CT血管造影阴性自发性蛛网膜下腔出血患者的处理

自2006年1月至2009年12月我院共收治自发性蛛网膜下腔出血(subarachnoid hemorrhage,SAH)患者645例,所有患者均首选CT血管造影(computed tomography angiography,CTA)检查,其中586例共发现颅内动脉瘤591个,12例为脑血管畸形、Moyamoya病等,47例CTA检查阴性,回顾性分析这     

三维CT血管造影术在急性蛛网膜下腔出血颅内动脉瘤诊断中的应用

目的探讨三维CT血管造影术（3D-CTA）在急性蛛网膜下腔出血（SAH）颅内动脉瘤诊断中的应用。方法采用3D-CTA和DSA对26例非外伤性SAH患者进行检查，3D-CTA通过最大密度投影（MIP）、表面遮盖法重建（SSD）和容积重建术（VRT）方法获得图像．根据3D-CTA和DSA所获得的关于动脉瘤的位置、大小等进行术前评估。结果在26例中24例3D-CTA检测出27个动脉瘤，瘤体直径3-2mm，1例后交通动脉瘤3D-CTA不能证实，1例未检出动脉瘤；14例行DSA检查，其中1例未检出动脉瘤而通过3D-CTA发现，1例右椎动脉梭形动脉瘤因DSA行右椎动脉造影失败而通过3D-CTA发现。12例仅凭3D-CTA手术，3D-CTA在检查动脉瘤的位置、大小、瘤体方向及对载瘤动脉和分支动脉的形态描述均优于DSA，它在诊断颅内动脉瘤的敏感性和特异性分别为96％和100％。结论3D-CTA是一种准确、价廉、非侵袭性的诊断颅内动脉瘤SAH的方法，在动脉瘤的急诊手术时较DSA更具优越性。     

造影阴性的动脉瘤性蛛网膜下腔出血

脑血管造影检查是揭示自发性蛛网膜下腔出血（SAH）病因的主要手段，但相当一部分病人因首次造影结果呈阴性而被漏诊。动脉瘤内及瘤周的复杂病理、生理改变，及某些人为因素如术前准备不足，术者操作不熟练等，均可导致首次造影呈阴性。本文即就蛛网膜下腔出血首次造影阴性的原因进行综述。     

首次造影阴性13例动脉瘤性蛛网膜下腔出血患者临床分析

目的探讨首次全脑血管造影阴性的动脉瘤性蛛网膜下腔出血患者的临床特点及治疗经验。方法回顾分析我科自2009-01—2015-12收治的首次DSA呈阴性,二次造影发现动脉瘤13例蛛网膜下腔出血患者的临床资料。结果 13例患者中动脉瘤部位:前交通动脉瘤6例,大脑中动脉瘤3例,胼周动脉瘤2例,眼动脉段动脉瘤2例;动脉瘤的大小及瘤颈情况:直径2~3mm动脉瘤7例(窄颈5例),4~5mm动脉瘤6例(窄颈5例)。结论微小或窄颈动脉瘤性蛛网膜下腔出血患者首次造影可能存在假阴性,及时复查DSA并给予适宜治疗,对改善患者预后十分重要。     

自发性蛛网膜下腔出血脑血管造影阴性的诊治对策

目的 探讨蛛网膜下腔出血(SAH)病人可能存在的出血原因，寻求当首次脑血管造影阴性时的诊治对策。方法 回顾性分析我科近5年来322例SAH出血病人，其中55例病人首次血管造影阴性。结果 17例因再出血或遵医嘱行2次脑血管造影，3例发现颅内动脉瘤，l例发现左颞叶底部脑动静脉畸形(AVM)。2例重复脑血管造影阴性行开颅手术探查，证实分别为前交通动脉瘤和左侧颈内动脉后交通动脉瘤；8例行MRI检查，1例发现胼胝体AVM；8例行CTA检查，1例发现前交通动脉瘤。1例因出现典型的下肢放射痛而行脊髓血管造影，发现L2AVM。结论 对于SAH后首次造影阴性的病人，应行重复血管造影，结合MRI、MRA及CTA检查可提高诊断率，必要时行手术探查。     

