动脉瘤破裂致蛛网膜下腔出血患者死亡原因分析

目的 探讨动脉瘤破裂致蛛网膜下腔出血患者住院期间死亡的原因并提出相应的对策. 方法 回顾性分析江苏大学附属人民医院神经外科自2003年1月至2010年12月收治且住院期间死亡的24例颅内动脉瘤破裂致自发性蛛网膜下腔出血患者的临床资料和死亡原因.结果 死亡原因分别为:颅内再出血11例,其中术前再出血5例,介入栓塞术中出血3例,栓塞术后颅内再次出血3例;术后脑血管痉挛或脑梗死8例,其中早期(术后3d内)CT表现为脑梗死3例,晚期(术后3d后)脑血管痉挛或脑梗死5例;椎动脉瘤栓塞术后呼吸骤停1例;肺部感染3例;肾功能衰竭1例. 结论 颅内再次出血、脑梗死或脑血管痉挛、非神经系统并发症是动脉瘤性蛛网膜下腔出血患者住院期间主要的死亡原因.     

替罗非班治疗支架辅助弹簧圈栓塞动脉瘤术中急性血栓形成

目的探讨动脉内灌注盐酸替罗非班在处理支架辅助弹簧圈栓塞颅内动脉瘤时术中急性血栓的有效性及安全性。方法收集2013年1月至2017年6月11例行颅内动脉瘤栓塞术中发生血栓患者,发生血栓后,均于微导管内靶向灌注盐酸替罗非班6ml,同时静脉泵注5ml/h,然后每5~10分钟造影观察血管溶通情况,直至血栓消失或血管开通。术后进行CT或MRI随访,观察有无脑梗塞或脑出血。结果 11例术中造影血管均完全再通,术后第1天、第7天及术后1月行头颅CT或MRI检查,均未发现与手术相关脑梗塞和脑出血的发生。结论支架辅助弹簧圈栓塞颅内动脉瘤时,术中出现急性血栓并发症时,经动脉靶向灌注盐酸替罗非班是一种安全、有效的方法。     

无蛛网膜下腔出血的破裂脑动脉瘤

目的 总结无蛛网膜下腔出血(SAH)的破裂脑动脉瘤的诊治经验.方法 对15例在起病后2 d内首次CT或MRI上表现为脑内出血(ICH),和(或)脑室内出血(IVH)、硬脑膜下血肿(SDH)和壁间出血(IMH)而无SAH的破裂脑动脉瘤患者的临床表现、影像学检查结果 、治疗方法 和预后进行回顾性分析.结果 本组首次CT或MRI检查表现为ICH者3例、IVH合并ICH者6例、SDH者1例、IVH者1例、IMH者3例和等高混合密度者1例.其中动脉瘤位于大脑中动脉6例、前交通动脉4例、后交通动脉3例、大脑前动脉1例和小脑后下动脉1例.开颅手术夹闭动脉瘤13例,血管内栓塞2例.出院时GOS评分:恢复良好8例、中残3例、重残3例和植物生存1例.本组15例占同期破裂脑动脉瘤的3.8%.结论 破裂脑动脉瘤首次CT扫描可表现为单纯ICH,和(或)IVH、SDH、IMH而无SAH,与CT扫描时间、动脉瘤的部位和指向以及出血量有关.早期控制颅内高压、及时诊断和有效处理破裂动脉瘤,是改善预后的关键.     

颅内破裂动脉瘤栓塞后再出血分析

目的分析颅内破裂动脉瘤栓塞后再出血的发生率及其可能的影响因素。方法随访285例破裂动脉瘤病人，随访时间2-72个月，平均28.1个月，通过书信，电信以及门诊的方式进行随访，内容以询问病人症状，体征为主，重点在于动脉 瘤栓塞后是否再出血。结果4例病人发生动脉瘤再次破裂出血，再出血率为1.4%，其中不全栓塞3例，大动脉瘤2例。结论颅内破裂动脉瘤应用弹簧圈栓塞后再出血发生率大大降低，再出血主要发生于不全栓塞的动脉瘤和何种较大的动脉瘤。     

