前循环动脉瘤破裂并脑内血肿的显微手术治疗

目的探讨前循环动脉瘤破裂伴脑内血肿手术方法及疗效。方法前循环动脉瘤破裂并脑内血肿患者29例行显微手术治疗,总结其临床特点:动脉瘤部位、大小、形态、合并脑内血肿大小、形态,术前Hunt-Hess分级、手术方式及三个月随访的格拉斯预后评分。结果 Hunt-Hess分级Ⅲ级10例、Ⅳ级17例、Ⅴ级2例。17例患者术前经常规血管造影,12例行三维CT血管造影(3D-CTA)检查证实。29例术中诊断与术前诊断一致,前交通动脉瘤6例,后交通动脉瘤7例,大脑中动脉瘤16例,29例患者共31枚动脉瘤均成功夹闭,3个月后随访时GOS评分Ⅴ级14例,Ⅳ级7例,Ⅲ级4例,Ⅱ级2例,Ⅰ级2例。结论颅内前循环动脉瘤破裂并脑内血肿患者病情危重,早期夹闭动脉瘤,清除血肿,效果良好。     

显微手术治疗大脑中动脉分叉部动脉瘤

目的 探讨大脑中动脉(MCA)分叉部动脉瘤的解剖特点、临床特征、影像学表现、显微手术技巧及临床疗效.方法 回顾分析41 例MCA 分叉部动脉瘤显微外科治疗患者的临床资料,39 例有动脉瘤破裂出血的临床表现,按Hunt-Hess 分级:0～Ⅰ级5 例,Ⅱ级15 例,Ⅲ级11 例,Ⅳ级9 例,Ⅴ级1 例.64 排螺旋CT 血管造影(CTA)确诊.41 例均行显微手术治疗,手术入路为翼点入路或扩大翼点入路.对多发动脉瘤采取早期与择期、一期与分期相结合的方法处理动脉瘤,原则是先处理破裂动脉瘤,再处理未破裂动脉瘤.结果 动脉瘤夹闭38 例,动脉瘤夹闭+包裹2 例,夹闭一侧动脉瘤,另一侧动脉瘤未处理1 例.依据GOS 判断:优良31 例,轻残6 例,重残2 例,死亡2 例.结论 显微外科手术治疗MCA 分叉部动脉瘤效果显著.熟悉MCA 分叉部动脉瘤的解剖特征有助于减少术中血管损伤和术后神经功能障碍;对合并脑内血肿的MCA 分叉部动脉瘤,应急诊手术清除血肿并夹闭动脉瘤.     

Continuous growth of remote intracerebral haematoma following angiographically successful endovascular embolisation of ruptured cerebral aneurysms

We describe a poorly recognised and rare complication following the endovascular embolisation of ruptured cerebral aneurysms. Three patients with dense focal subarachnoid haemorrhage (SAH) developed continuous growth of remote intracerebral haematoma (ICH) following endovascular embolisation of a ruptured aneurysm. All endovascular procedures were conducted within less than 6 hours after the onset of SAH with systemic anticoagulation and were completed uneventfully; external ventricular drainage was subsequently inserted. Repeated CT scans revealed continuous growth of ICH remote from the aneurysm without aneurysmal rebleeding. The authors suggest that endovascular embolisation for a ruptured aneurysm under systemic anticoagulation within 6 hours after SAH onset may increase the risk of expanding haematomas, especially in patients with dense focal SAH.     

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.     

颅内动脉瘤破裂合并颅脑损伤5例分析

目的探讨颅内动脉瘤破裂合并颅脑损伤的临床特征,以此鉴别创伤性蛛网膜下腔出血。方法对我院近三年来收治的5例颅内动脉瘤破裂合并颅脑损伤患者的临床资料进行回顾性研究,总结其临床特征。结果 4例患者入院后急诊经CTA检查证实为颅内动脉瘤破裂出血,其中前交通动脉瘤2例,大脑中动脉瘤1例,颈内动脉-后交通动脉瘤l例;1例患者为动脉瘤再次破裂后行CTA检查示颈内动脉-后交通动脉瘤。急诊开颅血肿清除及动脉瘤夹闭术2例,动脉瘤夹闭术1例,血管内介入栓塞治疗术1例,药物保守治疗1例。恢复良好3例,重残1例,死亡l例。结论对伴有颅脑外伤史的蛛网膜下腔出血应注意考虑颅内动脉瘤破裂的可能,以便采取积极合理的治疗方案。     

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.     

