家族性脑动脉瘤

为评价性别对家族性脑动脉瘤形成和破裂的影响,作者研究了连续就诊的14个家系的30例脑动脉瘤破裂病人,并与以往报告的散发性脑动脉瘤进行了比较。家族性脑动脉瘤80％发生在女性,而散发性脑动脉瘤仅59％为女性(P<0.05):年龄50岁以下者,家族性脑动脉瘤78％为女性,而散发性脑动脉瘤仅45％为女性(P<0.01);50岁以上者,家族性与散发性脑动脉瘤比较无显著性别差异。59％的女性家族性脑动脉瘤在50岁前破裂,而仅31％的散发性脑动脉瘤在50岁前破裂(P<0.01)。多数病例同一家系的脑动脉瘤破裂年龄相差不足10岁。家族性和散发性脑动脉瘤中多发性者发生率相当,但多发性家族性脑动脉瘤多发生在女性。多数病例同一家系的女性脑动脉瘤发生在同一部位,而散     

未破裂脑动脉瘤的诊断及处理

影响脑动脉瘤破裂出血的主要因素为动脉瘤的大小。根据动脉瘤的大小、位置及病人年龄提出未破裂动脉瘤的6级分级标准,O级者预后均良好,而6级者病残率和死亡率为66.6％。无创性磁共振血管造影(MBA)、三维增强CT扫描、全脑血管造影有助于发现无症状性动脉瘤。对于年龄小于70岁,大小超过5mm的未破裂的动脉瘤多主张手术治疗,对于不能手术者可采用血管内弹簧圈栓塞治疗。     

颅内AVM合并颅内动脉瘤

本文分析自1977年以来的22例颅内AVM合并颅内动脉瘤病例,占AVM总数的14％,男性为59％,女性为41％,年龄为11～55岁。其中9例(41％)发生颅内出血(7例为SAH,1例脑实质出血,1例脑室内出血)。出血原因:78％为动脉瘤破裂,22％为AVM破裂。22例病人有44个动脉瘤,多发     

诱发颅内动脉瘤破裂的相关因素分析

目的分析诱发颅内动脉瘤破裂的相关危险因素.方法对80例颅内未破裂动脉瘤患者进行横断面式的随访调查.I组44例患者未经受蛛网膜下腔出血(SAH);II组36例患者脑动脉经受了SAH的刺激,手术已将破裂或较大、引发相关症状的动脉瘤夹闭,仍留有未破裂动脉瘤的多发动脉瘤患者.结果共随访到53例(66.3%).I组26例,目前年龄(到随访时)8.17～76.17岁,平均46.06岁,平均随访4.02人年;II组27例,目前年龄14.83～73.25岁、平均51.74岁,平均随访6.61人年.I组5例,出院后平均1.22年因动脉瘤破裂而死亡,破裂率4.79/100人年;1例椎动脉瘤患者,出院后2.25年瘤体从27 mm增大到34mm,动脉瘤发展率1.30/100人年.II组患者无死亡,1例随访2.42年时,发现一新增的基底动脉瘤,动脉瘤形成率0.56/100人年.结论诱发颅内动脉瘤破裂的危险因素有患者年龄、性别、首发症状以及动脉瘤大小、部位等.     

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。     

血管内栓塞治疗破裂后交通动脉动脉瘤43例

目的总结血管内栓塞治疗破裂后交通动脉动脉瘤的经验。方法43例破裂后交通动脉动脉瘤均经血管内栓塞治疗。结果术后成功栓塞43个动脉瘤,动脉瘤腔100％闭塞35例,95％闭塞5例,90％闭塞3例。术中动脉瘤破裂2例,并发脑血管痉挛3例,术后发生支架内血栓1例。39例术后随访6个月一3年,未发现再出血。结论微弹簧圈血管内栓塞治疗破裂后交通动脉动脉瘤效果可靠;早期治疗,正确处理术中及术后并发症有助于改善患者预后。     