动脉瘤性蛛网膜下腔出血临床研究进展

血液外溢到脑表面充满脑脊液的腔隙中形成脑蛛网膜下腔出血(SAH),临床上将其分为创伤性和自发性两类,后者又分为原发性与继发性两种.因脑实质内出血血液穿磁脑组织流入蛛网膜下腔者称继发性SAH;由各种原因引起脑底部及脑表面血管破裂使血液流入蛛网膜下腔者称为原发性SAH.……     

CT血管造影在急性蛛网膜下腔出血诊断及治疗中的应用

我院自1998年7月至2000年1月对50例急性蛛网膜下腔出血(SAH)的病人进行了CT血管造影(CTA)检查,部分病例与数字减影血管造影(DSA)相比较,以探讨CTA对SAH的诊断价值及在手术设计中的指导意义。     

64排螺旋CT头颈部CTA检查对脑动脉瘤合并自发性蛛网膜下腔出血的临床应用

目的评价64排螺旋CT头颈部CTA检查对脑动脉瘤合并自发性蛛网膜下腔出血(SAH)的临床应用价值。方法回顾性分析83例脑动脉瘤合并SAH患者的CT血管成像(CTA)检查结果,影像学资料经容积再现(VR)、最大密度投影(MIP)、多平面重建(MPR)、仿真内窥镜(VE)技术等技术处理,将该结果与DSA或手术结果进行对照研究。结果 83例患者中,DSA或手术结果检出瘤体93个(单个瘤体73例,2个瘤体10例),CTA共检出瘤体91个,与DSA或手术结果比较漏诊2个,CTA的诊断敏感性为97.8%,诊断符合率很高(χ2=25.632,P=0.011)。结论 CTA检查脑动脉瘤合并SAH快速、无创,且敏感性很高,能够显示瘤体大小、瘤颈、瘤轴指向以及载瘤动脉与血管的关系等信息,具有很高的临床参考价值。     

颅内动脉瘤自发性蛛网膜下腔出血的介入治疗

目的 总结介入治疗自发性蛛网膜下腔出血的临床经验.方法 对26例自发性蛛网膜下腔出血患者进行数字减影脑血管造影(DSA)检查,23例确诊为动脉瘤患者进行血管内栓塞治疗.结果 23例动脉瘤患者全部成功栓塞治疗,2例术后出现脑梗死,经溶栓治疗完全康复.结论 介入技术为自发性蛛网膜下腔出血的治疗提供了崭新的方法.     

320排CT血管造影检测颅内动脉瘤的临床研究

目的探讨320排CT血管造影(CTA)对颅内动脉瘤的诊断价值。方法回顾性分析16例脑血管病人的临床资料,均先行320排CTA检查、DSA和三维旋转血管造影(3DRA)检查。所得图像均由2位神经外科专家行双盲法分析。结果 320排CTA发现动脉瘤13例、共15个;动脉瘤直径1.4~6.4 mm,平均为3.4 mm。DSA和3DRA发现动脉瘤14例、共17个;动脉瘤直径0.97～6.16 mm,平均为3.62 mm。经统计学分析,320排CTA与DSA和3DRA对颅内动脉瘤直径的测定差别有统计学意义(P<0.05)。结论 320排CTA检测颅内动脉瘤具有可行性,但可能会漏诊极小的动脉瘤,无法取代DSA和3DRA金标准的地位。     

Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic “triple‐H” therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.     

动脉瘤性蛛网膜下腔出血后脑血管痉挛与血浆花生四烯酸代谢产物的关系

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)病人血浆花生四烯酸代谢产物的含量与脑血管痉挛(CVS)发生、发展之间的关系。方法选取34例aSAH病人作为研究组,在aSAH后第1、3、7、14天抽取外周静脉血测定血栓素B2(TXB2)和6-酮-前列腺素F1α(6-Keto-PGF1α)的含量。另选取同时期健康成人6例作为对照组,进行对比研究。结果研究组发生CVS 23例,其中表现为迟发性缺血性神经功能障碍(DIND)的症状性CVS 10例,无症状性CVS(无DIND)13例。与对照组相比,研究组各时间点血TXB2含量均明显升高,而血6-Keto-PGF1α含量变化无显著性差异;与无CVS病人相比,CVS病人血TXB2含量在各时间点均明显升高,而血6-Keto-PGF1α含量仅在第7天时明显降低;与无DIND病人相比,DIND病人血6-Keto-PGF1α含量在第1、3、14天明显降低,而血TXB2含量仅在第3天时明显升高。结论 aSAH后CVS、DIND的发生、发展与血TXB2、6-Keto-PGF1α含量变化可能存在相关性。     

