颅内动脉瘤破裂的临床特点及相关危险因素探讨

目的探讨未破裂颅内动脉瘤发生破裂的临床特点及相关危险因素。方法对184例颅内动脉瘤患者的临床资料采用卡方检验及Logistic多元回归模型,对破裂组(150例)和未破裂组(34例)各相关危险因素进行统计学分析。结果颅内动脉瘤破裂出血的首发症状多为头痛(82.0%)、头晕(81.3%),多见于40~60岁,男∶女为1∶1.2。以ACA最常见,AComA其次,ICA最低。单因素分析表明,年龄(P=0.010)、吸烟(P=0.032)、嗜酒(P=0.038)、糖尿病(P=0.022)、瘤直径的大小(P=0.040)与颅内动脉瘤破裂有显著相关性;多因素Logistic分析结果显示,年龄、糖尿病是动脉瘤破裂的独立危险因素。结论颅内动脉瘤破裂好发于40~60岁,首发症状以头痛、头晕为主。年龄、糖尿病是动脉瘤破裂的危险因素。年龄≤60岁可增加动脉瘤破裂的风险,相反,糖尿病能降低动脉瘤破裂的风险。     

颅内动脉瘤夹闭术中动脉瘤破裂的危险因素分析

目的 探讨颅内动脉瘤病人夹闭术中动脉瘤破裂的危险因素。方法 回顾性分析2009年7月至2018年7月夹闭术治疗的296例颅内动脉瘤的临床资料。采用多因素logistic回归分析检验术中动脉瘤破裂的影响因素。结果 296例中,夹闭术中发生动脉瘤破裂59例,未破裂237例。多因素logistic 回归分析,年龄≥60岁、Hunt-Hess分级Ⅲ~Ⅴ级、发病至手术时间>3 d、手术器械不佳及手术操作不细致、动脉瘤瘤体血管弹性差及瘤体粘连是术中动脉瘤破裂的独立危险因素（P<0.05）。结论 高龄、Hunt-Hess分级高、发病至手术时间长、分离动脉瘤颈操作不细致、动脉瘤瘤体粘连为颅内动脉瘤病人夹闭术中动脉瘤破裂的主要危险因素     

未破裂颅内动脉瘤的治疗策略

随着医学影像学技术的发展,未破裂颅内动脉瘤的发现率越来越高。由于未破裂颅内动脉瘤有引起蛛网膜下腔出血(subarachniod hemorrhage,SAH)的潜在危险,且SAH后有较高的死亡率和伤残率,而目前所采取的干预性治疗,包括外科手术和血管内治疗,同样存在一定的死亡率和致残率,因此未破裂颅内动脉瘤治疗与否,越来越引起人们的注意。本文对未破裂颅内动脉瘤的出血的危险性和治疗的风险进行综述,希望能提出较佳的未破裂颅内动脉瘤处理策略。1未破裂颅内动脉瘤破裂出血的危险性未破裂颅内动脉瘤SAH发生率各家报道差别较大。Juvela[1]通过平均19.7…     

阿司匹林对伴缺血性脑血管病颅内未破裂小动脉瘤影响研究

目的评价缺血性脑血管病(ICVD)同时伴有直径≤5mm无症状性颅内未破裂小动脉瘤的患者,其口服阿司匹林致动脉瘤破裂的风险,为临床用药提供依据。方法收集2011年3月至2014年7月于沧州市中心医院神经内科住院的40~70岁(平均年龄56.3±9.7岁)伴有颅内单发无症状性未破裂小动脉瘤的脑梗死或TIA 63例,其随机分为口服阿司匹林和未口服阿司匹林两组,随访观察比较两组患者动脉瘤破裂及脑缺血事件复发的情况。结果两组患者63例,口服阿司匹林组32例,未口服阿司匹林组31例,随访1年。随访结果提示口服阿司匹林组患者脑缺血复发率明显低于未口服阿司匹林组[5/32 15.63%与17/31 54.84%,χ~2=10.65,P0.005]。口服阿司匹林组和未口服阿司匹林组患者动脉瘤破裂致蛛网膜下腔出血的发生率无差异[2/32 6.25%与1/31 3.23%,χ~2=0.32,P0.5]。结论患有脑梗死或TIA同时合并直径≤5mm无症状性颅内未破裂动脉瘤的患者,应常规口服阿司匹林预防ICVD的复发。     

