脑动脉瘤性蛛网膜下隙出血61例诊治分析

目的 分析和总结脑动脉瘤性蛛网膜下隙出血在基层医院中的诊断和治疗情况.方法 回顾性分析61例脑动脉瘤性蛛网膜下隙出血患者的诊治资料.CT血管造影(CTA)脑血管三维重建发现61例共64枚动脉瘤043例患者行数字减影血管造影(DSA)检查,发现颅内动脉瘤30例共33枚.19例行血管内栓塞动脉瘤介入治疗;20例急诊行动脉瘤夹闭术;转院治疗3例.其余19例动脉瘤患者予以保守治疗.结果 19例行血管内栓塞动脉瘤介入治疗患者中治愈18例,继发脑血管痉挛、延迟性脑缺血梗死而死亡1例;行动脉瘤夹闭术20例患者中死亡2例.转院治疗3例随访死亡1例.保守治疗19例患者中随访死亡8例.结论 脑动脉瘤性蛛网膜下隙出血的治疗主要是病因治疗.选择好个性化的治疗方案是提高脑动脉瘤性蛛网膜下隙出血治愈率的关键.     

上海市松江区缺血性脑卒中患者急性期治疗后死亡危险因素回顾性研究

目的 对上海市松江区某三级综合性医院（A院）和某二级综合性医院（B院）自2009年1月1日～2011年1月1日期间入院治疗的新发缺血性脑卒中病例进行随访,描述患者预后生存情况,同时分析死亡危险因素.方法 以问卷调查的形式随访患者所在社区医生.随访至2012年1月.采用Kaplan-Meier法分析生存率,生存曲线比较采用Log-Rank检验,危险因素分析采用Cox比例风险模型分析.结果 随访时间最长为35个月,平均随访时间为22.4个月,失访32例,死亡85例,患者1年、2年、3年生存率分别为为89％、80％、61％.结论 高龄、急性期出院NIH-SS评分高和无康复干预是缺血性脑卒中患者死亡的主要危险因素.系统规范的康复治疗可有效延长患者的生存时间.     

蛛网膜下腔出血71例诊治分析

目的探讨蛛网膜下腔出血（SAH）的病因及诊治。方法回顾总结71例SAH患者的诊治资料,结合文献资料进行分析。结果71例患者均经颅脑CT或脑脊液（CSF）检查确诊,其中32例患者行全脑血管造影（DSA）,17例患者发现动脉瘤,15例采用动脉瘤夹闭手术治疗,2例采用动脉瘤弹簧圈栓塞术,其余均采用内科保守治疗。结论SAH出血原因检查首选DSA,对瘤性SAH治疗尽可能早期采用动脉瘤夹闭术或动脉瘤弹簧圈栓塞,对年龄偏大患者慎用或不用抗纤溶药物。     

首次脑卒中患者生存率和死亡影响因素的研究

目的 描述首次脑卒中患者生存情况, 分析影响其死亡的相关因素。方法 收集2009 年浙江省慢性病监测信息管理系统中首次脑卒中患者, 通过主动和被动随访获得患者生存状况及死亡原因。应用Kaplan-Meier 法进行生存率分析, 采用Cox比例风险回归模型对影响患者死亡的危险因素进行单因素和多因素分析。结果 共收集患者78 189 例, 脑梗死、大脑内出血、蛛网膜下腔出血和未特指分别占61.65%、30.42%、2.32%和5.62%。随访期间, 共33 265 例患者死亡, 其中根本死因与脑卒中相关的有27 147 例（81.61%）。患者当天即因脑卒中死亡6 122 例, 病死率为7.83%;第28 天病死率为21.01%;1～4 年生存率分别为72.04%、68.92%、66.27%和64.29%;脑梗死、大脑内出血、蛛网膜下腔出血和未特指的4 年生存率分别为80.06%、50.15%、71.80%和21.41%。模型主效应显示影响患者死亡的主要因素有年龄、性别、文化程度、诊治医院级别、高血压和脑卒中类型。年龄与性别存在交互作用（P＜0.001）, 单独效应显示男性在75 岁之前的死亡风险高于女性, 而75 岁之后则相反。结论 急性和亚急性期脑卒中死亡风险最高, 年龄、性别、文化程度、诊治医院级别、高血压和脑卒中类型是影响其预后的危险因素。     