Whole brain CT perfusion combined with CT angiography in patients with subarachnoid hemorrhage and cerebral vasospasm

Objective

To assess cerebral vasospasm (CVS) and monitor cerebral microcirculatory changes in patients with acute subarachnoid hemorrhage (SAH) via CT angiography (CTA) combined with whole-brain CT perfusion (CTP) techniques.

Methods

Sixty patients with SAH (SAH group) and 10 patients without SAH (control group) were selected for a prospective study. CTP combined with CTA and digital subtraction angiography (DSA) studies were performed on patients with initial onset of SAH less than three days. CTA and DSA as well as the CTP parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time-to-peak (TTP) were acquired and analyzed. The relationship of CTA and CTP measurements was assessed in these acute SAH patients.

Results

CTP techniques were used to achieve the perfusion maps of the whole brain in patients with acute SAH. Compared to the control group, mean CBF value was significantly lower while both MTT and TTP values were significantly higher in SAH group (all p < 0.05). Further analysis revealed that mean CBF in patients with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V significantly decreased when compared to patients with nCVS, asCVS, Fisher I–II and Hunt–Hess I–II (p < 0.05). Furthermore both MTT and TTP values were also significantly reduced in patient with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V (p < 0.05).

Conclusion

The study demonstrated that changes of microcirculation in patients with SAH could be assessed by whole-brain CTP. CTP combined with CTA could detect both macroscopic evident vasospasm on CTA and alterations of microcirculation on CTP. Mean CBF was significantly lower in patients with SAH.     

Subarachnoid blood on CT and memory dysfunctions in aneurysmal subarachnoid hemorrhage

Ninety patients with a previous subarachnoid haemorrhage (SAH) were given a set of memory tests comprising immediate free recall of words (indexing long-term memory, LTM, and short-term memory, STM), final free recall of words (indexing LTM), final cued recall of words (indexing LTM), and a digit span test (indexing working memory, WM). Patients with a large amount of blood on CT, carried out within 72 h of the bleed, showed LTM as well as STM dysfunction, whereas patients with a small amount of subarachnoid blood evidenced only STM dysfunction. Patients with the ruptured aneurysm located on the anterior cerebral artery, however, constituted an exception with dysfunction of both LTM and STM together with intact WM, independent of the amount of subarachnoid blood. Also, patients with internal carotid artery or middle cerebral artery aneurysms and large volume SAH displayed LTM dysfunction, but differed concerning STM, the former showing intact STM and the latter showing STM dysfunction. Thus, it appears, that the combined information from factors such as the amount of subarachnoid blood and the location of the ruptured aneurysm is of vital importance for explaining the different patterns of memory dysfunctions after SAH.     

CT在诊断动脉瘤性蛛网膜下腔出血中的临床应用研究(附140例报道)

目的 探讨CT在诊断动脉瘤性蛛网膜下腔出血(ASAH)中的应用价值。方法 回顾性分析了140例CT。表现为SAH并拟诊为颅内动脉瘤(AN)的临床病例资料，从中找出AN破裂在CT。上的出血规律。结果 经CT诊断为ASAH140例，其中133例经脑血管造影(DSA)、核磁共振血管造影(MRA)和直接手术证实为AN，7例没有发现AN，CT诊断AN的阳性率为95％。发现不同部位的AN破裂所引起的SAH在CT上的表现不同，其出血有一定规律。结 论通过CT检查，可以初步对AN进行定位和定性诊断，对AN的进一步检查和治疗有重要的临床意义。     