单支架扰流技术治疗颅内动脉瘤

目的探讨单支架扰流技术治疗颅内动脉瘤的适应证及疗效。方法分析河北医科大学第二医院神经外科2015年12月至2016年7月采用单支架技术治疗的20例患者,共计21个囊性动脉瘤,其中20个动脉瘤直径≤3mm,1个直径约20mm;5个为破裂动脉瘤,16个为未破裂动脉瘤。每个动脉瘤均采用LVIS支架覆盖,手术即刻造影可见瘤腔内造影剂滞留,无出血及血栓形成并发症。分析术后6～27个月,平均(11.0±5.15)个月的随访结果。结果成功随访19例患者,1例失访。18个动脉瘤均实现瘤颈闭合,2个动脉瘤无变化。结论单支架扰流技术适合治疗未破裂微小动脉瘤,易操作。     

颅内动脉瘤破裂危险因素调查分析

目的调查分析导致颅内动脉瘤破裂的危险因素。方法颅内动脉瘤患者200例,共检出颅内动脉瘤260个,根据动脉瘤的破裂与否分为破裂组200例和未破裂组60例,对比分析2组临床资料及动脉瘤相关特征,进行单因素分析筛选,然后采用进行Logistic回归分析。结果危险因素有动脉瘤家族史(OR=14.335,95%CI=3.172~64.785)、吸烟史(OR=18.225,95%CI=4.428~75.034)、后交通动脉瘤(OR=4.264,95%CI=1.642~11.071)、中等动脉瘤(OR=5.640,95%CI=2.331~213.640)。结论导致颅内动脉瘤破裂的危险因素包括动脉瘤家族史、中等动脉瘤、后交通动脉瘤和吸烟史。     

颅内未破裂动脉瘤及其治疗策略

颅内未破裂动脉瘤在临床上比较常见,动脉瘤破裂的后果严重,因此未破裂动脉瘤的研究一直是神经外科的研究热点.颅内未破裂动脉瘤的破裂率与既往蛛网膜下腔出血史、性别与年龄、动脉瘤大小、所处位置、多发动脉瘤、家族动脉瘤史等相关,治疗颅内未破裂动脉的手段主要有开颅夹闭术、血管内介入动脉瘤栓塞术、保守治疗以及动脉瘤孤立术或载瘤动脉闭塞术＋血管吻合术,医师应该根据患者的情况（年龄、并发症等）,动脉瘤情况（大小、形态、位置）以选择合适的方法.现对颅内未破裂动脉瘤的危险因素和治疗方法进行综述.     

体积栓塞比对颅内动脉瘤破裂出血患者介入治疗预后的预测作用

目的探讨体积栓塞比对颅内动脉瘤破裂出血患者介入治疗预后的预测作用。方法对80例颅内动脉瘤破裂出血患者的临床资料展开回顾,均实施介入治疗,均计算体积栓塞比。术后均跟踪随访,统计不良预后的发生情况,对比各项不良预后发生者和未发生者体积栓塞比差异,以Logistic回归分析探讨体积栓塞比与颅内动脉瘤破裂出血患者介入治疗不良预后的关系。结果本组患者中不良预后事件发生率为22.50%;术后再出血发生者体积栓塞比低于未发生者,复发者低于未复发者,死亡者低于存活者,总不良预后发生者低于预后良好者,对比差异均有统计学意义(P0.05);预后不良者年龄60岁、发病至入院时间8h、颅内动脉瘤≥10mm、瘤颈4mm、Hunt-Hess IV～V级、体积栓塞比15%、术中破裂出血、术中出血量100ml、并发颅内血肿、并发脑疝、并发颅内感染者构成比均高于预后良好者(P0.05),经Logistic回归分析证实均为其独立危险因素(OR=4.993、5.936、2.812、5.441、4.674、4.121、4.023、5.517、4.707、6.253、4.302,P0.05)。结论颅内动脉瘤破裂出血患者介入治疗后不良预后事件发生风险高,且各项不良预后事件发生者体积栓塞比均较低,体积栓塞比15%、年龄60岁等均是患者不良预后事件发生的危险因素。     