动脉瘤性蛛网膜下隙出血后脑血管痉挛的治疗及临床分析

目的 总结动脉瘤性蛛网膜下隙出血(SAH)后脑血管痉挛的防治经验及体会.方法 选择住院治疗的58例颅内动脉瘤性SAH患者作为研究对象,对其临床资料进行回顾性分析.所有患者均行可脱性弹簧圈栓塞术血管内栓塞治疗颅内动脉瘤,术后采取腰大池持续引流、尼莫地平经深静脉持续泵入以及升高血压、增加血容量、稀释血液(3H)治疗等综合措施.结果 58例患者中术后有8例患者发生脑血管痉挛,发生率为13.8%(8/58),主要表现为短暂性偏瘫4例,意识障碍加深2例,短暂性失语2例,经积极治疗,运动功能、意识障碍及语言功能均完全恢复,无植物生存和死亡病例.结论 尽早行动脉瘤可脱性弹簧圈栓塞术,术后予脑脊液引流、尼莫地平静脉泵入、3H治疗等是治疗和预防动脉瘤性SAH后脑血管痉挛的有效方法.     

蛛网膜下腔再出血原因分析及预防

[目的]探讨蛛网膜下腔出血（SAH）再出血的危险因素及诱发因素。[方法]78例蛛网膜下腔出血患者住院治疗并随访观察6个月,对31例再出血的SAH患者（病例组）与无再出血的47例SAH患者（对照组）的有关危险因素进行比较。[结果]78例SAH的再出血率是39.7%;再出血组发病年龄﹥60岁,Hunt-Hess分级Ⅲ级及以上、伴高血压、动脉瘤、入院时间﹥24 h的比率均高于对照组。[结论]发病年龄﹥60岁、Hunt-Hess分级Ⅲ级及以上、伴高血压、动脉瘤、入院时间﹥24 h是SAH患者再出血的危险因素。预防再出血需注意控制危险因素,避免诱发因素。     

介入与手术相结合治疗Hunt-Hess分级Ⅲ～Ⅳ级颅内动脉瘤16例临床观察

目的 探讨Hunt-Hess分级Ⅲ～Ⅳ级颅内动脉瘤患者行血管内介入栓塞结合开颅去骨瓣减压术的应用价值及有效性.方法 对16例Hunt-Hess分级Ⅲ～Ⅳ级前循环囊状颅内动脉瘤患者先进行血管内介入栓塞颅内动脉瘤,继而转入手术室进行相应部位开颅去骨瓣减压术.结果 16例患者中,15例动脉瘤栓塞满意,介入栓塞技术成功率为93.75％(15/16);1例栓塞失败,血管迂曲,导管不能到达目标血管,改开颅手术夹闭动脉瘤.术后即刻造影完全栓塞10例,部分栓塞5例.血管闭塞事件1例,术后30 d内再出血1例,并发脑积水2例,待蛛网膜下隙血液吸收完再行脑室腹腔分流术.开颅去骨瓣减压术成功率100.0％(16/16).随访3年8例,动脉瘤复发1例,但未出血,采用开颅夹闭治愈.结论 对于颅内压较高,开颅风险较大的Hunt-Hess分级Ⅲ～Ⅳ级颅内动脉瘤患者,采用先行血管内介入栓塞后行开颅去骨瓣减压术的方法来降低患者在手术中的风险是有效的.     

