颅内破裂动脉瘤手术时机的探讨(附237例分析)

目的探讨颅内破裂动脉瘤手术时机与临床预后的关系。方法回顾性分析2005年我院收治的237例颅内破裂动脉瘤，其中196例行手术治疗。按入院时Hunt—Hess分级将手术病人分为A组（Ⅰ～Ⅲ级）162例，B组（Ⅳ、Ⅴ级）34例；根据手术时间分为早期手术组（SAH3d内手术）19例，延期手术组（SAH4～10d手术）82例，晚期手术组（SAH11d之后手术）95例。比较不同手术期别动脉瘤术中破裂率、术后1个月GOS评分及术后主要并发症（脑血管痉挛、脑积水）发生率，并进行统计学分析。结果24例（10．1％）因再出血丧失治疗机会。术中动脉瘤破裂早期手术组3例（15，8％），延期手术组8例（9．8％），晚期手术组6例（613％）。术后脑血管痉挛发生率早期手术组为15，8％，延期手术组为19，5％，晚期手术组为17，9％。脑积水发生率以晚期手术组最高（14，7％）。对术后1个月GOS评分Ridit分析结果显示：A、B两组中均以早期手术组治疗效果最佳．延期手术次之．晚期手术最差。结论早期手术可规避颅内破裂动脉瘤再出血的风险，降低主要并发症发生率。对于各个级别（包括Ⅳ、Ⅴ级）的SAH病人，均应根据治疗者的手术经验与技巧和所在医院的条件，及早诊断，尽早手术。     

GDC栓塞术中颅内动脉瘤再破裂的原因、对策与结果

目的探讨电解脱弹簧圈(Guglialm i detachab le coil,GDC)颅内动脉瘤栓塞术中动脉瘤再破裂的发生率、原因、对策及结果。方法302例颅内动脉瘤破裂患者行GDC栓塞术,其中8例发生术中动脉瘤再破裂。结果2例由微导丝穿破动脉瘤壁引起,3例由微导管穿破动脉瘤壁引起,2例由置放首枚弹簧圈时顶破动脉瘤壁引起,l例术中自发破裂,所有病例均继续行GDC动脉瘤填塞。2例死于动脉瘤破裂后大出血,其他6例均康复没有留下后遗症。本组术中动脉瘤再破裂发生率为2.6%,死亡率为25%。结论GDC血管内栓塞术中引起动脉瘤再破裂是十分少见的,但大部分病例经过继续填塞GDC可达到完全填塞动脉瘤,且不留下后遗症。     

Right axillary arterial perfusion for a ruptured type B aortic dissection: Report of a case

The results of surgical treatment for a ruptured type B aortic dissection remain far from satisfactory. It is believed that additional perfusion from the right axillary artery might be more beneficial than perfusion from only the femoral artery during surgery for a ruptured thoracic aneurysm. The right axillary perfusion is more likely to perfuse the vital organs proximal to the ruptured area, and thus avoid retrograde emboli. In addition, if the open proximal method is performed, then the right axillary perfusion is able to facilitate the evacuation of air from the aortic lumen. We present herein the case of a patient in whom a ruptured type B acute aortic dissection was successfully treated by applying right axillary perfusion through a left thoracotomy.     

Repair of a ruptured aortic arch aneurysm complicated by postoperative paraplegia: Report of a case

We report herein the rare case of a 79-year-old man who suffered permanent paraplegia after undergoing an otherwise successful total arch replacement for a ruptured aortic arch aneurysm. During cardiopulmonary bypass, perfusion to the distal aorta was maintained from the femoral artery, and postoperative aortography showed intact tributaries from the aorta including the intercostal arteries. Postoperative paraplegia is an extremely rare complication of operations on the aortic arch; however, we speculate that the paraplegia in this patient could be attributed either to a steal phenomenon involving the radicular artery, or to the anatomical particularity of the spinal cord artery described by Cole and Gutelius as the segmental system.     

