颅内动脉瘤破裂弹簧圈介入栓塞术围术期护理体会

目的总结颅内动脉瘤破裂弹簧圈介入栓塞术的围术期护理体会。方法对36例接受弹簧圈介入栓塞治疗的颅内动脉瘤破裂患者给予围术期综合护理措施,回顾性分析患者的临床资料。结果本组患者术后出现脑积水5例,经侧脑室置管引流1周后拔除引流管痊愈。发生甲状腺功能减退3例,经口服甲状腺素片,甲状腺功能恢复正常。其余28例患者均顺利康复出院。随访6~16个月,全部患者均未遗留神经功能障碍,未发生再次出血,生活可以完全自理。结论弹簧圈介入栓塞治疗动脉瘤破裂,微创、治愈率高。护理人员应熟悉其临床特征、了解手术的方法及意义,做好围术期综合护理措施,以改善治疗效果,使患者早日康复出院。     

颅内动脉瘤弹簧圈栓塞治疗术中动脉瘤再破裂的防治

目的颅内动脉瘤在弹簧圈栓塞过程中发生破裂是最可怕的术中并发症之一，本文探讨处理、预防这一并发症的初步经验。方法2002年4月-2006年12月，共有153例患有颅内动脉瘤的患者在我院接受了可脱卸弹簧圈栓塞治疗，其中141例患者曾有过动脉瘤破裂引起蛛网膜下腔出血史。5例有动脉瘤破裂出血史的患者术中再次发生动脉瘤破裂。术中动脉瘤再破裂时，常规使用鱼精蛋白中和肝素，并设法用弹簧圈尽快填塞动脉瘤腔。微导丝引起动脉瘤破裂时，尽量保持微导丝不动，微导管尽快送到瘤腔中进行填塞治疗。若微导管引起破裂而微导管头端位于瘤壁外蛛网膜下腔时，微导管且勿退入瘤腔内，应将弹簧圈经微导管送入蛛网膜下腔一部分后，再将微导管头撤入瘤腔内，继续弹簧圈填塞。若弹簧圈引起破裂，要将弹簧圈完全或部分送出去，将破裂口堵住后，调整微导管头端位置继续弹簧圈填塞。结果在接受动脉瘤栓塞治疗的153例患者中，141例曾有过动脉瘤破裂引起蛛网膜下腔出血，治疗中5例发生了术中再破裂，占动脉瘤破裂引起蛛网膜下腔出血的3．5％，总发生率为3．3％。1例破裂由导丝引起，1例由微导管引起，1例由弹簧圈过度填塞引起，弹簧圈穿孔1例，其余1例由微导管和弹簧圈共同引起。2例死亡，死亡率占术中破裂的40％，占总例数的1．3％；1例患者出院时遗留有右下肢瘫痪，其余2例患者无残留神经系统并发症。结论动脉瘤栓塞术中动脉瘤的再破裂是一少见、威胁生命但又不可避免的事件。应该立即采取妥善措施以挽救患者生命、改善预后、降低可怕并发症的发生。如处理恰当，多数术中动脉瘤破裂的患者能够存活，无后遗症。     

颅内动脉瘤栓塞术的护理

颅内动脉瘤致死的主要原因是出血及早期并发症，以往直接手术夹闭为主要治疗方法，但损伤较大。近年来，随着介入放射学的发展，血管内栓塞成为新的独特的治疗方法，它的主要特点在于微创性，利用人体正常的血管通道，到达动脉瘤腔进行施治，故无需开颅亦不必翻动脑组织，同时也避免了外科的血管分离操作，缩短了住院和康复时间，降低了手术死亡率．。近几年来我院共行血管内栓塞治疗动脉瘤9例，效果满意，现就护理方法介绍如下。     

动脉瘤性蛛网膜下腔出血后脑血管痉挛和围术期容量治疗

背景 动脉瘤破裂蛛网膜下腔出血后脑血管痉挛(cerebral vasospasm,CVS)是一个常见而严重的并发症.CVS造成的继发性脑组织缺血或迟发性脑损伤严重影响患者的预后,是动脉瘤性蛛网膜下腔出血(aneurysm subarachnoid hemorrhage,aSAH)患者伤残和死亡的主要因素. 目的 探究围术期液体治疗和循环容量管理在aSAH后CVS预防和治疗中的有效性,为减少脑动脉瘤手术后CVS发生、改善预后提供参考. 内容 探究动脉瘤破裂蛛网膜下腔出血后CVS病因、病理生理以及如何选择合适的液体进行容量治疗和三高疗法来防治CVS的发生. 趋向 深入研究脑动脉瘤破裂出血后CVS的发病机制和探讨围术期液体治疗以及循环容量管理,为临床防治CVS提供新的思路和方法.     