颅内动脉瘤破裂栓塞治疗后症状性脑血管痉挛的发生及影响因素分析

目的探讨破裂颅内动脉瘤经血管内栓塞治疗后症状性脑血管痉挛的发生及相关因素。 方法河南大学附属南石医院神经外科自2008年5月至2010年1月应用电解可脱性弹簧圈栓塞治疗破裂动脉瘤78例,回顾性分析患者的临床资料,判定症状性脑血管痉挛的发生并分析其影响因素。 结果本组78例患者栓塞治疗均成功,术后出现症状性脑血管痉挛20例(25.6％),不同Hunt-Hess分级、Fisher分级患者术后症状性脑血管痉挛的发生率差异有统计学意义(P＜0.05)。经积极治疗后14例恢复正常,3例中度致残,3例放弃治疗。 结论栓塞治疗破裂动脉瘤后症状性血管痉挛的发生与神经功能损害和出血量大小有关,腰大池引流对降低血管痉挛发生有积极意义。     

自发性脑叶出血73例病因分析

报告73例经CT证实的自发性脑叶出血,均行DSA检查,确定病因者61例(84％)。包括25例AVM,5例隐匿性血管畸形(经手术病理证实),28例动脉瘤,烟雾病、高血压和肿瘤各1例,其余12例原因未明。在30例脑血管畸形中,年龄40岁以下者29例,说明年青人脑叶出血的主要病因是AVM。28例动脉瘤中,前交通动脉瘤破裂的发生率最高,为16例(57％),且均造成额叶血肿,年龄50岁以上者13例,提示对年长者的额叶血肿,应注意前交通动脉瘤破裂的可能性。54例经手术治疗去除出血病因获痊愈。     

血管内介入治疗颅内动脉瘤(附59例报告)

目的总结颅内动脉瘤血管内栓塞治疗的经验。方法对59例不同部位和类型颅内动脉瘤分别行可脱性微弹簧圈栓塞、Neuroform支架辅助弹簧圈栓塞及载瘤动脉可脱性球囊闭塞治疗。结果动脉瘤腔完全致密栓塞48例,非致密栓塞8例,动脉瘤颈部有残留3例。55例破裂动脉瘤中死亡1例,患者系术前Hunt-Hess分级Ⅴ级,因额叶脑内血肿脑疝致中枢性呼吸循环衰竭死亡。1例遗留明显偏瘫,其余恢复良好。4例未破裂动脉瘤均临床治愈。结论针对不同部位、不同类型的颅内动脉瘤,采取合理的血管内介入治疗方法可获得满意效果。     

大脑后动脉瘤的手术入路和方法

大脑后动脉瘤发生率仅0.7％～2.3％。作者报告11例大脑后动脉瘤,平均年龄是43.8岁,男3例,女8例。8例表现为蛛网膜下腔出血(SAH),其中5例瘤体破裂。3例合并其它部位的动脉瘤破裂。动脉瘤位于P_1段3例、P_1—P_2段3例。P_2段3例、P_3段2例。10例施行手术治疗,1例合并动静脉畸形(AVM)未行手术治疗。手术效果良好7例、不良2例、死亡1例。     

Impact of unruptured intracranial aneurysms on public health in the United States.

BACKGROUND AND PURPOSE: Unruptured intracranial aneurysms constitute a significant public health problem that has not been quantified. The purpose of this study is to document the magnitude of this problem in the United States. METHODS: National Hospital Discharge Survey data from 1979, 1984, and 1989 served as the basis for calculating patient numbers and frequency distributions. Cost estimates included the direct costs of hospitalization and surgery for those who had surgery, disability and lost income from morbidity, and lost income from mortality. RESULTS: The estimated lifetime cost (including hospitalization, surgery, morbidity, and mortality) for annual cases of patients hospitalized with unruptured intracranial aneurysms in the United States is $522,500,000 compared with $1,755,600,000 for patients with aneurysmal subarachnoid hemorrhage. CONCLUSIONS: These data underscore the need to better understand unruptured intracranial aneurysm as a risk factor for subarachnoid hemorrhage, to define other subarachnoid hemorrhage risk factors, and to optimize the management of patients with these conditions.     

