颅内动脉瘤弹簧圈栓塞治疗术中动脉瘤再破裂的防治

目的颅内动脉瘤在弹簧圈栓塞过程中发生破裂是最可怕的术中并发症之一，本文探讨处理、预防这一并发症的初步经验。方法2002年4月-2006年12月，共有153例患有颅内动脉瘤的患者在我院接受了可脱卸弹簧圈栓塞治疗，其中141例患者曾有过动脉瘤破裂引起蛛网膜下腔出血史。5例有动脉瘤破裂出血史的患者术中再次发生动脉瘤破裂。术中动脉瘤再破裂时，常规使用鱼精蛋白中和肝素，并设法用弹簧圈尽快填塞动脉瘤腔。微导丝引起动脉瘤破裂时，尽量保持微导丝不动，微导管尽快送到瘤腔中进行填塞治疗。若微导管引起破裂而微导管头端位于瘤壁外蛛网膜下腔时，微导管且勿退入瘤腔内，应将弹簧圈经微导管送入蛛网膜下腔一部分后，再将微导管头撤入瘤腔内，继续弹簧圈填塞。若弹簧圈引起破裂，要将弹簧圈完全或部分送出去，将破裂口堵住后，调整微导管头端位置继续弹簧圈填塞。结果在接受动脉瘤栓塞治疗的153例患者中，141例曾有过动脉瘤破裂引起蛛网膜下腔出血，治疗中5例发生了术中再破裂，占动脉瘤破裂引起蛛网膜下腔出血的3．5％，总发生率为3．3％。1例破裂由导丝引起，1例由微导管引起，1例由弹簧圈过度填塞引起，弹簧圈穿孔1例，其余1例由微导管和弹簧圈共同引起。2例死亡，死亡率占术中破裂的40％，占总例数的1．3％；1例患者出院时遗留有右下肢瘫痪，其余2例患者无残留神经系统并发症。结论动脉瘤栓塞术中动脉瘤的再破裂是一少见、威胁生命但又不可避免的事件。应该立即采取妥善措施以挽救患者生命、改善预后、降低可怕并发症的发生。如处理恰当，多数术中动脉瘤破裂的患者能够存活，无后遗症。

Prevention and management of intraprocedural rupture of intracranial aneurysm with detachable coils during embolization

Objective To investigate the prevention and management of intra-procedural rupture of Intracranial aneurysms during embolization.Methods From April 2002 to December 2006,153 patients with cerebral aneurysms were treated with detachable coils.Intra-procedural aneurysm rupture occurred in 5 patients with histories of previously ruptured aneurysms.In the event of intra-procedure hemorrhages,we routinely performed heparin reversals with protamine sulphate.Results Of the 141 patients with previously ruptured aneurysms,5(3.5%) endured intra-procedural aneurysmal ruptures.These ruptures were caused by a microguidewire in 1 case,a microcatheter in 1,over-packing in 1 and a coil perforation in 1.The remaining one patients endured ruptures caused by both the microcatheter and the coils.Two patients died because of aneurysmal re-rupture,yielding a mortality rate of 40%.One patient presented with a slight disability in the right leg and no neurological deficits were observed in the remaining two patients.Conclusion Intra-procedural aneurysm rupuure during embolization is a rare,but unavoidable and life-threatening event.Proper measures should be taken to reduce and improve the outcome of this tragic occurrence.The majority of patients with an intra-procedural ruptured aneurysm can survive without severe sequalae if managed appropriately.