颅内动脉瘤的介入治疗进展

颅内动脉瘤是一种较常见的脑血管疾病,是引起蛛网膜下腔出血的主要原因,死亡率可高达25%～60%[1].介入治疗颅内动脉瘤,因其创伤小,疗效好,能解决部分开颅手术无法解决的问题,已成为治疗颅内动脉瘤的重要手段.     

颅内椎动脉夹层动脉瘤介入治疗个体因素分析

目的 总结介入栓塞治疗颅内椎动脉夹层动脉瘤(IVADA)影像和临床效果,探讨个体化治疗策略.方法 回顾性分析2011年至2015年郑州大学第一附属医院分别采用单纯弹簧圈栓塞、夹层动脉瘤及载瘤动脉闭塞、支架辅助弹簧圈栓塞和覆膜支架植入术治疗的24例IVADA患者资料、治疗经过及临床疗效,探讨不同动脉瘤介入治疗时须考虑的个体化因素.结果 24例IVADA患者介入治疗均获成功:动脉瘤和载瘤动脉闭塞5例,弹簧圈栓塞动脉瘤1例,支架辅助弹栓塞动脉瘤16例,覆膜支架植入2例.术后临床随访平均11个月(5～29个月),所有患者症状明显减轻或消失,无新发出血.12例获脑血管造影随访,11例夹层动脉瘤不显影,1例复发,再次介入治疗.结论 介入栓塞术治疗IVADA安全有效,须结合夹层动脉瘤是否破裂及相关临床症状、是否位于优势侧椎动脉及对侧椎动脉情况、动脉瘤形态及是否累及小脑后下动脉制定个体化治疗方案.     

血管内介入治疗周围型颅内动脉瘤17例

目的 报道血管内介入治疗周围型颅内动脉瘤的效果和临床经验,探讨介入治疗策略.方法 2010年1月至2015年12月采用血管内介入术治疗17例周围型颅内动脉瘤(男7例,女10例,平均年龄52.1岁),1例为偶然发现的血流相关性动脉瘤,16例为蛛网膜下腔出血,其中3例伴有脑实质内血肿,1例伴发脑室内出血,1例为偶然发现的其它部位动脉瘤破裂.动脉瘤位于小脑上动脉1例,脉络膜前动脉1例,大脑前动脉8例,小脑后下动脉4例,大脑后动脉3例.囊性动脉瘤9例,夹层动脉瘤7例,假性动脉瘤1例.所有动脉瘤均为小动脉瘤,2例梭形夹层动脉瘤缺乏明确瘤颈,15例为窄颈,其中5例体-颈比≤2,10例体-颈比＞2.结果 血管内介入治疗技术成功率为100％.术后即刻,11例弹簧圈栓塞患者中7例囊状动脉瘤完全闭塞,1例囊状动脉瘤和2例夹层囊状动脉瘤不全闭塞,1例夹层囊状动脉瘤瘤颈残留;6例动脉瘤和载瘤动脉同时栓塞患者中5例完全闭塞,1例不全闭塞、载瘤动脉部分闭塞.术后3例出现神经功能缺损,其他患者无新发神经功能缺损.出院时改良Rankin量表(mRS)评分为0分14例,2分1例,4分2例.术后6～9个月血管造影和临床随访显示,11例弹簧圈栓塞患者中7例动脉瘤仍保持完全闭塞,3例不全闭塞,1例瘤颈残留患者复发;6例动脉瘤和载瘤动脉同时栓塞患者中5例动脉瘤仍保持完全闭塞,1例载瘤动脉再通.末次随访显示14例保持mRS评分0分,1例保持4分不变,2例mRS评分有明显改善.结论 对于外科手术治疗较困难的周围型颅内动脉瘤,血管内介入治疗是一种安全有效的治疗方法.选择何种血管内介入治疗策略取决于动脉瘤部位、性质、形态、血管入路迂曲程度和载瘤动脉供血区功能重要程度.     