破裂后颅内动脉瘤介入手术相关并发症分析与防治对策

目的 分析破裂后颅内动脉瘤血管内栓塞手术相关并发症的发生原因及防治方法. 方法 68例破裂后颅内动脉瘤采用早期血管内栓塞治疗,术中对动脉痉挛采用经微导管灌注罂粟碱或球囊扩张解痉:对弹簧圈堵塞载瘤动脉采用抗凝或抗血小板治疗:对动脉瘤破裂采用中和肝素继续栓塞;对动脉血栓形成采用栓塞后经微导管灌注r-tPA溶栓. 结果 68例中出现并发症8例,占11.77%.其中大脑中动脉广泛性痉挛1例,出现脑梗死,轻度偏瘫;局限性痉挛2例,治疗后无后遗症;弹簧圈部分进入大脑中动脉1例,治疗后无脑梗死;弹簧圈脱落脑梗死1例,术中动脉瘤破裂1例,继续栓塞无不良后果;术后1周动脉瘤再次破裂死亡1例;血栓形成大面积脑梗死偏瘫1例. 结论 清楚显示动脉瘤的部位、形态、大小以及与载瘤动脉的关系有助于栓塞的成功;合理选择弹簧圈规格及熟练掌握操作技术能降低并发症的发生率;术中及时妥当处理并发症可明显改善预后情况.     

Ruptured aneurysm at the peripheral branch of the posterior cerebral artery with systemic lupus erythematosus]

We report a 73-year-old woman with systemic lupus erythematosus (SLE) in whom intracerebral and intraventricular hemorrhage developed secondary to a ruptured aneurysm on the peripheral branch of the posterior cerebral artery. We reviewed data on 22 patients (43 aneurysms) in previous reports of ruptured cerebral aneurysms associated with SLE, including our case. Of these aneurysms, 34 (79.1%) were located on the major artery, and 9 (20.9%) were located on the peripheral small artery. Fusiform aneurysms accounted for 27.9% of the total. The prognosis was poor, and 14 patients (63.6%) died. Direct aneurysmal surgery was performed in 11 patients (50%), but 4 patients died of other diseases associated with SLE.     

脑梗塞继发脑干出血的病理与临床

探讨脑梗塞继发脑干出血的临床、ＣＴ、病理学特点及其发病机理。方法１０３例连续尸解脑梗塞病例中，经病理检查发现１１例继发脑干出血，分析其临床、ＣＴ及病理检查结果。结果脑梗塞继发脑干出血的临床特点是发病急、进展快、昏迷、四肢瘫、过高热及呼吸衰竭，ＣＴ一般不能发现脑干高密度病灶，病理结果均为半球大病灶脑梗塞，严重海马回疝致脑干严重受压、变形和移位，继发脑干出血以中脑为主，可累及桥脑，主要位于中线部位。结论脑梗塞继发脑干出血是由于严重脑干受压、变形导致脑干微小穿动脉、静脉及毛细血管被牵拉、破裂所致。     

脑卒中并发上消化道出血的临床研究

目的掌握急性脑卒中患者并发上消化道出血的临床特点。方法对763例急性脑卒中患者并发上消化道出血的情况进行调查研究。结果在763例患者中,急性脑出血并发上消化道出血的发生率明显高于急性脑梗死组,病变累及脑干时尤为突出。伴意识障碍的患者并发上消化道出血的发生率较高。脑卒中并发上消化道出血发生时间多在发病后24h内出现,亦可发生于病程10d左右。并发上消化道出血的脑卒中患者死亡率明显高于未并发上消化道出血者。结论脑卒中并发上消化道出血预后不良,早期应采取措施,积极预防。     

颅内动脉瘤破裂后的早期栓塞治疗

目的 研究颅内动脉瘤破裂后早期栓塞治疗的意义、可行性及相关事宜。方法 对32例破裂的颅内动脉瘤在3d内施行栓塞治疗,微导管选用Tracker、Excel、Prowler、Rebar或Echelon系列,栓塞材料选用GDC、EDC或Orbit。结果 动脉瘤90％栓塞20例、95％栓塞8例、完全栓塞4例,死亡4例。结论 动脉瘤破裂后的早期栓塞可减少再出血的风险,操作受血管痉挛的影响较小,对血管痉挛有治疗作用,术后需辅以“3H”治疗。     