脑动脉瘤和脑血管畸形微导管栓塞术的麻醉探讨

脑动脉瘤和脑血管畸形微导管栓塞术的麻醉探讨孔庆仕微导管（Ｍａｇｉｃ－ＢＤ２Ｌ）栓塞术使脑动脉瘤、脑血管畸形患者无需开颅而得到治疗目的。本文应用神经安定镇痛麻醉（ＮＬＡ）和ＳＮＰ控制性降压行微导管栓塞术８例取得满意效果。现将麻醉方法进行总结和探讨。临床...     

持续输注尼莫地平对颅内动脉瘤夹闭术中脑血管痉挛的影响

目的 了解颅内动脉瘤夹闭术中异氟醚麻醉复合输注尼莫地平对脑血管痉挛的影响。方法择期颅内动脉瘤夹闭术患者30例,随机表法分为两组:异氟醚组和尼莫地平组(各15例),异氟醚组术中吸入1个肺泡气最低有效浓度(MAC)异氟醚维持麻醉;尼莫地平组在诱导后输注尼莫地平20 μg·kg-1·h-1至手术结束后,同时吸入1 MAC异氟醚维持麻醉。术中于动脉瘤夹闭前、夹闭后即刻、2 h、4 h取脑脊液采用酶联免疫吸附试验法测定S100B含量;于动脉瘤夹闭前后测定载瘤动脉近心端及远心端血流速度。结果(1)尼莫地平组在动脉瘤夹闭前后脑脊液SIOOB含量无显著变化,而异氟醚组在动脉瘤夹闭后4 h S100B含量显著升高(F=4.11,P<0.05)。(2)尼莫地平组在动脉瘤夹闭前后载瘤动脉近心端血流速度[(15±9)与(19±8)cm／s]显著低于异氟醚组[(24±13)与(26±10)cm／s,t=2.08,P<0.05],而远心端血流速度无显著性差异。结论在颅内动脉瘤夹闭术中持续输注尼莫地平20μg·kg·-1·h-1对脑血管痉挛有一定预防作用。     

弹簧圈栓塞联合枕大池置管引流治疗脑动脉瘤破裂

破裂脑动脉瘤 (ＡＮ)的传统治疗方法是开颅夹闭瘤颈并尽可能地清除位于蛛网膜下腔的血块。电解可脱式弹簧圈(ＧＤＣ)栓塞术能在不开颅的情况下闭塞ＡＮ[1] ,防止再出血。但其缺点是无法清除蛛网膜下腔的血块 ,而后者是导致脑血管痉挛 (ＣＶＳ)的直接原因。我科在ＧＤＣ栓塞ＡＮ后 ,采用微导管插入枕大池注射尿激酶 (ＵＫ)溶解血块并持续引流的方法治疗急性破裂期ＡＮ。1 临床资料与方法 :(1)一般资料 :2 0 0 0年 9月～ 2 0 0 2年 1月 ,采用本法治疗 15例 72ｈ内破裂的脑ＡＮ。其中男 6例 ,女 9例 ;平均年龄 5 2岁 ;Ｆｉｓｈｅｒ分级[3 ] :Ⅲ…     

颅内动脉瘤显微夹闭术后脑血管痉挛防治的护理配合

目的探讨颅内动脉瘤显微夹闭术后脑血管痉挛防治的护理方法及疗效。方法随机收集行颅内动脉瘤显微夹闭手术病人30例,所有病例均实施3H疗法,对之实施强化护理,观察其疗效。结果30例中,术后经TCD证实发生脑血管痉挛者15例,其中出现脑缺血临床症状者12例,给予3H(即高血压、高血容量及高血液稀释度)治疗及护理等综合处理后病人脑血管痉挛均逐渐获得改善,无死亡病例。植物生存状态5例,完全生活自理18例,部分生活自理者7例。结论颅内动脉瘤显微夹闭术后继发脑血管痉挛是影响病人预后的重要因素,在众多防治脑血管痉挛对策中,3H疗法是一种更具希望的方法,在该疗法的实施过程中,我们体会到有意识地配合及加强对病人血压、中心静脉压、出入量、呼吸、心率等临床指标的动态监测,对于保证该疗法的顺利实施及避免相关并发症的发生是具有肯定作用的,值得临床推广。     