颅内动脉夹层及夹层动脉瘤个体化治疗的临床研究

目的分析颅内动脉夹层及夹层动脉瘤的临床特点,总结开颅手术夹闭治疗及血管内栓塞治疗的临床经验。方法回顾性分析20例颅内动脉夹层及夹层动脉瘤患者的临床资料,其中采用开颅手术夹闭治疗8例,血管内栓塞治疗12例。结果8例开颅手术夹闭治疗患者中,动脉瘤完全闭塞4例,不全闭塞1例,早期死亡1例,2例夹闭术后再破裂出血行血管内支架辅助微弹簧圈栓塞治疗完全闭塞。12例m管内栓塞治疗患者中,9例动脉瘤完全闭塞,3例不全闭塞,其中8例随访6个月至3年,均痊愈,遗留轻度偏瘫2例及动眼神经麻痹1例;1例正在随访中。结论根据颅内动脉夹层及夹层动脉瘤的不同部位、不同病理特点,选择不同的治疗方法,综合应用各种处理手段,制定个体化的治疗方案,才能有效安全闭塞颅内动脉夹层及夹层动脉瘤。     

78例动脉瘤性蛛网膜下腔出血介入栓塞和手术夹闭治疗的对比研究

目的对比分析动脉瘤性蛛网膜下腔出血介入栓塞和手术夹闭两种治疗方法的优劣性。方法回顾性分析动脉瘤性蛛网膜下腔出血介入栓塞45例和手术夹闭33例的疗效。结果介入栓塞45例46枚动脉瘤中44枚动脉瘤行弹簧圈栓塞,2枚行支架植入＋弹簧圈栓塞,术后恢复良好者36例,轻残6例,重残0例,死亡3例;手术33例42枚动脉瘤40枚行单个动脉瘤夹夹闭,2枚行两个动脉瘤夹夹闭,术后恢复良好者12例,轻残15例,重残1例,死亡5例。结论动脉瘤性蛛网膜下腔出血的治疗中,介入栓塞较手术治疗创伤小,见效快,致残率和致死率相对较低,但费用相对昂贵。     

前循环破裂动脉瘤急性期显微手术治疗经验

目的探讨颅内前循环破裂动脉瘤急性期显微手术治疗疗效。方法总结分析46例患者54个颅内前循环动脉瘤破裂出血的临床病例资料,其中颈内动脉动脉瘤26个,前交通动脉瘤16个,胼周动脉瘤2个,大脑中动脉瘤10个。所有患者均在出血后3d内行显微外科手术治疗。结果应用显微手术成功夹闭43例前循环动脉瘤,3例动脉瘤行包裹治疗,无术中死亡病例,术后27例恢复良好,9例有轻度神经功能障碍,6例重度神经功能障碍,死亡4例。结论颅内前循环动脉瘤急性期显微手术治疗效果明显,可有效防止再出血及脑血管痉挛,改善患者预后。     

动脉瘤性蛛网膜下腔出血术后低钠血症相关危险因素分析及临床特点

目的 探讨动脉瘤性蛛网膜下腔出血术后低钠血症发生的相关危险因素,观察动脉瘤性蛛网膜下腔出血术后低钠血症的临床特点.方法 回顾性分析2004年3月～2011年4月126例在某院收治的动脉瘤性蛛网膜下腔出血患者的临床资料,分析术后低钠血症的相关危险因素及临床特点.结果 126例患者中有35例术后并发低钠血症,占27.78％.将性别、年龄、术前Hunt-Hess分级、动脉瘤部位、手术时机等危险因素引入二项分类Logistic回归分析模型之中,性别、手术时机等与低钠血症发生无关,差异无统计学意义(P＞0.05),年龄、动脉瘤部位、术前Hunt-Hess分级等与低钠血症发生有关,差异有统计学意义(P＜0.05).结论 年龄、动脉瘤部位、术前Hunt-Hess分级等与低钠血症发生有关,50～60岁之间,前交通动脉瘤,术前Hunt-Hess分级级别越高,其术后并发低钠血症的可能性越大.     