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

Abstract

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^-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. [Neurol Res 2000; 22: 151-155     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

Incidence of Neo-Intimal Hyperplasia in Anterior Circulation Aneurysms Following Pipeline Flow Diversion

IntroductionFlow diversion of the distal anterior circulation cerebral vasculature may be used for management of wide necked aneurysms not amenable to other endovascular approaches. Follow-up angiography sometimes demonstrates neo-intimal hyperplasia within or adjacent to the stent, however there is limited evidence in the literature examining the incidence in MCA and ACA aneurysms. We present our experience with flow diversion of the distal vasculature and evaluate the incidence of neo-intimal hyperplasia.Materials and methodsRetrospective review of patients who underwent Pipeline embolization device (PED) treatment for ruptured and unruptured anterior circulation aneurysms.ResultsA total of 251 anterior circulation aneurysms were treated by pipeline flow diversion, of which 175 were ICA aneurysms, 14 were ACA aneurysms and 18 were MCA aneurysms. 6-month follow-up angiography was available in 207 patients. The incidence of neo-intimal hyperplasia was 15.9%, 21.4%, and 61.1% in ICA, ACA, and MCA aneurysms, respectively. MCA-territory aneurysms developed neo-intimal hyperplasia at a significantly higher rate than aneurysms in other vessel territories. Rates of aneurysmal occlusion did not significantly differ from those patients who did not exhibit intimal hyperplasia on follow-up angiography.ConclusionIn our experience, flow diversion of distal wide-necked MCA and ACA aneurysms is a safe and effective treatment strategy. The presence of neo-intimal hyperplasia at 6-month angiography is typically clinically asymptomatic. Given the statistically higher rate of neo-intimal hyperplasia in MCA aneurysms at 6-month angiography, we propose delaying initial follow-up angiography to 12-months and maintaining dual antiplatelet therapy during that time.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

脑动静脉畸形供血动脉远端动脉瘤破裂栓塞治疗

目的 探讨脑动静脉畸形相关的供血动脉远端破裂动脉瘤的特点与血管内治疗方法.方法 11例以自发性蛛网膜下腔出血发病的患者均接受数字减影血管造影,并被证实出血来源于脑动静脉畸形供血动脉远端破裂动脉瘤.根据动脉瘤的形态和供血动脉特点,选择以弹簧圈闭塞动脉瘤和载瘤动脉,或以高浓度生物胶栓塞动脉瘤和载瘤动脉.结果 11例栓塞后的动脉瘤均消失,未发生再出血,以弹簧圈栓塞的7例术后未发生新的神经系统症状;以生物胶栓塞的4例有2例术后发生栓塞部位的脑梗死.结论 脑动静脉畸形供血动脉远端动脉瘤破裂后血管内栓塞治疗可取得较好的效果,首选以弹簧圈栓塞动脉瘤和载瘤动脉,也可用高浓度生物胶栓塞,动静脉畸形可择期再处理.     

Early posttraumatic subarachnoid hemorrhage due to dissecting aneurysms in three children

Subarachnoid hemorrhage (SAH) due to a ruptured saccular aneurysm is uncommon in children. Pediatric traumatic aneurysms have been reported relatively frequently, tending to bleed after an interval of weeks after head injury. The authors describe three children with acute SAH after head injury caused by intracranial dissecting aneurysms. When head trauma in children is complicated by SAH in basal cisterns, dissecting aneurysms should be considered and treated, because rebleeding may occur.