颅内动脉瘤的影像诊断进展

颅内动脉瘤是一种较常见的脑血管疾病,是引起自发性蛛网膜下腔出血(subarachnoid hemorrhage,SAH)的主要原因,约占54%～75%[1].最近由Van Gijn等[2]统计的资料在SAH中颅内动脉瘤占85%.颅内动脉瘤致死率可高达25%～60%[3].因此颅内动脉瘤的早期诊断、早期治疗显得尤为重要.国内外学者就如何及时、准确地诊断颅内动脉瘤做了大量研究.我们现就其影像学诊断及其进展综述如下.     

介入治疗基底动脉夹层动脉瘤效果分析

目的 评价血管内介入治疗基底动脉夹层动脉瘤的安全性、有效性.方法 回顾性分析2009年1月至2015年4月在我院接受血管内介入治疗的26例基底动脉夹层动脉瘤患者.按瘤体大小分为大型-巨大型组和中小型组,比较两组患者治疗效果.记录并发症和随访情况.结果 26例基底动脉夹层动脉瘤患者均获得成功治疗,其中接受单纯支架植入9例,支架植入结合弹簧圈栓塞17例.围手术期共发生5例并发症,其中3例为后循环梗死(单纯支架组1例,支架结合弹簧圈组2例),2例为小脑出血(均发生于支架结合弹簧罔组),随后4例恢复良好出院,1例支架内急性血栓形成死亡.22例患者获得DSA随访,结果显示12例改善,7例稳定,3例复发(2例有新发症状).亚组分析显示单纯支架组并发症发生率低于支架结合弹簧罔组,两组远期疗效相当;大型-巨大型组并发症发生率和严重残死率均高于中小型组,差异均有统计学意义(P=0.020,Z=3.247).结论 血管内介入治疗基底动脉夹层动脉瘤有较好的安全性和有效性.多重支架技术仍然是目前优先推荐的术式,需依据不同病变特点确定是否使用弹簧罔辅助.大型和巨大型夹层动脉瘤治疗仍然棘手,需要进一步研究.     

颅内椎基底动脉狭窄的支架成形术治疗

目的　初步总结血管内支架成形术治疗颅内椎基底动脉狭窄的经验 ,探讨治疗的可行性、安全性及有效性 ,分析技术要点和围手术期处理。方法　 2 2例 2 3个颅内椎基底动脉狭窄进行了支架植入扩张成形治疗 ,其中颅内段椎动脉狭窄 10个 ,基底动脉狭窄 13个 ,术前平均狭窄程度 (72 .4±11.3 ) % (5 0 %～ 90 % ) ,平均狭窄长度 (6.8± 3 .1)mm(3～ 12mm) ,植入球囊扩张支架 2 3枚 ,作临床及造影随访。结果　 2 3个狭窄支架植入均成功 ,狭窄率降低到 (9.3± 5 .2 ) % ,无夹层动脉瘤、血管破裂、支架内急性闭塞并发症 ,手术造成缺血性小卒中 1例 (4.5 % ) ,无死亡。临床随访 3～ 2 4个月 ,无脑缺血性事件发生 ,血管造影随访 10例 ,无再狭窄发生。结论　症状性颅内椎基底动脉狭窄的血管内支架成形治疗是一种有效、安全的方法 ,但远期结果仍需要进一步随访     

栓塞颅内动脉瘤治疗蛛网膜下腔出血的护理探讨

目的：探讨微弹簧圈栓塞颅内动脉瘤治疗蛛网膜下腔出血的护理。方法：术前做好各项准备，包括病人、药品、器械及介入室内的准备。估计术中可能发生的问题，并制定相应的抢救护治措施，备齐特殊的抢救药品及器械。术中严密监测生命体征，动态观察意识及瞳孔变化。采取描施预防并发症。结果：本组100％闭塞32例，95％闭塞2例，90％以下闭塞1例；30例恢复良好，2例发生轻度肢体功能障碍。1例严重偏瘫，2例死亡。结论：充分术前准备．术中默契配合，术后防治各种并发症，是手术成功的必备条件。这一方法可以降低死亡率和致残率．明显改善预后．值得临床推广应用。     