超选择肾动脉分支栓塞术治疗肾部分切除后假性动脉瘤破裂出血一例

肾部分切除术后,肾内形成假性动脉瘤并破裂出血,是比较少见而严重的并发症,尤其是当双肾功能不全或为孤立肾时,处理甚为困难。我院用超选择性肾动脉分支栓塞术治疗1例肾部分切除术后假性动脉瘤破裂并反复严重出血、同时存在肾功能不全的患者,取得成功。现报道如下。患者,男性,54岁。因两腰隐痛伴血尿20年,KUB示双肾多发巨大结石,IVP示双肾显影不佳,于1988年5月24日在外院作右肾部分切除(切除下极约1/5)取石术。取出结石1000余枚,最大6×4     

破裂与未破裂宽颈动脉瘤支架辅助栓塞治疗的效果研究

目的分析破裂与未破裂宽颈动脉瘤支架辅助栓塞治疗的效果。方法选择2015-01—2017-01间收治的35例破裂宽颈动脉瘤患者作为破裂组,选择同期收治的35例未破裂宽颈动脉瘤患者作为未破裂组。2组均行支架辅助栓塞治疗。比较2组疗效、致残率与病死率、围手术期不良事件的发生率。结果未破裂组预后良好率高于破裂组,差异有统计学意义(P0.05)。2组致残率、病死率及围手术期不良事件的发生率,差异无统计学意义(P0.05)。结论支架辅助栓塞治疗破裂宽颈动脉瘤,具有一定的效果,但仍需要谨慎选用。     

Rebleeding after endovascular embolization of ruptured cerebral aneurysms

This study retrospectively reviewed 227 patients with ruptured solitary cerebral aneurysm who underwent endovascular embolization with detachable coils between March 1997 and March 2006 to establish the incidence of rebleeding after endovascular treatment for ruptured cerebral aneurysm and identify the risk factors. The site and size of the aneurysm, the interval between treatment and rebleeding, and the outcome were investigated in six of the 227 patients (2.6%) who rebled after treatment. Four patients had large or giant aneurysms located on the internal carotid artery at the origin of the posterior communicating artery. The interval between treatment and rebleeding was less than 1 year in four patients (mean 394.2 days). Two patients died, and the survivors had modified Rankin Scale scores of 0, 2, 3, and 4. Re-embolization was performed in four patients and no further bleeding occurred during the mean follow-up period of 1.9 years after re-treatment. Patients with giant aneurysms of the internal carotid artery are at increased risk for rebleeding. Re-treatment should be considered if there is conventional and/or magnetic resonance angiographic evidence of dome filling. Patients with ruptured cerebral aneurysms must be followed up with diagnostic imaging closely during the first 12 months post-embolization because rebleeding frequently occurs within 1 year after initial treatment. Re-embolization is safe and effective in patients with recurrent hemorrhage from aneurysms previously embolized with detachable coils.     

Acute serious rebleeding after angiographically successful coil embolization of ruptured cerebral aneurysms

Purpose  

The present study investigated the incidence of acute rebleeding after successful coil embolization of a ruptured cerebral aneurysm, including clinical outcomes, and possible mechanisms of the events other than coil compaction and/or incomplete embolization.     

Treatment of vasospasm after ruptured cerebral aneurysms by 'pellet-cisternal-drain: PCD' containing sustained-release vasodilators

Diltiazem or papaverine hydrochloride as vasodilators were polymerized with silicon polymer (MDX-4-4210: Dow Co.). The silicon pellets containing the drugs were placed in cisternal drainage tubes made of silicon, and used for the continuous cisternal drainage after the operations of ruptured cerebral aneurysms. This system was tentatively termed 'pellet-cisternal-drain; PCD'. The rate of diffusion of the drug from the pellets was examined in 30 patients who underwent surgery for ruptured cerebral aneurysms in the acute phase on the 0-4th postical days. 73.3% of patients had severe subarachnoid hemorrhage as group 3-4 in Fisher's classification in CT scan. The concentration of either drug in the cerebrospinal fluid on the 2nd to 3rd postoperative days reached the level of the maximum concentration obtained after bolus injection, and the level on the 5th to 10th postoperative days was similar to that observed several hours after bolus injection. The data showed that the sustained release pellet can act as a vasodilator, and its effects on cerebral vessels after an episode of subarachnoid hemorrhage continue for 2 to 3 weeks. All patients except one showed excellent results and returned to normal life.     