Unruptured intracranial saccular aneurysms less than 20 mm in diameter in adults. Radical surgery in 89 cases

Between 1972 and 1989, 131 unruptured intracranial saccular aneurysms were clipped in the Neurosurgical Department of La Pitié Hospital, Paris. Only 89 of these are considered here, the remaining 42 aneurysms having been discovered and clipped during surgery for a ruptured aneurysm. All isolated unruptured aneurysms were detected by angiography, computerized tomography or magnetic resonance imaging. Twenty out of the 89 aneurysms were asymptomatic ("incidental") while 69 were accompanied by clinical symptoms indicating radiological examination. It is generally accepted that in ruptured aneurysms the mortality rate during 3 days following the rupture is about 50 percent, and for this reason many neurosurgeons are in favour of unruptured aneurysms being treated either by open surgery with clipping of the aneurysmal neck or by inserting a balloon into the aneurysmal sac. The results obtained in 377 published cases, including ours, justify this approach: no recurrent bleeding was observed after open surgery and the mortality rate was nil when the contra-indications of surgery were respected. There was a permanent morbidity of less than 2 per cent directly related to the surgeon's experience.     

Patients with unruptured intracranial aneurysms at the waiting list for intervention: risk of rupture

Unruptured intracranial aneurysms are usually not managed on an emergency basis, although for patients, uncertainty and waiting can be stressful. We assessed the incidence of aneurysms rupturing during the initial period of awareness of having an aneurysm. We studied all patients visiting our service with an unruptured intracranial aneurysm between January 2000 and March 2013. For the exposure time (time between diagnosis and discussion of treatment plan, together with time on waiting list for treatment), we calculated incidence of aneurysmal rupture with corresponding 95 % confidence intervals. We compared this incidence with expected incidence (based on size and site for each aneurysm). 398 patients were included; five had aneurysmal rupture during the exposure time. The observed incidence of aneurysmal rupture during exposure time was 47/1,000 patient-years (95 % confidence interval 15–111); the expected incidence was 0.7/1,000. Our data suggest that the risk of aneurysmal rupture early after detection of unruptured aneurysms is higher than expected based on aneurysm characteristics.     

Preoperative factors affecting the outcome of unruptured posterior circulation aneurysm surgery

We retrospectively investigated preoperative variables contributing to adverse surgical outcome for repair of unruptured posterior circulation aneurysms on data collected prospectively between October 1989 and March 2010. Putative risk factors including age, sex, smoking status, positive family history, modified Rankin Score prior to the surgery, size of the aneurysm, specific site (basilar caput and trunk, vertebral artery and posterior inferior cerebellar artery), midline location, presence of calcium, thrombus or irregularity in the aneurysm on preoperative imaging, associated arteriovenous malformation and preoperative coiling were investigated using regression analyses. In a total of 121 operations, surgical mortality and morbidity was 16.3%. For patients with aneurysms less than 9 mm this rate was 3.2%. Among the investigated variables we found that size, calcification of the aneurysm and age were each predictors of surgical outcome of unruptured posterior circulation aneurysms.     

三维CT血管造影在颅内动脉瘤诊治中的临床价值

目的探讨三维CT血管造影(3D-CTA)在颅内动脉瘤诊治中的临床应用价值。方法回顾性分析自2006年1月至2009年3月以来72例颅内动脉瘤患者的3D-CTA及DSA影像学资料,3D-CTA及DSA图像分别由两位神经外科医师及放射科医师采用双盲法进行对比分析。结果经手术证实72例患者共85个动脉瘤,其中单发动脉瘤61例;多发动脉瘤11例,9例发现2个动脉瘤,2例发现3个动脉瘤。3D-CTA发现67例80个动脉瘤,而DSA发现70例83个动脉瘤。动脉瘤体最大径及瘤颈宽度的测量值在CTA与DSA组间比较无显著性差异(P0.05)。3D-CTA的敏感性及特异性分别为97.65%及94.12%,而DSA的敏感性及特异性则分别为98.82%及97.65%,两组间也无显著差异(P均0.05)。结论 3D-CTA是一种快速、价廉的无创性检查技术,对颅内动脉瘤诊断的敏感性及特异性较高,并可准确显示动脉瘤的位置、形态及大小,较好评估动脉瘤体、载瘤动脉及周围血管之间的关系,从而为选择适当的手术治疗方案提供了可靠的直观依据。     