颅内动脉瘤在电解可脱式弹簧圈栓塞术中破裂危险因素分析及处理体会

目的 探讨颅内动脉瘤在电解可脱式弹簧圈(GDC)栓塞术中发生破裂的危险因素及处理方法.方法 2000年8月至2010年6月,以GDC栓塞术治疗420例动脉瘤性蛛网膜下隙出血(SAH)患者,对其临床资料进行回顾性总结,统计分析颅内动脉瘤在GDC栓塞术中发生破裂的危险因素.结果 共16例术中发生动脉瘤破裂,发生率为3.8%(16/420),术后13例致密填塞,3例部分填塞.单因素分析显示:SAH发作次数≥2次、瘤体≤4 mm、有假性动脉瘤、Hunt-Hess分级为Ⅳ～Ⅴ级、有高血压病史以及瘤颈窄是引起颅内动脉瘤GDC栓塞术中发生破裂的危险因素.多因素 Logistic回归分析显示:SAH发作次数≥2次(P=0.0424,OR=6.798)以及有假性动脉瘤(P=0.0069,OR=4.423)是引起颅内动脉瘤GDC栓塞术中发生破裂的独立危险因素.结论 颅内动脉瘤在GDC栓塞术中发生破裂主要与SAH多次发作以及存在假性动脉瘤有关,临床上对存在危险因素者应警惕发生术中破裂,一旦发生应积极给予合理的治疗,大多数患者能获得良好预后.

Abstract：

Objective To investigate the risk factors and treatment experience of cerebral aneurysms rupture in the course of Gugliemi detachable coil (GDC) embolization. Methods From August 2000 to June 2010,420 patients with aneurysmal subarachnoid hemorrhage (SAH) received GDC embolization and their clinical data were retrospectively reviewed to analyse the risk factors of cerebral aneurysms rupture in the course of treatment. Results Sixteen patients had intraoperative aneurysm rupture, the incidence rate was 3.8%(16/420),including 13 cases density filling,3 cases partial filling postoperative.Univariate analysis showed:SAH episodes ≥2 times,tumor size ≤4 mm,the presence of pseudoaneurysm,Hunt-Hess grade Ⅳ - Ⅴ as well as history of hypertension were the risk factors of cerebral aneurysms rupture in the course of GDC embolization. Logistic regression analysis showed:SAH episodes ≥2 times (P = 0.0424,OR =6.798)and the presence of pseudoaneurysm (P = 0.0069, OR = 4.423) were the independent risk factors of cerebral aneurysms rupture. Conclusions Rupture of intracranial aneurysm in the course of GDC embolization is mainly related to the multiple SAH and the presence of pseudoaneurysm. It should be alert to the risk factors and take active treatment as soon as the occurrence of rupture in clinic work, for this, most patients can get a good prognosis.     

The relationships of gender, cigarette smoking, and hypertension with the risk of aneurysmal subarachnoid hemorrhage: a case-control study in Nagoya, Japan

PURPOSE: To examine the relationship of gender, cigarette smoking, and a history of hypertension to the risk of aneurysmal subarachnoid hemorrhage (SAH), using a case-control study. METHODS: Case subjects consisted of a consecutive series of 201 patients with spontaneous SAH with aneurysm(s) confirmed by angiography and/or CT scan. One hospital and one community control subject was matched to each case by gender and age (+/- 2 years). Multiple conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) adjusted for potential confounders. RESULTS: Current smoking and a history of hypertension were each significantly associated with an increased risk of subarachnoid hemorrhage for men and women combined. There was also a non-significant trend towards synergism between these two factors with respect to an increased risk of subarachnoid hemorrhage for each gender separately and both combined. A significantly increased risk was observed for a history of hypertension (adjusted OR, 3.5; 95% CI, 1.2-14.7) among men, for current smoking alone (adjusted OR, 2.9; 95% CI, 1.1-7.7), and a history of hypertension alone (adjusted OR, 2.6; 95% CI, 1.4-5.1) among women. CONCLUSIONS: Trends towards gender differences and synergism emerged in the relationship of cigarette smoking and a history of hypertension of the risk of SAH provides useful information for targeting individuals/populations in programs for the primary prevention of SAH by gender.     