大脑中动脉动脉瘤的显微手术治疗

目的总结显微外科手术处理大脑中动脉动脉瘤的经验。方法1998年1月～2006年1月共手术治疗大脑中动脉动脉瘤36例，男19例，女17例。年龄12～65岁（平均41岁）。36例共计38个大脑中动脉动脉瘤，动脉瘤大小3～60mm，其中3～7mm9个，8～14mm17个，15～24mm7个，≥25mm5个。术前破裂出血30例，其中14例形成脑内血肿；6例因其它疾病或体检时偶然发现。所有病例经DSA检查，部分病人同时行MRA或CTA检查，其中2例病人DSA检查未发现动脉瘤，而CTA则清楚显示动脉瘤。4例病人合并有其它部位动脉瘤，2例为双侧镜影动脉瘤。动脉瘤位于大脑中动脉分叉部30个，分叉部近端7个、远端1个。采用翼点入路，显微镜下打开侧裂，依动脉瘤部位，逆行或顺行沿大脑中动脉主干（支）寻找分离动脉瘤，并夹闭之。结果全部38个动脉瘤均用一个或多个动脉瘤夹夹闭，其中8个大或巨大动脉瘤同时摘除血栓并切除大部瘤体以解除其占位效应。术后恢复良好28例，发生偏瘫失语7例（因局部脑梗塞所致），死亡1例。结论显微手术治疗大脑中动脉动脉瘤可以获得满意疗效，术中应尽量避免损伤大脑中动脉的分支，防止术后发生脑梗塞造成患者神经功能障碍。     

Ruptured Saccular Aneurysm Arising from Fenestrated Proximal Anterior Cerebral Artery : Case Report and Literature Review

The aneurysm arising from fenestrated proximal anterior cerebral artery (ACA) is considered to be unique. The authors report a case of a 59-year-old woman who presented with a subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm originating from the fenestrated A1 segment of right ACA. The patient had another unruptured aneurysm which was located at the right middle cerebral artery bifurcation. She was successfully treated with surgical clipping for both aneurysms. From the previously existing literatures, we found 18 more cases (1983-2011) of aneurysms associated with fenestrated A1 segment. All cases represented saccular type of aneurysms, and 79% of the patients had SAH. There were three subtypes of the fenestrated A1 aneurysms depending on the anatomical location, relative to the fenestrated segment. The most common type was the aneurysms located on the proximal end of fenestrated artery (82%). Azygos ACA and hypoplastic A1 were frequently accompanied by the aneurysm (33% and 31%, respectively), and multiple aneurysms were shown in three cases (16%). Considering that fenestrated A1 segment is likely to develop an aneurysm, which has high risk of rupture, early management may benefit patients with aneurysms accompanied by fenestrated proximal ACA.     

High incidence of hyponatremia in patients with ruptured anterior communicating artery aneurysms

We studied the incidence and timing of hyponatremia (Na < 135 mEq l-1) after subarachnoid hemorrhage (SAH) with special reference to ruptured anterior communicating artery (A-com) aneurysms. Hunt and Kosnik (HK) grading, symptomatic vasospasm in A-com aneurysm, and hydrocephalus were analyzed for connections to hyponatremia in 55 patients with ruptured A-com aneurysms, 65 with ruptured internal cerebral artery (ICA) aneurysms, and 49 with ruptured middle cerebral artery (MCA) aneurysms. Hyponatremia occurred in 28 (51%) of 55 patients with A-com aneurysms and in nine (18%) of 49 patients with MCA aneurysms. Severe hyponatremia (Na < 130 mEq l-1) occurred in 16 patients (29%) in the A-com group, four patients (6%) in the ICA group, and three patients (6%) in the MCA group. The A-com aneurysm group had a significantly higher incidence of mild hyponatremia (p < 0.01) and severe hyponatremia (p < 0.001) than other groups. Among A-com cases, hyponatremia occurred significantly more often in HK grade III and IV cases (p < 0.05), in cases with vasospasm (p < 0.001), and in cases with hydrocephalus (p < 0.01). Respective days of onset for symptomatic vasospasm and for hyponatremia were day 7.6 +/- 4.4 and day 10.6 +/- 5.8 following SAH, representing a 3-day delay for hyponatremia (p < 0.05). In most patients hyponatremia resolved within 28 days following SAH. Hyponatremia occurred more often with A-com aneurysms, possibly because of vasospasm around the A-com or hydrocephalus causing hypothalamic dysfunction. Since hypervolemic therapy can cause hyponatremia, particularly careful observation is required during such therapy in patients with A-com aneurysm.     