颅内动脉瘤与出血

探讨颅内动脉瘤与蛛网膜下腔出血的关系。材料和方法：对110例动脉瘤患者，根据部位、年龄、大小、性别及单发或多发分别进行分组来探讨动脉瘤与蛛网膜下腔出血的关系。结果：（1）发生于大脑前动脉、大脑中动脉、前交通动脉的动脉瘤容易出血。（2）年龄越大，动脉瘤越容易出血。（3）多发性动脉瘤比单发性动脉瘤容易出血。（4）动脉瘤的大小与动脉瘤出血也有一定的关系。（5）动脉瘤出血与性别的关系不大。结论：对于发生于大脑前动脉、大脑中动脉、前交通动脉的动脉瘤、对于发生于老年人的动脉瘤、及多发性动脉瘤要及早手术。     

颅内动脉瘤破裂急性期血管内栓塞治疗

闭塞颅内动脉瘤的方式主要有开颅动脉瘤夹闭和血管内栓塞治疗,随着血管内介入技术的提高和栓塞材料及设备的改进,颅内动脉瘤的介入治疗所占比例有增多的趋势。以下通过回顾性分析比较栓塞和手术夹闭治疗颅内动脉瘤的临床效果,评价栓塞治疗在颅内动脉瘤破裂急性期治疗中的应用。     

椎基底动脉夹层动脉瘤的影像学特征

椎基底动脉夹层动脉瘤的影像学特征孙林泉，松本清，岩田隆信，黄强，杜子威颅内椎基底动脉夹层动脉瘤（ｄｉｓｓｅｃｔｉｎｇａｎｅｕｒｙｓｍ）曾破认为是罕见的血管病变，１９６９年Ｃａｍｐｉｃｈｅ等旨次报道了经血管造影证实的椎基底动脉夹层动脉瘤，而在这以前只有...     

MRI in spontaneous dissection of vertebral and carotid arteries

Summary Fifteen patients were observed between 1987 and 1990: there were six with angiographically confirmed vertebral artery dissection, and 9 with carotid artery dissection. Results showed concordance of MRI and angiographic findings, in all cases but one. The dissected portion consistently showed a semilunar hyperintensity narrowing the residual eccentric signal void of the lumen when the artery was not completely occluded. In one angiographically occluded vessel, MR detected a small signal void within the hyperintensity, indicating that the artery was not completely occluded. The length of the dissected portion was clearly demonstrated by MR. Follow up MR and angiographic studies confirmed the regression of the dissection, and also allowed examination of the cerebral parenchyma.     

Endovascular treatment of extracranial vertebral artery stenosis

Percutaneous angioplasty and stenting for the treatment of extracranial vertebral artery(VA) stenosis seems a safe,effective and useful technique for resolving symptoms and improving blood flow to the posterior circulation,with a low complication rate and good long-term results.In patients with severe tortuosity of the vessel,stent placement is a real challenge.The new coronary balloon-expandable stents may be preferred.A large variability of restenosis rates has been reported.Drug-eluting stents may be the solution.After a comprehensive review of the literature,it can be concluded that percutaneous angioplasty and stenting of extracranial VA stenosis is technically feasible,but there is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management.     