脑脊液置换及椎管内尿激酶注射治疗动脉瘤术后蛛网膜下腔出血的临床研究

目的　探索救治蛛网膜下腔出血(SAH)患者的有效方法。方法　对经DSA、CT、手术证实的30例SAH患者,用等量生理盐水置换脑脊液(CSF)和椎管内尿激酶(UK)注射治疗,并与对照组进行比较。结果　治疗组头痛等症状明显减轻至消失,迟发性脑血管痉挛(DCVS)发生率明显降低。与对照组比较差异有显著性意义(P <0 .0 5 )。结论　应用生理盐水置换脑脊液可快速消除SAH患者之急性症状,对DCVS也有较好治疗和预防作用,而早期加用小剂量尿激酶椎管内注射,可以明显提高以上疗效,同时又不会增加再出血的危险。     

ICU脑出血患者死亡的影响因素分析

目的分析重症监护室(ICU)脑出血患者死亡的影响因素。方法回顾性分析2019年2月至2020年2月我院ICU收治的60例脑出血患者的临床资料,根据预后分为院内病死组25例和院内存活35例。收集患者基本信息,分析ICU脑出血患者死亡的影响因素。结果单因素分析显示,院内病死组的血肿体积>50 m L占比、出血累计范围超出侧脑室占比、 APACHEⅡ评分>25分占比均高于院内存活组,差异有统计学意义(P <0.05);Logistic多因素分析显示,血肿体积>50 m L、出血累计范围超出侧脑室、 APACHEⅡ评分>25分是ICU脑出血患者死亡的危险因素(OR>1, P <0.05)。结论血肿体积>50 mL、出血累计范围超出侧脑室、 APACHEⅡ评分>25分是ICU脑出血患者死亡的危险因素,临床需对上述危险因素予以重点关注并采取针对性干预措施,以有效降低患者院内病死率。     

不明原因的蛛网膜下腔出血重复脑血管造影的探讨

目的探讨不明原因的蛛网膜下腔出血(SAH)患者重复脑血管造影的益处和危险性。方法回顾分析140例SAH患者154次(首次140例，重复14例)脑血管造影的结果及其并发症。结果首次造影发现动脉瘸107例(76％)，烟雾症2例，血管畸形1例。14纠重复脑血管造影捡查时发现前交通动脉瘸1例；12例进行了脑、脊髓MRI扫描，发现丘脑、脊髓血管畸形各1例、全部154次造影检查中，术后8h内死亡1例，脑梗死1例，血管痉挛6例，穿刺点感染2例，并发症比例4．2％(10／154)。结论首次脑血管造影检查时，若技术及设备优良，拍片仔细。结合CT MRI检查及临床特点，则重复造影不必进行；当首次造影结果无可靠，伴有脑血管痉挛或再出血者，重复脑血管造影才是合理的。     

Subarachnoid hemorrhage without aneurysm on the angiogram: the value of repeat angiography

OBJECTIVE: To determine the yield of repeated angiography in patients with a non-perimesencephalic subarachnoid haemorrhage (SAH) and a negative first cerebral angiogram. DESIGN: Retrospective. METHOD: All diagnostic data of patients with a spontaneous SAH admitted to the Department of Neurology, St. Elisabeth Hospital, Tilburg, the Netherlands, in the period 1 January 1992-30 June 2000 were analysed. Patients with a perimesencephalic haemorrhage on a CT-scan were excluded and follow-up was completed. A negative angiogram was considered false-negative, if an aneurysm was shown on a repeat angiogram or after a rebleed. These angiograms were reviewed. RESULTS: A total of 333 patients with a spontaneous SAH were registered. Of these, 249 patients had one or more angiograms made, which resulted in 59 first angiograms being negative (24%). A total of 36 patients had a non-perimesencephalic SAH (26 women and 10 men; mean age: 54 years (range: 25-77)). In 25 of these 36 patients, angiography was repeated revealing 9 aneurysms. Four patients suffered from a rebleed after a previous negative angiogram. Altogether, in 13 of these 36 patients the first negative angiogram was false-negative (36%). In 5 of the 9 patients with a positive repeat angiogram, the first angiogram had been incorrectly assessed as negative. CONCLUSION: Of the 36 patients with a non-perimesencephalic subarachnoid haemorrhage and a negative angiogram, 13 were revealed to have an aneurysm. Nine of these 13 aneurysms were demonstrated on a repeat angiogram. Technical and interpretation factors appeared to play an important role in missing an aneurysm on a cerebral angiogram.     

