);B组45例随访7～47个月,22例完全闭塞(49%),2组差异有统计学意义(P＜0.01＝.最后一次随访结果显示,完全康复A组22例、B组27例,2组间差异无统计学意义(x2=0.352,P＞0.05).结论 脑血管造影结果显示Willis覆膜支架置入术治疗颅段动脉瘤的结果优于弹簧圈栓塞术,而临床表现2组无明显差别.

Abstract：

Objective To evaluate the clinical results of Willis covered stent implantation and coil embolization in the treatment of cranial internal carotid artery (CICA) aneurysm. Methods Eighty-nine patients with CICA aneurysms were selected for treatment with Willis covered stents (n = 43, group A) or coil embolization (n =46, group B) according to the patients'will. Data on the technical success, initial procedure time and in-hospital interval, initial and final angiographic results, mortality, morbidity, and final clinical outcomes were collected and analyzed for the two groups at 6 months post-procedure. Results Endovascular covered stent placement and coil embolization were technically successful in all patients,except for one patient in group A. The initial angiographic results showed complete occlusion in 34 patients of group A (81%, 95% CI: 69%, 93% ) and 24 patients of group B (52%, 95% CI: 37%, 67% ) ( P ＜0. 05). The final angiographic results indicated complete occlusion in 39 patients of group A (39/41,95%,95% CI: 88%, 102% ) and 22 patients of group B (22/45,49%, 95% CI: 34%, 64% ,P ＜0. 01 ). The average procedure time was(103 ± 13)min in group A and (143 + 39) min in group B (P＜0. 01). No significant differences were seen between the two groups in technique success, mortality, morbidity, or final clinical outcomes. Conclusion In this nonrandomized, prospective trial, CICA aneurysm treatment with covered stents yielded midterm angiographic results that were superior to those of coil embolization.     

脂联素与心血管疾病的研究现状与展望

肥胖与心血管疾病及代谢紊乱密切相关。脂联素是一种脂肪源性血浆蛋白,在与肥胖相关的代谢紊乱及疾病中含量降低,低脂联素水平与肥胖相关的心血管疾病危险性增加有关。有研究表明,脂联素可直接作用于心肌及血管细胞发挥作用,可通过多种机制保护心血管系统。其中主要包括调节一磷酸腺苷活性蛋白酶介导的信号通路、抑制炎症与促进内皮细胞功能等。脂联素所共有的调节代谢、抗炎及血管保护、心肌保护作用,可为临床治疗代谢综合征性心血管疾病,提供新的干预靶点和治疗思路。     

血管内栓塞与手术夹闭治疗前或后交通动脉破裂动脉瘤的效果和成本比较

目的 比较手术夹闭与血管内介入治疗两种术式用于前、后交通动脉动脉瘤治疗的效果和成本,并进行成本效益分析.方法 采用回顾性队列研究分析2002年至2006年期间华山医院收治的接受手术夹闭或介入治疗的前、后交通动脉动脉瘤患者治疗转归和花费等资料.结果 共纳入302例患者,其中手术夹闭组150例[男性65例,年龄(48.11±9.94)岁],介入治疗组152例[男性75例,年龄(52.56±11.09)岁],前组年龄低于后组(t=-3.670,P=0.000).两组患者术前临床情况,如动脉瘤位置、术前Hunt-Hess分级无显著差异.介入治疗组转归良好率显著高于手术夹闭组(84.87%对74.67%,χ2=4.875,P=0.027).手术夹闭组院内病死率(5.33%对3.94%,χ2=0.328,P=0.567)和并发症发生率(26.67%对19.74%,χ2=2.036,P=0.154))与介入治疗组无显著差异,但手术夹闭组术中动脉瘤破裂(10.67%对3.95%,χ2=5.047,P=0.028)和术后颅内感染发生率(6/144对0/152,χ2=6.203,P=0.014)高于介入治疗组.介入治疗组住院日显著短于手术夹闭组[(10.0±7.0)d对(23.0±11.0)d,Z=-10.35,P＜0.001].介入治疗组治疗成本中位数为95 327.63元,四分位间距为26 312.98元;显著高于手术夹闭组(中位数3 0 072.01元,四分位间距11 178.54元)(Z=-14.449,P＜0.001).与手术夹闭相比,介入治疗组mRS评分增高0.10分的成本约为66 438元,手术夹闭更具成本效益.结论 介入治疗前、后交通动脉动脉瘤的效果优于手术夹闭,病死率和总的并发症发生率与手术夹闭相当,住院时间更短,但治疗费用较高,从经济学考虑,手术夹闭更具成本效益.