Selective endovascular treatment of intracranial aneurysms using micrus microcoils: preliminary results in a series of 78 patients

PURPOSE: To determine the safety and reliability of a new platinum microcoil (Micrus), in the treatment of intracranial aneurysms. PATIENTS AND METHODS: Seventy-eight patients (28 male and 50 female patients; age range, 28-83 years; mean age, 44 years) with 80 intracranial aneurysms were treated in 10 centers in Belgium and France. All aneurysms were smaller than 15 mm. Nine aneurysms (11%) were located in the posterior circulation and 71 (89%) in the anterior. Fifty aneurysms (63%) were ruptured and 30 (37%) unruptured. Micrus microcoil is a new platinum coil. It is electrically detached with a time of detachment close to 5 seconds. RESULTS: The degree of occlusion of the aneurysm was classified as total in 49 aneurysms (61%), subtotal in 28 cases (35%) and incomplete in 3 cases (4%). Technical complications were encountered in 10 patients (13%) including parent artery occlusion and thromboembolism (4 cases), coil migration (2 cases) and non-detachment of the coil (2 cases). The immediate morbidity rate was 1.3% and mortality rate 1.3%. CONCLUSION: Micrus microcoils are effective and safe in the selective treatment of ruptured and unruptured intracranial aneurysms. Spherical microcoils are helpful to create a good basket in the aneurysmal sac at the beginning of treatment.     

The Merits of Endovascular Coil Surgery for Patients with Unruptured Intracranial Aneurysms

Objective

The purpose of this study was to report the morbidity, mortality, angiographic results, and merits of elective coiling of unruptured intracranial aneurysms.

Methods

Ninety-six unruptured aneurysms in 92 patients were electively treated with detachable coils. Eighty-one of these aneurysms were located in the anterior circulation, and 15 were located in the posterior circulation. Thirty-six aneurysms were treated in the presence of previously ruptured aneurysms that had already undergone operation. Nine unruptured aneurysms presented with symptoms of mass effect. The remaining 51 aneurysms were incidentally discovered in patients with other cerebral diseases and in individuals undergoing routine health maintenance. Angiographic and clinical outcomes and procedure-related complications were analyzed.

Results

Eight procedure-related untoward events (8.3%) occurred during surgery or within procedure-related hospitalization, including thromboembolism, sac perforation, and coil migration. Permanent procedural morbidity was 2.2% ; there was no mortality. Complete occlusion was achieved in 73 (76%) aneurysms, neck remnant occlusion in 18 (18.7%) aneurysms, and incomplete occlusion in five (5.2%) aneurysms. Recanalization occurred in 8 (15.4%) of 52 coiled aneurysms that were available for follow-up conventional angiography or magnetic resonance angiography over a mean period of 13.3 months. No ruptures occurred during the follow-up period (12-79 months).

Conclusion

Endovascular coil surgery for patients with unruptured intracranial aneurysms is characterized by low procedural mortality and morbidity and has advantages in patients with poor general health, cerebral infarction, posterior circulation aneurysms, aneurysms of the proximal internal cerebral artery, and unruptured aneurysms associated with ruptured aneurysm. For the management of unruptured aneurysms, endovascular coil surgery is considered an attractive alterative option.     

Familial intracranial aneurysms

The study included 38 patients with intracranial aneurysms, whose close relatives had experienced intracranial hemorrhages. The patients' relatives were divided into 2 groups according to the verification of the source of hemorrhage. The individuals at risk for aneurysmal disease in whom aneurysms should be sought before their rupture were examined. The patients with familial aneurysms were found to tend to rupture at younger age than those without familial aneurysms (the so-called sporadic aneurysms). The high rates of mortality due to intracranial bleeding were observed among the relatives of patients from the study group. Screening study of the first-order relatives of the patients with prior aneurysmal subarachnoidal hemorrhage is the method of choice in detecting unruptured cerebrovascular aneurysms. Early detection and switching-off of asymptomatic aneurysms may reduce mortality and disability rates in this group of patients.     