颅内动脉瘤59例临床分析

回顾性分析我院2004～2010年收治的59例经全脑血管造影(DSA)证实为颅内动脉瘤患者的临床资料如下.1临床资料1.1一般资料59例颅内动脉瘤患者中,男28例,女31例;年龄13 ～79岁,平均56.7岁;其中＜20岁8例,20～60岁40例,＞ 60岁15例.本组颅内动脉瘤破裂造成蛛网下腔出血(SAH)患者34例,其中男18例,女16例;平均年龄分别为45.6岁和51.3岁.1.2临床表现因突发头痛、恶心呕吐、意识障碍、癫(癎)发作2.5 ～15 h,平均7.9h,诊断SAH后急诊入院34例;因视力减退、复视、眼球运动障碍、颈部僵硬2～7d,平均4.3d入院19例;因声音嘶哑、呛咳、头痛头晕、颈部疼痛6～ 13 d,平均8.9d入院6例.     

介入栓塞治疗颅内破裂微小动脉瘤临床分析

目的探讨介入栓塞治疗颅内破裂微小动脉瘤(直径≤3 mm)的疗效和技术要点。方法选取2013-01—2019-04济宁医学院附属医院35例颅内破裂微小动脉瘤行介入栓塞治疗的患者,采用3D-DSA选择工作角度测量动脉瘤大小(前后径、上下径、最大径、瘤颈和载瘤动脉的弯曲角度)。随访脑血管造影3～20个月(平均6个月)。结果对所有35个微小动脉瘤成功实施了弹簧圈栓塞,其中30例采用支架辅助弹簧圈栓塞,5例单纯弹簧圈栓塞。术中均未破裂出血,发生脑栓塞事件2例,术中弹簧圈不能完全填入1例。术后即刻造影示完全栓塞28个,次全栓塞5个,部分栓塞2个。术后半年复查造影,27例复查DSA,动脉瘤完全闭塞22例,不完全闭塞5例。结论介入栓塞是治疗颅内破裂微小动脉瘤有效手段,治疗关键是准确的术前评估和术中精细操作。     

Intraoperative rupture in the surgical treatment of patients with intracranial aneurysms

Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.     

破裂与未破裂镜像后交通动脉瘤形态与血流动力学分析

目的探讨破裂与未破裂颅内动脉瘤的血流动力学与形态学差异,分析动脉瘤破裂的危险因素。方法回顾性分析8例镜像后交通动脉瘤病人（均为一侧破裂,一侧未破裂）的临床资料,均行3D—DSA检查,建立数值模型。将16个动脉瘤按是否破裂分组,分析破裂组与未破裂组之间的形态学与血流动力学参数特征。结果破裂组动脉瘤平均擘面切应力（WSS）明显低于未破裂组（P〈0．05）;而低壁面切应力面积（LSA）比率和体颈比值明显高于未破裂组（P〈0．05）。剪切震荡指数（OSI）、动脉瘤直径、大小比率、血管角度和动脉瘤倾角组间差异无统计学意义（P〉0．05）。结论镜像后交通动脉瘤可能是研究动脉瘤破裂风险的理想模型,血流动力学与形态学在判断动脉瘤破裂风险方面同等重要。     

Carotid ligation: what happens in the long term?