617例缺血型脑卒中患者生存率及死亡影响因素的回顾性研究

目的对住院缺血型脑卒中患者进行随访,描述患者病后生存状况,并分析影响死亡的危险因素。方法回顾性收集2002年1月至2005年6月第四军医大学西京医院神经内科确诊的617例连续性缺血型脑卒中病例,采用电话、信访等方式随访患者的生存状况及死亡原因,2006年1月完成随访工作。应用Kaplan-Meier法进行生存率分析,采用Cox比例风险回归模型对影响患者死亡的危险因素进行单因素和多因素分析。结果随访时间最长47个月,失访59例（9．5%）。随访期间死亡80例,其中缺血型脑卒中60例,脑出血3例,心脏病10例,其他死因7例,中位生存时间42．16月。患者1、2、3年生存率分别为91．9%、89．4%、85．3%。单因素及多因素Cox比例风险模型显示,影响缺血型脑卒中患者死亡的主要危险因素有：高龄（RR=1．043,95%CI：1．013～1．074）, Glasgow评分低（RR=O．855,95%CI：0．742～0．985）,意识水平差（RR=4．085,95%CI：2．128～7．844）和存在并发症（RR=1．765,95%CI：1．108～2．812）。结论高龄、Glasgow评分低、意识水平差和存在并发症是缺血型脑卒中患者死亡的主要危险因素。     

Intracranial aneurysms. A review

Intracranial aneurysms are common, and their rupture carries a grave prognosis. There is no effective way of preventing the development of intracranial aneurysms, but noninvasive means of detection are becoming increasingly practical and, at present, should be used routinely--at least in populations at high risk. SAH is frequently preceded by warning signs that, when recognized by the primary care or the emergency room physician, can lead to prompt and safe surgical intervention. About half the patients who suffer a major rupture either die or remain in poor condition as a result of the hemorrhage. In the rest, surgical intervention has become safer and very effective in preventing subsequent hemorrhage, which occurs in about 50% of patients if the aneurysm is left untreated. Since early surgery should be at least considered in the majority of these patients and since the early treatment of a patient after SAH is so specialized, it appears prudent to manage patients with SAH in units where the necessary neurological and neurosurgical specialized intensive care is available.     

The joint effect of oxidative stress and antioxidants on the risk of an aneurysmal rupture subarachnoid hemorrhage: a case-control study in Japan

PURPOSE: A case-control study was conducted in Japan to examine the joint effects of oxidative stress and antioxidants on the risk of subarachnoid hemorrhage (SAH). METHODS: The study included 201 consecutive patients with first spontaneous SAH aged 30 to 79 years who had aneurysm(s) confirmed by angiography and/or computed tomographic scan and were admitted to two medical hospitals in Nagoya, Japan, from April 1992 to March 1997. Community control subjects were identified and matched to each case by gender and age (+/-2 years). Conditional logistic regression modeling was used to compute odds ratios (ORs) adjusted for body mass index, physical activity, family history of SAH, a history of hypertension, drinking habit, and frequency of green-yellow vegetables and fruits, and tea consumption. RESULTS: The greatest risk for SAH was posed by combination of current smoking and a less frequent intake of soy products (adjusted OR = 5.3; 95% confidence interval [CI], 2.0 to 14.3). Less frequent intake of soy products significantly elevated SAH risk, independent of smoking habits. CONCLUSION: These data suggested that enhancement of the antioxidant defense system such as much intake of soy products may be important in preventing SAH rather than the reduction of such oxidants as smoking. Our findings should prove useful for targeting individuals/populations in programs for primary prevention of SAH.