颅内破裂动脉瘤合并脑内血肿的复合手术治疗

目的 探讨复合手术治疗颅内破裂动脉瘤合并脑内血肿的疗效。方法 回顾性分析簧圈栓塞术后行颅骨钻孔血肿腔引流术治疗的5例颅内破裂动脉瘤合并脑内血肿的临床资料。结果 5例头颅CT均表现为典型蛛网膜下腔出血（SAH）合并脑内血肿;DSA发现动脉瘤位于大脑前动脉A2段分叉部1例、大脑前动脉A2段1例、前交通动脉1例、颈内动脉后交通动脉1例、大脑中动脉分叉部1例;术前Hunt-Hess分级Ⅱ级2例,Ⅲ级2例,Ⅳ级1例。引流术后3~4 d血肿大部分引流干净,无再出血、感染及脑梗死。术后6个月GOS评分3分1例,4分1例,5分3例。结论 对合并脑内血肿的自发性SAH,首先应考虑动脉瘤破裂出血可能,需尽早行DSA检查明确诊断;复合手术对于部分未发生脑疝又合并脑内血肿的破裂动脉瘤是可行的,能取得良好的疗效。     

Prophylactic volume expansion therapy for the prevention of delayed cerebral ischemia after early aneurysm surgery. Results of a preliminary trial

From June 1986 to June 1987, 47 consecutive patients with ruptured intracranial aneurysms were treated with immediate aneurysm surgery and prophylactic volume expansion therapy for ten to 14 days after subarachnoid hemorrhage (SAH). Twenty-four patients were admitted within three days of SAH. Twenty-three of these patients had an excellent result, and one patient died. There were no cases of delayed cerebral infarction. In 18 of 23 patients admitted more than three days after SAH, there was an excellent result. The other five patients had permanent morbidity related to the original SAH. These preliminary data suggest that immediate aneurysm surgery and aggressive postoperative prophylactic volume expansion in all patients can substantially reduce rebleeding and delayed cerebral ischemia, potential causes of morbidity, after aneurysmal subarachnoid hemorrhage. A more extensive prospective trial of this approach will be required to test this hypothesis.     

Dissecting aneurysms limited to the basilar artery: Report of two cases and review of the literature.

Spontaneous dissecting aneurysms limited to the basilar artery are rare. We describe two patients who presented to our institution with different clinical problems, one with brain stem infarction and the other with subarachnoid hemorrhage. We describe the clinical and imaging features in these patients, their treatment, and outcome. We also reviewed the literature concerning this entity, and we have identified 32 patients (including our two pateints) with angiographically confirmed dissecting aneurysms limited to the basilar artery. Of these, 40.6% presented with brain stem infarction, 50.0% presented with subarachnoid hemorrhage, and 9.4% presented with both infarction and subarachnoid hemorrhage. Patients who presented with basilar artery dissecting aneurysms and brain stem infarction tended to be younger (mean age, 38 +/- 7 years) than those who presented with subarachnoid hemorrhage (48 +/- 12 years) and were more likely to be male. We discuss the natural history of this entity and suggest an approach to clinical management for these patients.     

Clinical analysis of vitreous hemorrhage combined with ruptured aneurysm

Eight cases of vitreous hemorrhage with ruptured intracranial aneurysm (Terson's syndrome) were experienced in our clinic from April, 1978 to April, 1983. They consisted of five males and three famales between 45 and 69 years old. All cases had unconscious attacks and three of them experienced repeated episodes of subarachnoid hemorrhage within 24 hours. CT scan, performed 24 hours within the attack, revealed remarkable high density areas at prepontine and suprasellar cisterns, interhemispheric and sylvian fissures. Ruptured aneurysms, confirmed by cerebral angiography and operative findings, were three anterior communicating artery aneurysms, three internal cerebral artery aneurysms, one middle cerebral artery aneurysm and one anterior cerebral artery aneurysm. We performed radical operation for the ruptured aneurysm, six cases at acute atage, one at 11 days and one at 18 days after the attack. Postoperative courses were all good. Five cases had bilateral vitreous hemorrhages and three had unilateral ones. At first they were treated conservatively. Visual acuity of six cases, 13 eyes improved gradually, but three cases, four eyes did not improve after four or five months after the attack. So we let ophthalmologist to perform vitrectomy, which showed effective results. Vitreous hemorrhage following a ruptured intracranial aneurysm is not a so rare complication than has been assumed and also its prognosis is not so poor. In most cases vitreous hemorrhage following a ruptured intracranial aneurysm should be treated conservatively, but in selected cases effective results would be given by vitrectomy.     

Distribution of delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage and implications for regional neuromonitoring

Objectives

Many neuromonitoring devices provide data applicable to a limited region of the brain. Risk of DIND is common after aSAH and may occur near or remote from the ruptured aneurysm. The aim of this study is to determine the distribution of DIND after aneurysms rupture as it relates to the potential value of regional monitoring in detection of vasospasm.

Patients and methods

The study enrolled aSAH patients presenting to a tertiary referral center over a three year period who received treatment for an identified ruptured aneurysm and survived >10 days with subsequent DIND. Only those patients receiving routine neuroimaging were included. To account for the anticipated effect on infarct distribution, patients were divided into groups of midline and non-midline aneurysms and assessed for vasospasm and stroke with respect to vascular distribution. Comparisons of clinical characteristics were made to determine factors predisposing to remote infarction.