The authors reviewed a consecutive series of 115 patients who underwent common carotid ligation during the period 1954-1984. Average follow-up was 10 years. Seventy-three (63%) patients presented following a subarachnoid haemorrhage (SAH) and 42 (36%) presented with the mass effect of an unruptured aneurysm. Thirty-nine (34%) patients were lost to follow-up of whom 27 had had a previous SAH. Forty-six (63%) of the 73 patients traced had suffered a SAH and amongst this group, 11 patients (24%) died from a proven or suspected recurrent haemorrhage within 10 years of ligation. The fatal recurrent haemorrhage rate was, therefore, 2.4%/year. Thirty (71%) of the 42 patients who presented with unruptured aneurysms were traced. Seven of these (23%) died: two following haemorrhage, 1 year and 16 years after carotid ligation and three patients died as a direct consequence of carotid ligation. Check angiographic studies were available for 55 patients following carotid ligation, a mean of 8.4 years after the procedure. Thirteen were conventional angiograms and 42 were intravenous angiograms obtained using the digital subtraction technique. Seventy-six per cent of the aneurysms visualised on the initial studies were either smaller or had apparently disappeared. Only four new aneurysms were detected and in two of these instances, the initial angiographic studies had been incomplete. The authors conclude that the annual rate of fatal recurrent haemorrhage from an intracranial aneurysm following common carotid ligation is of a similar magnitude to that of the natural history of conservatively managed ruptured intracranial aneurysms. Moreover, carotid ligation apparently does not prevent haemorrhage from a previously unruptured aneurysm and the procedure appears to carry a significant morbidity and mortality, even in patients with an unruptured aneurysm.     

血清Caspase-3水平与颅内动脉瘤的相关性研究

目的探讨人血清天冬氨酸特异性半胱氨酸蛋白酶-3（Caspase-3）与人颅内动脉瘤的关系,为临床早期诊断和筛选提供一种简易检验方法。方法用双抗体夹心免疫酶联吸附试验测定50例住院颅内动脉瘤患者（动脉瘤组）与50例健康成人（健康组）血清中Caspase-3水平。结果健康组血清Caspase-3水平为（84.6±17.6）ng/ml,未破裂颅内动脉瘤患者血清Caspase-3为（111.7±22.6）ng/ml,较对照组明显升高（P〈0.05）;破裂颅内动脉瘤患者血清Caspase-3水平为（1013.8±34.7）ng/ml,较未破裂颅内动脉瘤患者和对照组均明显升高（P〈0.05）。结论血清中Caspase-3水平升高可能与颅内动脉瘤形成以及破裂相关。     

Cost-effectiveness analysis of screening for asymptomatic, unruptured intracranial aneurysms. A mathematical model.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage (SAH) due to aneurysmal rupture is a major cause of cerebrovascular disease-related death. This problem could be eliminated by diagnosis and successful treatment of aneurysms before rupture. Recent developments in high-resolution imaging technology have made screening for unruptured aneurysms possible in the general population. Such screening has become widespread in Japan ("No Dokku, " or brain checkup). As a result, unruptured aneurysms are being identified with increasing frequency. However, the economic implications of treatment decisions for unruptured aneurysms have not been analyzed. Therefore, we performed such an analysis. METHODS: We used a Markov model to evaluate the cost-effectiveness of screening for asymptomatic, unruptured intracranial aneurysms. The model involved a set of variables describing discrete health states. Each state was assigned a quality of life score and an associated medical cost. A comparison of the expected outcomes was then made between 2 hypothetical cohorts, one receiving screening and the other no screening. A sensitivity analysis was performed by altering the input values within clinically reasonable ranges to reflect uncertainty in the baseline analysis and then assessing the effects on outcomes. RESULTS: Combining the incremental cost and effectiveness data revealed a cost per quality-adjusted life-year of $7760 for an annual rate of subarachnoid hemorrhage due to unruptured aneurysms (rupture rate) of 0.02; this cost was $39 450 for a rupture rate of 0.01. There was no benefit (negative quality-adjusted life-year benefit) for a rupture rate of 0.005, the rupture rate found in a recently published international cooperative study. The risks of surgery for unruptured aneurysms and the discounting ratio used to assess the impact of timing of costs and benefits on future outcomes also had significant effects on the results. Other variables had little impact on cost-effectiveness. CONCLUSIONS: The cost-effectiveness of screening for an unruptured aneurysm is highly sensitive to the annual rate of subarachnoid hemorrhage due to unruptured aneurysms. The low annual rupture rate seen in the recent large international cooperative study implies that screening asymptomatic populations to identify and treat unruptured aneurysms would not be cost cost-effective.     