Abstract：

Objective To compare the efficacy and cost of surgical clipping and endovascular embolization in the treatment of anterior and posterior communicating artery aneurysm and to conduct cost-effectiveness analysis. Methods The data of treatment outcomes and costs in patients with anterior or posterior communicating artery aneurysms admitted to Huashan hospital from 2002 to 2006 were analyzed using a retrospective cohort study. Results A total of 302 patients were included in the study. They were divided into surgical clipping group (n = 150; 65 males, age [48. 11 ±9. 94] years), interventional treatment group (n = 152;75 males, age [52. 56 ± 11. 09] year). The age of the former was lower than that of the latter (t = -3. 670, P =0. 000). There was no significant difference in preoperative clinical conditions (such as location of aneurysms and Hunt-Hess grade) between the two groups. The good outcome rate in the interventional treatment group was significantly higher than that in the surgical clipping group (84. 87% vs. 74. 67%, χ2 = 4. 875, P = 0. 027). There was no significant difference in hospital mortality (5. 33% vs. 3. 94%,χ2 =0. 328, P =0. 567) and complication rate (26.67% vs. 19. 74% , χ2 =2.036, P =0.154) between the surgical clipping group and the interventional treatment group, but the intraoperative aneurysm rupture (10. 67% vs. 3. 95%, χ2 =5.047, P =0.028) and the incidence of postoperative intracranial infection (6/144 vs. 0/152, χ2 = 6.203, P =0.014) in the surgical clipping group were higher than those in the interventional treatment group. The length of hospital stay in the interventional treatment group was significantly shorter than that in the surgical clipping group ([10. 0 ± 7. 0] dvs. [23.0 ± 11. 0] d, Z = -10. 35, P ＜0.001). The median cost of treatment was 95 327.63 %,yuan in the interventional treatment group, and the interquartile range (IQR) was 26 312. 98 yuan; it was significantly higher than the surgical clipping group (median 30 072. 01 yuan, IQR 11 178. 54 yuan) (Z = -14.449, P＜0.001). Compared with the surgical clipping group, while the mRS score improved in the interventional treatment group 0. 10, the cost was about 66 438 yuan, so that the surgical clipping was more cost-effective. Conclusions The efficacy of the intervention treatment of anterior and posterior communicating artery aneurysms is better than that of the surgical clipping The mortality and total complication rate are almost the same with the surgical clipping Thehospital stay is shorter, but the cost of treatment is higher. From an economic point of view, the surgical clipping is more cost-effective.     

非黏附性液体栓塞剂治疗脑动静脉畸形

目的 探讨新型液态栓塞剂Onyx栓塞脑动静脉畸形的技术要点和临床效果。方法 对21例脑动静脉畸形患者采用Seldinger技术在股动脉内置入6F鞘,6F导引导管进入颈内动脉或椎动脉。以Ultraflow微导管超选择进入畸形团内,采用“阻断和前推技术”长时间缓慢注射Onyx栓塞脑动静脉畸形。本组患者中有13例动静脉畸形位于功能区(运动区、语言区、视觉中枢),6例位于大脑半球深部,2例位于小脑半球。畸形团大小为3cm的9例,3～6cm的8例,6cm以上的4例。结果 治疗后脑动静脉畸形的体积缩小程度为20％～100％。初期因使用Onyx经验不足,在拔出微导管时有2例患者发生严重脑出血．行外科手术救治,其余19例患者无严重并发症。结论 Onyx栓塞技术可作为治疗体积较大、位于大脑深部及功能区脑动静脉畸形的重要方法之一,长期疗效有待随访结果的验证。     

脑移植与TRH联合治疗脑性瘫痪的对比观察

近年来,我们对90例脑性瘫痪病人随机分为促甲状腺素释放激素(TRH)组(下称A组)、脑移植组(下称B组)和脑移植加TRH组(下称C组)进行治疗,结果证明,C组近期疗效较好。 临床资料:本组年龄2.5～21岁;男65例,女25例;均经多种神经营养药物等综合治疗无效。病人以痉挛型脑性瘫痪和智能落后为主要临床症状,50％有癫痫发作史。     

自发性颅颈多发夹层动脉瘤一例及文献复习

患者男,20岁,学生。2011年8月21日因＂1个月前突发剧烈头痛伴意识障碍1次＂收入复旦大学附属华山医院。患者入院前1个月情绪激动时突发剧烈头痛,当时伴有意识障碍,呕吐数次,四肢抽搐数分钟,15 min后患者意识障碍逐渐自行缓解。于当地医院急诊行头部CT检查,显示蛛网膜下腔出血（SAH）（图1a）,予以止血、解痉、镇静等保守