动脉瘤性蛛网膜下腔出血的影像学诊断及治疗

动脉瘤性蛛网膜下腔出血是最常见的非外伤性蛛网膜下腔出血,早期确诊和及时治疗可以显著降低病残率和死亡率.综述了确定蛛网膜下腔出血和动脉瘤的形态位置的各种影像学方法的优势与不足,总结了影像学判断动脉瘤性蛛网膜下腔出血并发症的作用,对比了手术夹闭和血管内动脉瘤栓塞术的危险性,并归纳了血管内动脉瘤栓塞术的最新进展.     

动脉瘤性蛛网膜下腔出血的反思

颅内动脉瘤本身是一种良性疾病,但其伴发的动脉瘤性蛛网膜下腔出血(aSAH)却严重制约了临床疗效.前期的研究显示脑内大动脉痉挛是导致临床预后不良的关键因素,但近来内皮素A受体拮抗剂的临床实验结果却显示脑内大血管痉挛可能并非关键因素.aSAH的研究重点也因此转向了以微循环障碍、皮质播散性抑制、早期脑损害、血-脑脊液屏障损伤...     

尼莫地平治疗动脉瘤性蛛网膜下腔出血疗效观察

本文作者临床观察了用尼莫地平治疗动脉瘤性上腔出血的３３例病人。尼莫地平的应用方法是通过微量泵静脉注入,最初剂量为０．５ｍｇ／ｈ,每６ｈ增加量,直到达到２ｍｇ／ｈ,维持３周,持续监测动脉压和心电图,入院３个月后统计病人的预后情况。良好５７％,中残１５％,重残１２％,死亡１６％,比过去的文献统计动脉瘤性蛛网膜下腔出血的预后明显改善。     

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。     

Hunt-Hess Ⅳ～Ⅴ级蛛网膜下腔出血的早期病因诊断及治疗

目的：探讨Hunt-HessⅣ～Ⅴ级蛛网膜下腔出血（SAH）的早期病因诊断方法及治疗原则，并客观评价其治疗效果。方法：对31例SAH患者发病后7d内进行CT及DSA检查，寻找SAH的原因，明确SAH均为脑动脉瘤破裂所致。明确病因后，即刻采用电解可脱性弹簧圈（GDC）进行动脉瘤囊内栓塞，术后早期处理出血并行有效的对症治疗。对于动脉瘤直径和瘤颈宽度不同患者的疗效和病死率进行比较，结果经X^2检验。结果：31例患者经CT、DSA检查，均明确诊断。SAH均为脑动脉瘤破裂所致，所有动脉瘤均经栓塞治疗。其中动脉瘤腔100％闭塞26例、95％闭塞者3例、90％闭塞者2例。术中并发脑血管痉挛5例，1例动脉瘤复发并经第2次补充GDC栓塞而治愈。29．0％（9／31）出现与SAH有关的永久性后遗症。治疗结果根据Glasgow预后评分：Ⅰ级6例、Ⅱ级9例、Ⅲ级4例、Ⅳ级2例、Ⅴ级10例；病死率32．3％（10／31）。术后随访3～68个月均无再出血。动脉瘤直径11～25mm组7例，死亡5例；5～10mm组21例，死亡4例，2组比较差异有统计学意义（r=6．60，P〈0．05）。瘤颈≤4mm组24例，动脉瘤完全栓塞23例，死亡5例；瘤颈〉4mm组7例，动脉瘤完全栓塞3例，死亡5例，2组动脉瘤完全栓塞率和病死率差异均有统计学意义（分别X^2=11．24、P〈0．01，X^2=6．35、P〈0．05）。结论：CT及DSA可对Hunt-HessⅣ～Ⅴ级SAH进行早期病因诊断；对已破裂的动脉瘤早期采用电解可脱性弹簧圈囊内栓塞，术后早期处理出血并有效的对症治疗，是提高动脉瘤性SAH治愈率和降低病死率及致残率的有效方法。     

动脉瘤性蛛网膜下腔出血的治疗指南重点介绍

动脉瘤性蛛网膜下腔出血（SAH）是一种常见的脑血管疾病,约占卒中患者的5%,但SAH的预后仍不理想,死残率高达45%。近年来,动脉瘤性蛛网膜下腔出血的诊断方法、血管内治疗、外科手术和围手术期处理均取得一定进展,主要是一些多中心、前瞻性、随机试验和前瞻性队列研究有了新的结果。因此,美国心脏病协会（AHA）在循证医学的指导下综合目前最新的研究结果形成新的指南,重点是动脉瘤性蛛网膜下腔出血的诊断与手术治疗选择。本治疗指南是根据AHA证据等级标准制定的,其目的是总结治疗动脉瘤性蛛网膜下腔出血的最好证据,并对以后研究提出建议,对单个患者的治疗应该实行个体化原则。     