Benefits of Surgical Treatment for Unruptured Intracranial Aneurysms in Elderly Patients

Objective

Due to longer life spans, patients newly diagnosed with unruptured intracranial aneurysms (UIAs) are increasing in number. This study aimed to evaluate how management of UIAs in patients age 65 years and older affects the clinical outcomes and post-procedural morbidity rates in these patients.

Methods

We retrospectively reviewed 109 patients harboring 136 aneurysms across 12 years, between 1997 and 2009, at our institute. We obtained the following data from all patients : age, sex, location and size of the aneurysm(s), presence of symptoms, risk factors for stroke, treatment modality, and postoperative 1-year morbidity and mortality. We classified these patients into three groups : Group A (surgical clipping), Group B (coil embolization), and Group C (observation only).

Results

Among the 109 patients, 56 (51.4%) underwent clipping treatment, 25 (23%) patients were treated with coiling, and 28 observation only. The overall morbidity and mortality rates were 2.46% and 0%, respectively. The morbidity rate was 1.78% for clipping and 4% for coiling. Factors such as hypertension, diabetes mellitus, hypercholesterolemia, smoking, and family history of stroke were correlated with unfavorable outcomes. Two in the observation group refused follow-up and died of intracranial ruptured aneurysms. The observation group had a 7% mortality rate.

Conclusion

Our results show acceptable favorable outcome of treatment-related morbidity comparing with the natural history of unruptured cerebral aneurysm. Surgical clipping did not lead to inferior outcomes in our study, although coil embolization is generally more popular for treating elderly patients. In the treatment of patients more than 65 years old, age is not the limiting factor.     

Intracranial aneurysms and subarachnoid hemorrhage in children and adolescents

Thirty-eight cases of symptomatic cerebral aneurysms or spontaneous subarachnoid hemorrhage in children and adolescents were observed from 1965 to 1984; 33 cases were treated from 1970 to date. This group represents 2.6% of the total number of patients with subarachnoid hemorrhage treated at our institute in the same period. The cause of subarachnoid hemorrhage was unknown in 7 cases; an intracranial aneurysm had ruptured in 29 cases, and was unruptured but symptomatic in 2 remaining cases. Three aneurysms were mycotic. The most frequent aneurysmal locations were the internal carotid bifurcation and the anterior communicating artery; peripheral branches of the middle cerebral artery were also a relatively common location. Four patients were 3 years of age or younger: each presented peculiar clinical features, and 3 of the 4 had middle cerebral artery aneurysms. The remaining 34 patients were all above 9 years of age. Two groups were identified: (a) in 14 patients between 10 and 15 years of age, the aneurysm was most commonly at the internal carotid bifurcation (37%), and an intracerebral hematoma was observed in 50% of these cases; (b) in 20 patients between 16 and 20 years of age, the most common aneurysmal location was the anterior communicating artery (35%), and intracerebral hematomas were rare (10% of cases). Among patients with aneurysms, 19 underwent surgical exclusion by clip, with 10% morbidity and 5% mortality; 5 patients in moribund conditions were not operated on; 5 patients were conservatively treated; in 2 patients the aneurysm had disappeared at a second angiography. Ischemic deterioration from vasospasm was observed only in 3 patients, all above 17 years of age, and with a consistent or thick subarachnoid blood deposition on early CT scan. Hydrocephalus was also rarely observed (13% of cases), requiring a shunt in only 3 patients. Overall management results were significantly better than in adult patients, with 73% good results and 21% deaths. The better prognosis in the group under 20 years of age is probably accounted for (a) by the frequently observed reversibility of neural injury in young patients and (b) the very low incidence of ischemic disturbances in this age group.