他汀类药物的使用和颅内动脉瘤破裂相关性分析

目的 探讨他汀类药物对颅内动脉瘤破裂的影响。方法 2010年3月至2014年3月收治颅内囊状动脉瘤67例,其中破裂者32例,未破裂者35例。采用多变量Logistic回归评估他汀类药物的使用和颅内动脉瘤破裂的关系。结果 破裂组术前使用他汀类药物4例（12.5%,4/32）,未破裂组16例（45.7%,16/35）。破裂组服用他汀类药物的百分比显著低于未破裂组（P<0.01）。纠正潜在的混杂干扰后（or值: 0.30,95%可信空间:0.12~="" 0.64）显示,颅内动脉瘤破裂与他汀类药物的使用呈显著负相关,也与高血清总胆固醇浓度有关。结论 本结果提示他汀类药物对颅内动脉瘤破裂有一定的预防效果。     

颅内动脉瘤破裂与CD8~+CD28~-调节性T细胞的关系

目的探讨CD8+CD28-调节性T细胞在颅内动脉瘤发生破裂中所起的作用。方法收集确诊未破裂动脉瘤患者20例,破裂者17例,采用流式细胞术检测其外周血CD8+CD28-调节性T细胞的百分含量;并选择16例正常人及12例脑胶质瘤患者作为对照。对未破裂的患者进行为期2年随访,观察CD8+CD28-T细胞的变化情况。结果健康对照组的CD8+CD28-T细胞含量为27.82%±3.59%,胶质瘤患者的含量为23.71%±8.21%,未破裂动脉瘤患者为13.87%±4.17%,而破裂者为6.93%±2.08%。破裂患者的CD8+CD28-T细胞水平显著低于未破裂者(t=-1.865,P=0.041),且两组动脉瘤患者均低于正常人(均为P<0.01),但胶质瘤患者与正常人与无统计学差异(P=0.117);经过2年随访,共有5例患者失访,在余下的15例患者当中有3例发生破裂(分别在第16、18及22个月发生破裂),此3例患者第1年末的CD8+CD28-T细胞含量已明显低于随访前(P<0.05),且发生破裂后该细胞的含量显著低于第一年末(P<0.05)。结论 CD8+CD28-调节性T细胞减少可能与动脉瘤发生破裂相关。     

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。     

Surgical management of aneurysms of the bifurcation of the internal carotid artery

Internal carotid artery (ICA) bifurcation aneurysms are rare and easily bleed in younger patients, but are difficult to treat surgically, due to perforators surrounding and adherent to the aneurysm. A series of 25 patients treated by clipping under the operating microscope are analyzed and compared with previous cases. Twenty-five patients, 11 men and 14 women (mean age 51 years), were treated by the same neurosurgeon. Seventeen patients presented with subarachnoid hemorrhage (Hunt & Kosnik Grade I in three, II in five, III in two, IV in seven), five with unruptured ICA bifurcation aneurysms, and three with unruptured ICA bifurcation aneurysms but another ruptured aneurysm. There were 23 small, one large, and one giant ICA bifurcation aneurysms. The projection was superior in 12, anterior in seven, and posterior in six cases. Pterional approach was employed for all cases. Outcomes were evaluated at discharge with the Glasgow Outcome Scale. Favorable outcomes (good recovery (GR) and moderate disability (MD)) were obtained in ten of 17 patients with ruptured ICA bifurcation aneurysm. Favorable outcomes were significantly greater in Grades I and II (three in I, four in II) than in Grades III and IV (one in III, two in IV; P=0.0498). Seven of eight patients with unruptured ICA bifurcation aneurysm had favorable outcomes. Temporary clipping and projection of the aneurysm did not affect the outcome. Causative factors of unfavorable outcomes were primary brain damage in cases of small and large aneurysms and perforator damage in the case of giant aneurysm. Poor clinical grade and vasospasm are the causative factors of poor outcome in patients with ruptured ICA bifurcation aneurysm. Preservation of perforators is crucial in cases of giant aneurysm. Clipping of unruptured ICA bifurcation aneurysms is recommended since they tend to bleed at a lower age than other aneurysms.