脑室内注射硝普钠防治动脉瘤性蛛网膜下腔出血术后脑血管痉挛的疗效分析

目的研究脑室内注射硝普钠防治动脉瘤性蛛网膜下腔出血后脑血管痉挛的疗效及安全性。方法将313例动脉瘤性蛛网膜下腔出血病人随机分为硝普钠治疗组（105例）和常规治疗组（208例）。均在出血后3 d内行动脉瘤夹闭术,硝普钠治疗组术后予常规治疗和脑室内注入硝普钠,而常规治疗组则仅予常规治疗。结果与常规治疗组比较,术后1-7 d硝普钠治疗组病人大脑中动脉流速均显著降低（P〈0.05）。硝普钠治疗组发生迟发性脑血管痉挛（DCVS）14例（13.3%）,继发性脑梗死7例（6.7%）;常规治疗组发生DCVS 45例（21.6%）,继发性脑梗死34例（16.3%）;两组DCVS和继发性脑梗死发生率差异均有统计学意义（P〈0.05）。两组预后差异显著（P〈0.05）,而并发症发生率差异无统计学意义（P〉0.05）。结论脑室内注入硝普钠能显著改善蛛网膜下腔出血后脑血管血流动力学变化,副作用小,是一种治疗DCVS安全、有效的新疗法。     

动脉瘤性蛛网膜下腔出血后脑血管痉挛和脑低灌注的相关性分析

目的分析动脉瘤性蛛网膜下腔出血(aSAH)后脑血管痉挛及脑灌注异常的相关性。方法回顾性分析52例aSAH病人的临床资料。在出血后3～15d内均接受CT血管造影(CTA)和CT灌注成像(CTP)检查,了解大脑前动脉(ACA)和大脑中动脉(MCA)血管痉挛的严重程度,以及相关供血区域的脑灌注情况,对获取的参数进行统计学分析和比较。结果无脑血管痉挛23例,其中发生脑低灌注5例(21%)(位于脑分水岭区4例,在脑沟积血附近1例)。轻中度脑血管痉挛18例,其中存在相关供血区域脑低灌注7例(38%)。重度脑血管痉挛11例,其中发生相关供血区域脑低灌注9例(81%)。比较无脑血管痉挛与重度脑血管痉挛血管节段的血流灌注区域,在局部脑血流量(rCBF)和平均通过时间(MTT)两方面,差异均存在统计学意义(P0.05)。结论重度脑血管痉挛是相关供血区域发生脑低灌注的高危因素。无明显脑血管痉挛的病人,在脑分水岭区和脑沟积血附近也可发生脑低灌注,可能与脑微血管痉挛有关。     

Value of repeat-angiography in cases of unexplained subarachnoid hemorrhage (SAH)

Purpose – To investigate the rate of false negative initial cerebral angiography in spontaneous SAH and to ascertain why aneurysms remain undetected. Furthermore to validate CCT in predicting the presence and site of an angiographically missed aneurysm. Methods – Forty-two patients with spontaneous SAH were investigated, in whom initial cerebral angiography did not reveal any bleeding cause. Repeat-angiography was performed in all patients 5 to 55 days (mean 15 days) after the bleeding event. All patients underwent CCT scans within 48h after the ictus. Results – In 8 of 42 patients (19%) repeat-angiography revealed an aneurysm missed on initial angiography. The aneurysms were located on the AcomA (n = 2), the MCA (n = 2), the ACA (n= 1), the PICA (n = 2) and the junction of ICA and PcomA (n = 1). Presumable reasons for missing an aneurysm were spasms detected in four of eight cases on initial angiography and thrombosis of the aneurysm found in two cases at surgery. In two cases, multiple additional views just revealed the aneurysm appearing different in size and shape on repeat-angiography. CCT blood distribution pattern in four cases indicated presence and site of an aneurysm, while blood distribution was non-specific in the other four cases. Conclusion – Repeat-angiography plays an important role in defining the site of an initially occult aneurysm and should be performed in all cases of unexplained SAH. It is of particular importance if vasospasm has compromised the initial angiogram or if one part of the vascular tree is not optimally seen.