Hydrocephalus and vasospasm after subarachnoid hemorrhage from ruptured intracranial aneurysms

The incidence of hydrocephalus and vasospasm and the relationship between them were analyzed retrospectively in 87 patients with subarachnoid hemorrhage from ruptured intracranial aneurysms. Sixty-seven per cent of the patients showed ventricular enlargement on a computed tomographic scan done within 30 days of the hemorrhage; in patients whose first scan was done within 3 days of the hemorrhage, 63% seemed to have ventricular enlargement by a neuroradiologist's interpretation. Shunts were required in 14% of the patients because of delayed neurological deterioration or enlarging ventricles; 3% required ventriculostomy shortly after admission. Seventy-four per cent of the patients had angiographic spasm on an angiogram done within the first 30 days after hemorrhage. Sixty-two per cent of the patients had both hydrocephalus and vasospasm: 22% had neither. Five per cent had hydrocephalus, but no spasm; 11% had spasm, but no hydrocephalus. Hydrocephalus and vasospasm were significantly associated (P less than 0.01, chi2). These data document a high incidence of mild ventricular enlargement and angiographic vasospasm after subarachnoid hemorrhage. They also emphasize that these two sequelae of subarachnoid hemorrhage are closely linked, probably by the presence of blood in the basal cisterns obstructing cerebrospinal fluid flow and surrounding arteries there.     

Timing and indication of surgery for ruptured intracranial aneurysms with regard to cerebral vasospasm

Summary The authors survey 443 cases of intracranial aneurysms treated in the past seven years. 403 cases were operated upon with microsurgical techniques. The operative mortality was 5.4 per cent, and 82.4 per cent of surgically treated cases are well and working, leading useful social lives. It was found that cases submitted to surgery in the first three days after subarachnoid haemorrhage (SAH) (the day of SAH being counted as the first day) showed good results, little appearance of postoperative vasospasm, and no mortality due to vasospasm. Cases operated upon after one week from the insult of SAH also showed good results, whereas fatal postoperative vasospasm was seen in cases operated upon on the 4th–7th day after SAH. Cisternal, ventricular, and epidural drainage are recommended after the clipping of aneurysms in the acute stage of SAH.There were 68 cases with preoperative vasospasm. There was no case in which vasospasm was identified during the first four days after SAH, while 66 per cent of the cases exhibited vasospasm between the sixth and ninth days after SAH. These 68 cases can be classified into four groups: 1. 8 cases died from vasospasm before surgery; 2. 8 cases had renewed bleeding mainly when vasospasm began to subside; 3. 22 cases underwent surgery after vasospasm had subsided, the duration of vasospasm ranging from 8 to 24 days, on an average 14 days; 4. 30 cases underwent surgery while vasospasm was still present; of this group, (4E) 15 cases submitted to surgery, on an average 4.5 days after the onset of vasospasm, manifested deterioration of clinical states because of aggravation or new appearance of vasospasm; (4L) 15 cases which underwent surgery, on an average 7.4 days after the onset of vasospasm, showed no such deterioration. In the follow-up, well and working cases were seen in 45.5 per cent (3.), 60 per cent (4E), and 80 per cent (4L), respectively.The authors classified vasospasm into three types: Type 1, extensive diffuse, Type 2, multi-segmental, and Type 3, local. Type 1 was prognostically worst, Type 3 good, and Type 2 was located between these two types.     

Re-bleeding during embolization of ruptured cerebral aneurysms by Guglielmi detachable coil

Intra-aneurysmal embolization by Guglielmi detachable coil (GDC) is becoming an important method in treatment of intracranial aneurysm. However, intraoperative bleeding remains an essential problem. We reviewed our anesthesia records in patients treated with GDC embolization. Ninety four cases of ruptured cerebral aneurysms were treated with GDC embolization, including 59 females and 35 males. Their ages ranged from 21 to 88, with mean age of 67 years. Preoperative Hunt and Hess grading scales were 1 in 3 cases, 2 in 31, 3 in 40, 4 in 16 and 5 in 4. Intraoperative re-bleeding occurred in 3 cases. These were confirmed by extravasation in angiography or by increased HDA in CT. Each case has berry aneurysm. Acute hypertension at re-bleeding was treated with nicardipine as well as by increasing dose of anesthetic, and hemostasis was obtained by hypotension and reversal of heparin with protamine. After disappearance of extravasation, the procedures were continued. Anesthesia was maintained with fentanyl-propofol in 1 case and sevoflurane in 2 cases. Direct hemostasis is impossible during endovascular surgery and management of systemic circulation by an anesthesiologist is necessary.