颅内破裂动脉瘤栓塞术后并发脑疝的危险因素分析

目的 探讨颅内破裂动脉瘤血管内栓塞术后发生脑疝的危险因素及预后。方法回顾性分析2017年5月至2019年5月行血管内治疗的303例颅内破裂动脉瘤的临床资料。结果26例术后发生脑疝，脑疝发生率为8.58%。多因素logistic回归分析显示入院WFNS分级Ⅳ~Ⅴ级、动脉瘤再次破裂、脑水肿是术后发生脑疝的独立危险因素（P<0.05）。ROC曲线分析显示，对于预测术后发生脑疝的效能:入院WFNS分级Ⅳ~Ⅴ级的曲线下面积（AUC）为0.734（95% CI 0.639~0.829；P<0.001），动脉瘤再破裂的AUC为0.632（95%CI 0.504~0.760；P=0.026），脑水肿的AUC为0.826（95% CI 0.723~0.928；P<0.001）；入院WFNS分级Ⅳ~Ⅴ级+动脉瘤再次破裂+脑水肿的AUC为0.897（95% CI 0.819~0.974；P<0.001）。26例脑疝中，8例去骨瓣减压术治疗（4例出院时死亡；4例存活，随访1年，预后良好2例，预后不良2例），18例未行去骨瓣减压术均死亡。26例脑疝病死率为84.62%。结论颅内破裂动脉瘤血管内栓塞术后发生脑疝，去骨瓣减压术可以作为急救手段，但效果有限；为改善病人预后，预防和治疗脑水肿、防止动脉瘤再破裂对预防脑疝的形成尤为重要。

Risk factors of herniation in patients with ruptured intracranial aneurysm after endovascular treatment

Objective To investigate the risk factors and prognosis of herniation in the patients with ruptured intracranial aneurysm after endovascular embolization. Methods The clinical data of 303 patients with ruptured intracranial aneurysm who underwent endovascular treatment from May 2017 to May 2019 were retrospectively analyzed. Results Herniation occurred in 26 patiuents after the embolization, and the incidence rate of herniation was 8.58%. Multivariate logistic regression analysis showed that WFNS grade Ⅳ~Ⅴ on admission, re-rupture of aneurysm and cerebral edema were independent risk factors for postoperative herniation (P<0.05). ROC curve analysis showed that for prediction of postoperative herniation: the area under the curve (AUC) of WFNS grade Ⅳ~ Ⅴ on admission was 0.734 (95% CI 0.639~0.829; P<0.001); the AUC of aneurysm re-rupture was 0.632 (95% CI 0.504~0.760; P= 0.026); the AUC of cerebral edema was 0.826 (95% CI 0.723~0.928; P<0.001); the AUC of WFNS grade Ⅳ~Ⅴ on admission+aneurysm re-rupture+cerebral edema was 0.897 (95% CI 0.819~0.974) ; P<0.001). Decompressive craniectomy was performed on 8 of 26 patients with herniation, of whom 4 patients died at discharge and 4 survived (2 patients with good prognosis and 2 with poor prognosis according to the follow-up 1 year after the discharge). Eighteen patients who did not receive decompressive craniectomy died at discharge. The mortality rate of 26 patients with herniation was 84.62%. Conclusions Decompressive craniectomy can be used as first aid treatment for the patients with herniation after endovascular embolization, but the clinical efficacy is limited. The prevention and treatment of cerebral edema and the prevention of aneurysm re- rupture are essential for preventing herniation in the patients with uptured intracranial aneurysm.