颅内动脉瘤性蛛网膜下腔出血患者脑脊液中NSE和MBP含量测定

神经元特异性烯醇化酶 (ＮＳＥ)和髓鞘碱性蛋白质 (ＭＢＰ)是脑损伤的标志物之一。有关动脉瘤性蛛网膜下腔出血(ＳＡＨ)后患者脑脊液 (ＣＳＦ)或血清中ＮＳＥ和ＭＢＰ含量与其病程的发展及预后关系的报道不多。我们对 2 8例动脉瘤性ＳＡＨ患者脑脊液中ＮＳＥ、ＭＢＰ含量进行了检测 ,现报道如下。资料与方法1.病例。选择 2 8例收入我科治疗并经ＣＴ、脑血管造影及术中证实的颅内动脉瘤破裂致ＳＡＨ的患者 ,其中男 17例 ,女 11例 ,年龄 45～ 6 6岁 ,平均 5 8 42岁。全部患者均于发病后 3ｄ内入院。其中颈内动脉瘤 13例 ,前交通动脉瘤 11例 ,…     

动脉瘤性蛛网膜下腔出血致脑血管痉挛的治疗研究进展

蛛网膜下腔出血(subarachnoid hemorrhage,SAH)是指脑底部或脑表面的病变血管破裂,血液直接流入蛛网膜下腔引起的一种临床综合征,约占急性脑卒中的10.0%[1]。SAH的最主要病因为颅内动脉瘤破裂,约占85.0%。脑血管痉挛(cerebral vasospasm,CVS)是动脉瘤性蛛网膜下腔出血致残、致死重要原因。目前关于造成CVS的发病机制的研究较多,由于各种因     

Computed tomography and subarachnoid hemorrhage

Summary CT scans have been made on 39 of 41 patients who presented with subarachnoid hemorrhage. Blood could be visualized in the cisterns of 18 of 32 examinations performed within five days of the hemorrhage all having aneurysms. Among the other 14 there were three in whom no aneurysm was found on angiography. The distribution of blood in those that showed it was useful in pointing to the position of the aneurysm. Much other information was obtained, for instance about rebleeding and infarction. CT should routinely be the primary examination, followed by selective angiography.     

Autosomal dominant polycystic kidney disease presenting as subarachnoid hemorrhage

Intracranial aneurysms occur in patients with autosomal dominant polycystic kidney disease (ADPKD) approximately five times more often than in the general population, and in the same patient group, subarachnoid hemorrhage from rupture of aneurysms occurs about a decade earlier than in the general population. We present a case of unsuspected ADPKD presenting as spontaneous subarachnoid hemorrhage from a ruptured intracranial aneurysm.     

Magnetic resonance imaging of subarachnoid hemorrhage

Summary Magnetic resonance (MR) imaging of subarachnoid hemorrhage (SAH) due to a ruptured aneurysm has been evaluated in relation to CT findings on 30 patients. In the acute stage, particularly less than 24 hours after the bleeding episode (25 patients), SAH appeared of high intensity relative to the surrounding brain on a T-2 weighted SE image but isointense where the corresponding CT scan showed blood clot of attenuation value over 60H. A T-2 weighted SE image was able to reveal subtle evidence of SAH not visible on the CT scan. The T-1 weighted IR image was not as sensitive. Blood clot (HU>60) appeared isointense, but mild and moderate SAH (HU<60) was indistinguishable from normal CSF. MR imaging was also sensitive to subacute and chronic SAH (5 patients). Three out of four SAH appearing normal on CT showed high intensity on T-2 weighted images. Thirteen out of 24 aneurysms (54%) larger than 5 mm in diameter on angiography were detected on T-2 weighted images. Smaller aneurysms less than 4 mm were not visualized. MR imaging was able to indicate the ruptured one in cases of multiple aneurysms by showing hemorrhagic lesions more clearly than CT. We conclude that MR imaging is very helpful for diagnosing SAH, particularly when CT is normal, and in indicating aneurysm location as well as rupture site.     