Effects of Different Non-Haemic Fluids in Open-Heart Surgery. An Experimental Study in the Pig

Extracorporeal circulation was established in pigs in order to evaluate different types of non-haemic priming fluids. In addition to clinical chemical analyses of blood and serum constituents, the main guide-lines for this evaluation were the need for electrolyte solutions to maintain an adequate blood volume and arterial pressure and the changes in extracellular volume, measured with radioactive sulfate. The priming fluid in clinical use at our hospital contains albumin and large amounts of glucose and has an osmolality of 460 mosmol/kg water. When albumin was omitted, the need for additional fluid increased considerably. Less than 700 ml was required when the serum total protein concentration was reduced to about 60% of the pre-operative value, whereas more than three times and seven times as much were needed in animals were the protein levels fell to 50% and 33%, respectively. The use of an isotonic priming fluid led to a slight increase in the need for additional infusions, but the sulfate space did not differ significantly from that of the pigs which received hypertonic prime. A net influx of glucose to the blood took place during perfusion, giving an elevated glucose level even when a priming fluid poor in glucose was used. The radiosulfate curves showed satisfactory equilibration after each major event of the procedure, thus making it possible to determine a sulfate space by an extrapolation technique. However, the biological half-life of the radioactivity in serum increased strikingly during the experiments and more after the hypertonic than after the isotonic priming fluid. The explanation is obscure; one possibility is damage of cell membranes with leakage of water into the cells.     

经食管超声心动图引导经胸微小切口封堵主动脉窦瘤破裂的可行性

目的 探讨经食管超声心动图（TEE）引导经胸微小切口封堵主动脉窦瘤破裂（RASA）的可行性。方法 回顾性分析30例接受TEE引导经胸微小切口封堵治疗的RASA患者的资料。对右冠状动脉窦瘤破裂者,准确测量破口与冠状动脉开口之间的距离,术中以TEE准确引导导丝及鞘管顺利进入窦瘤破口,术后仔细评估封堵伞位置、稳定性及对瓣膜的影响。对右冠窦瘤破裂患者,确保封堵器未遮挡冠状动脉开口。结果 30例RASA患者中,TEE引导下成功封堵20例,其中右冠窦瘤破裂10例（破入右心室7例、破入右心房3例）;无冠窦瘤破裂10例（破入右心房8例、破入右心室2例）。封堵成功患者各项生命体征平稳,心腔结构未发生明显改变,心功能正常。术后多次复查,封堵器位置正常,主动脉瓣启闭运动正常,未见狭窄及反流信号,也未检测到残余分流。结论 TEE可较为准确地诊断RASA,并引导术者准确放置封堵器;单纯TEE引导下经胸微小切口封堵RASA是一种可行的方法。     

Repeated resection for extrahepatic recurrences after hepatectomy for ruptured hepatocellular carcinoma

In March 1999, a 54-year-old man with chronic hepatitis C was referred to our hospital because of ruptured hepatocellular carcinoma (HCC) located in Couinaud’s segments 4 and 8. He underwent central bisegmentectomy of the liver with partial resection of the diaphragm. After the first surgery, extrahepatic metastases were found on different occasions in the abdominal wall, thoracic cavity, and greater omentum and were all surgically resected. In February 2001, the serum protein induced by vitamin K absence or antagonist-II (PIVKA-II) level increased markedly to 19?000?mAU/l. Magnetic resonance imaging showed a massive right subphrenic tumor with invasion to the right diaphragm and posterior segment of the liver. The patient underwent en bloc resection of the tumor, diaphragm, posterior segment of the liver, and right lower pulmonary lobe. After the surgery, the PIVKA-II level rapidly decreased, and it has remained within the normal range to date. Two years after the last surgery, the patient is doing well without any extrahepatic recurrence, although small intrahepatic recurrences have been completely treated by radiofrequency ablation and transcatheter arterial chemoembolization. Ruptured HCC often exacerbates the risk of peritoneal dissemination and is usually difficult to completely resect. This is an extremely rare case of a patient who successfully underwent five repeated resections for extrahepatic recurrences after hepatectomy for ruptured HCC.