Results

Twenty-nine patients met criteria with 15 patients harboring non-midline aneurysms. The rarity of isolated remote DIND prohibited adequate assessment of predictive clinical characteristics. For non-midline aneurysms, DIND occurred ipsilateral to the ruptured aneurysm in 93% and within the same vascular territory in 86% of patients. Midline anterior circulation aneurysms frequently resulted in ACA infarction. A neuromonitoring device with 100% sensitivity for ischemia placed in the MCA territory ipsilateral to a non-midline ruptured aneurysm would identify 71% of DIND.

Conclusion

Vasospasm related infarction occurs most commonly ipsilateral to or in the same distribution of the ruptured aneurysm. Less anatomical correlation is seen with midline aneurysms. Rupture of posterior circulation aneurysms infrequently results in supratentorial infarction. Decisions regarding placement of regional monitors for the purpose of vasospasm detection should consider this distribution of ischemic risk.     

动脉瘤破裂致蛛网膜下腔出血24 h内微弹簧圈栓塞干预的预后分析

目的分析动脉瘤破裂致蛛网膜下腔出血24 h内行微弹簧圈栓塞干预的预后。 方法纳入2014年1月至2017年6月黄冈市中心医院神经外科收治的127例动脉瘤破裂致蛛网膜下腔出血患者进行回顾性分析,将24 h内接受微弹簧圈栓塞患者纳为超早期组（71例）,将≥24 h患者纳为非超早期组（56例）。对比2组患者围手术期疗效及术后6个月的预后。 结果超早期组术前再出血、术后脑梗死及脑积水发生率均明显低于非超早期组,差异有统计学意义（P<0.05）。2组患者院内死亡率对比,差异无统计学意义（P>0.05）。2组患者术后6个月的改良Rankin量表评分比较,差异无统计学意义（P>0.05）。 结论对动脉瘤破裂致蛛网膜下腔出血患者在24 h内开展微弹簧圈栓塞术治疗,虽然能够减少术前再出血风险和术后并发症发生率,但对显著提升患者预后并无明显作用。     

平板3D-DSA在前交通动脉瘤血管内治疗中的价值

目的评估平板3D-DSA在前交通动脉瘤血管内栓塞治疗中的应用价值。方法回顾性分析12例前交通动脉瘤行介入栓塞治疗的资料,常规全脑血管DSA检查后,再行三维重建,选择适合的栓塞材料及工作角度进行手术,并分析3D-DSA对介入栓塞治疗的应用意义。结果 8例动脉瘤100%栓塞,2例栓塞95%,1例栓塞90%,1例栓塞80%,急性脑血栓形成1例,血管痉挛2例,无动脉瘤破裂出血及死亡病例。结论 3D-DSA能够详细地显示前交通动脉瘤的解剖信息,可明确其诊断,对制定栓塞手术计划及介入治疗具有重要的临床应用价值。     

Stroke in Saudi Arabian young adults: a study of 120 cases

One hundred and twenty cases of stroke occurring in Saudi Arabian subjects aged 15 to 45 years are reviewed. These constituted 12.7% of a group of 946 stroke patients. Males outnumbered females (76/44). The frequency of intracranial hemorrhage, including subarachnoid hemorrhage, was slightly lower than cerebral infarction (41.5 vs 58.5%). The causes of large cerebral infarction were as follows: atherosclerosis 17 (28%), cardiac embolism 12 (19.5%), uncommon and uncertain causes 21 (34.5%). Some unusual causes were encountered such as dissecting arterial aneurysm due to popular healing manoeuvres or to traditional dance, retrograde embolism from a thoracic outlet syndrome or embolism from a fibroelastoma of the mitral valve chorda. Lacunar cerebral infarction was diagnosed in nine cases. Hypertension (25.5%) and arteriovenous malformations (20.5%) were the main causes of cerebral hemorrhage; all subarachnoid hemorrhages except one were due to berry aneurysms. The cause was undetermined in 16% of cerebral infarction and 26% of intracranial hemorrhage. The high frequency of stroke in young Saudi Arabian adults is probably a reflection of the demographic structure of the predominantly young Saudi society. The observed causes were relatively similar to those in industrial societies. Contrary to other developing countries infectious disease no longer seems to be an important cause of stroke. Drug abuse, which is becoming an important cause in Western societies, was encountered in only two of our cases.