Pediatric subarachnoid hemorrhage: Pseudotrauma

We report three pediatric patients presenting with acute subarachnoid hemorrhage in a clinical setting of trauma. A berry aneurysm was ultimately diagnosed in each patient as the source of hemorrhage, and we believe that the trauma that these patients sustained was not contributory to their subarachnoid hemorrhage. We now use magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) to evaluate these patients noninvasively. MRI/MRA is useful for the diagnosis and subsequent guidance of treatment planning in pediatric patients with subarachnoid hemorrhage without severe head trauma. The opinions and assertions contained herein are solely those of the aforementioned authors and are not to be construed as official or as representing those of the U.S. Army Medical Department, U.S. Army, or Department of Defense.     

Interest of repeated cerebral angiography in subarachnoid hemorrhages

The risk of rebleeding from an unoperated-upon aneurysm is high. That is why cerebral angiography is repeated if the first study is negative. In order to evaluate the importance of the second angiography we studied retrospectively 100 consecutive patients with subarachnoid hemorrhage, admitted in our institution between November 1991 and November 1992. The initial cerebral angiography is done as soon as possible, usually within 3 days following the bleeding. These studies showed at least one aneurysm in 80 of 100 patients. In 20 patients the initial investigation was negative and angiography was repeated between the third and sixth week after the initial result. Two new aneurysms were demonstrated. This 2% of false-negative results justifies repeated angiographies in patients with subarachnoid hemorrhage and negative initial angiography. Correspondence to: L. Picard     

Clinical outcome after endovascular coil embolization in elderly patients with subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is not an unusual disease in an elderly population. The clinical outcome has improved over time. It has been suggested that elderly SAH patients would benefit from endovascular aneurysm treatment. The aim of this study was to evaluate technical results and clinical outcome in a series of elderly SAH-patients treated with endovascular coil embolization. Sixty-two patients ( 65 years) presenting with aneurysmal SAH underwent early endovascular coil embolization at Uppsala University Hospital between September 1996 and December 2000. In all 62 cases included in the study, endovascular coil embolization was considered the first line of treatment. Admission variables, specific information on technical success, degree of occlusion and procedural complications, and outcome figures were recorded. Clinical grade on admission was Hunt and Hess (H&H) I–II in 39%, H&H III in 27% and H&H IV–V in 34% of the patients. The proportion of posterior circulation aneurysms was 24%. Coil embolization was successfully completed in 94%. The degree of occlusion of the treated aneurysm was complete occlusion in 56%, neck remnant in 21%, residual filling in 11%, other remnant in 5% and not treated in 6%. The rate of procedural complications was 11%. Outcome after 6 months was favorable in 41%, severe disability in 36% and poor in 22%. Favorable outcome was achieved in 57% of the H&H I–II patients, 47% of the H&H III patients and 17% of the H&H IV–V patients. Endovascular aneurysm treatment can be performed in elderly patients with SAH with a high level of technical success, acceptable aneurysm occlusion results, an acceptable rate of procedural complications and fair outcome results.This study was approved by the local research ethics committee in Uppsala, Sweden (Ups Dnr 01–104)     

CT诊断特殊征象的蛛网膜下腔出血

目的:探讨蛛网膜下腔出血的特殊CT征象,提高对此病变的诊断率。方法:回顾性分析17例经证实的具有特殊CT表现的蛛网膜下腔出血病例,分析其形成机理,CT表现特征及与硬膜下血肿的鉴别要点。结果:所有病例均含有颅骨内板下新月形高密度影这种酷似硬膜下血肿的CT表现,但具有内缘不锐利,密度较低且不均匀的特征。结论:CT可以诊断具此特殊表现的蛛网膜下腔出血并与硬膜下血肿鉴别。     

蛛网膜下腔出血的CT诊断及其漏误诊原因分析

目的探讨蛛网膜下腔出血的CT诊断并分析其误诊、漏诊的常见原因。方法对100例经CT复查证实的蛛网膜下腔出血CT资料进行回顾性分析。结果100例中因出血部位及出血量不同,CT表现为分布于脑沟、裂、池内的线状、带状、片状或铸型高密度影。纵裂池及小脑幕出血灶边缘一般较模糊。出血部位以侧裂池和脚间窝最多,分别为46例及56例,2例纵裂池出血首次误诊为硬膜下血肿;1例四叠体池出血因出血量少首次CT检查为阴性,通过适时CT复查得以确诊。结论CT对蛛网膜下腔出血的诊断价值较高,可避免漏诊及误诊,并对其临床治疗具有重要把寻意义。