高分辨力MRI对颅内椎基底动脉夹层动脉瘤的诊断价值

颅内椎基底动脉属于后循环,穿支血管丰富,毗邻脑干等重要结构,功能极其重要。当椎基底动脉发生病变,特别是发生夹层动脉瘤时,预后不良。高分辨力MRI(HRMRI)技术是近几年发展起来的诊断颅内动脉夹层的技术,具有安全无创、分辨力高、无需使用对比剂的特点,可对管壁及管腔进行成像,对椎基底夹层动脉瘤(VBDA)的诊断和鉴别诊断可提供重要的影像信息。就HRMRI新技术对VBDA的研究进展及临床应用予以综述。     

Stent fracture in revascularization for symptomatic ostial vertebral artery stenosis

Introduction We assessed the long-term follow-up examinations and complications of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic ostial vertebral artery (VA) stenosis. Methods A retrospective study was done to evaluate 12 patients with symptomatic ostial VA stenosis who underwent PTAS. Six patients were treated with the Palmaz stent and six with a balloon-expandable coronary stent. Initial angiographic follow-up examination was conducted about 12 months after PTAS in all patients. Simple radiographic, ultrasonographic and clinical follow-up examinations were scheduled every 6 months. Results Excellent dilatation was achieved in all patients without any procedural complications. Initial angiographic follow-up obtained at a mean of 13 months after PTAS detected no restenosis. However, an asymptomatic severe restenosis was detected at 24 months after PTAS in one patient (8%). During a mean follow-up of 31.5 months, three stent fractures were detected in deployed coronary stents (50%). None of the stent fractures was associated with either recurrent stroke or restenosis. No patients developed recurrent symptoms during the follow-up period. Conclusion PTAS for symptomatic ostial VA stenosis is effective in preventing recurrent stroke. As the open-cell single-joint type of stent is associated with the risk of fracture, long-term follow-up examinations including simple radiography are needed.     

Endoluminal treatment of aortic dissection

Aortic dissection is most often a catastrophic medical emergency which, if untreated, can be potentially fatal. The intention of therapy in patients with aortic dissection is to prevent aortic rupture or aneurysm formation as well as to relieve branch vessel ischaemia. Patients with aortic dissection are often poor candidates for anaesthesia and surgery and the surgical procedure itself is challenging requiring thoracotomy, aortic cross clamping, blood transfusion as well as prolonged hospital stay in some cases. Operative mortality is especially high in patients with critical mesenteric or renal ischaemia. The past decade has experienced the emergence of a number of interventional radiological or minimally invasive techniques which have significantly improved the management of patients with aortic dissection. These include stent grafting for entry site closure to prevent aneurysmatic widening of the false lumen as well as percutaneous techniques such as balloon fenestration of the intimal flap and aortic true lumen stenting to alleviate branch vessel ischaemia. False lumen thrombosis following entry closure with stent grafts has been observed in 86–100% of patients, whereas percutaneous interventions are able to effectively relieve organ ischaemia in approximately 90% of the cases. In the years to come, it is to be expected that these endoluminal techniques will become the method of choice for treating most type-B dissections and will assist in significantly reducing the number of open surgical procedures required for type-A dissections. The intention of this article is to provide an overview of the current status of these endoluminal techniques based on our own experience as well as on a review of the relevant literature.     

Spontaneous healing of cervical pseudoaneurysm in vertebral artery dissection under anticoagulant therapy

We report a 41-year-old woman with embolic stroke of the mid-pons attributed to embolism from vertebral artery dissection. Angiography revealed an occluded artery on one side and an incidental pseudoaneurysm of the midcervical portion of the vertebral artery on the other. After 3 months of warfarin therapy control angiography showed complete occlusion of the pseudoaneurysm. We discuss therapeutic choices and review the literature. Received: 3 January 1997 Accepted: 26 January 1997     

Value of endovascular stent placement for symptomatic spontaneous isolated superior mesenteric artery dissection

Objective

To evaluate the feasibility and efficacy of endovascular stent placement for the treatment of symptomatic spontaneous isolated superior mesenteric artery dissection.

Materials and methods

This retrospective study was undertaken in 12 consecutive patients who suffered from symptomatic spontaneous isolated superior mesenteric artery dissection. Seven patients with severe clinical symptoms underwent endovascular stent placement as a primary treatment and the other 5 patients received conservative treatment. The technical results, complications and clinical outcomes were analyzed. Follow-up was performed with computed tomographic angiography.

Results

Primary endovascular stent placement was successfully performed in 7 patients with severe clinical symptoms. Successful conservative treatment was achieved in 3 patients. Endovascular stent placement was additionally performed in 2 patients with unsuccessful conservative treatment. A stent was misplaced in the false lumen in one of those two patients due to a severely stenotic true lumen. The fasting time and length of stay were significantly shorter in patients with successful endovascular therapy (median: 3 days and 5.5 days) than in those conducted conservatively (median: 9 days and 14 days) (p < 0.05). During the follow-up period (median, 21 months; range, 10–36 months), 1 patient with endovascular stent placement had recurrent abdominal pain because of the wall adherent thrombus in the proximal segment of the superior mesenteric artery during the first follow-up month. No thrombosis or stenosis was found in the lumina of the stents.

Conclusion

Endovascular stent placement is a safe and feasible therapeutic approach for symptomatic spontaneous isolated superior mesenteric artery dissection with immediate success and satisfactory outcomes.     

MR imaging of intracranial vertebral artery occlusion

Summary Magnetic resonance (MR) images of nine patients with intracranial vertebral artery occlusion (five proved, four presumed) have been reviewed. In two of nine, both vertebral arteries were occluded and in five of the nine, the basilar artery was also blocked. All occluded arteries showed absence of flow void and were clearly demonstrated as mildly hypo-mildly hyperintense structures to brainstem parenchyma on the T1-weighted images. In two of five patients with basilar artery occlusion, retrograde filling of the distal basilar artery was detected. Thus, MR imaging, in particular the T1-weighted image, is a pertinent diagnostic modality for evaluating intracranial vertebral artery occlusion. Angiography does not seem to be required for confirmation.     

血管内支架成形术治疗椎动脉狭窄

目的 观察血管内支架成形术治疗椎动脉狭窄的短期疗效。方法 将球囊扩张性支架通过椎动脉狭窄部位，扩张球囊释放支架使狭窄部位恢复正常管径。结果 45例药物治疗无效的表现为后循环缺血症状的患者，43例成功的采用支架成形术，术前术后平均狭窄程度分别为75．7％和10．3％。临床随访35例症状完全缓解，4例明显好转，2例症状无改善。无一例发生内膜撕裂或血栓栓塞形成，短期随访未发现有再狭窄及内膜过度增生。结论 血管内支架成形术是治疗椎动脉狭窄的有效方法，长期疗效需进一步的随访观察。     

血管内支架成形术治疗颅内动脉狭窄

目的:探讨颅内动脉狭窄血管内球囊支架成形术的可行性、安全性及其疗效。方法:17例患者术前3天给予阿司匹林300mg/天和噻氯吡啶250mg/天,6F(Envoy)导引导管放置到颈内动脉远段或椎动脉近颅底段,造影获得工作位,评价血管狭窄程度:狭窄率=(1-狭窄处管径/狭窄远端管径)×100%,微导丝在路途导引下通过颅内动脉狭窄段,向远端直至P2或M2段,确保足够的支撑力。选择支架大小的依据为狭窄远端正常血管的直径,导丝引导下支架通过狭窄部位,造影确定支架位置正确,充盈球囊至5～6大气压,支架释放后造影确认展开良好,回撤球囊,无并发症,操作完毕。随访3～10月。结果:17例患者颅内动脉狭窄处植入支架,技术成功100%,造影显示狭窄由术前(78.3±12.9)%降至术后(6.8±7.3)%,狭窄的动脉管径恢复,短期随访(3～10个月)显示很好临床效果。术中出现一例蛛网膜下腔少量出血(SAH),对症治疗痊愈。6例随访造影未见血管再狭窄。结论:颅内动脉狭窄支架植入增加血管内径,改善血流量,减轻临床症状,是一种安全、可行有效的治疗方法。