显微外科手术治疗高分级动脉瘤性蛛网膜下腔出血的临床疗效观察

目的探讨显微外科手术治疗高分级动脉瘤性蛛网膜网下腔出血（aSAH）的临床疗效。方法回顾性分析37例经显微外科手术治疗的高分级aSAH患者（入院时Hunt—hess分级Ⅳ～V级）的临床资料。发病≤72h手术者为早期手术（19例），〉72h手术者为延期手术（18例）；对20例存在脑内血肿，严重脑室积血、积水的患者行动脉瘤夹闭并减压术，其余17例患者行单纯动脉瘤夹闭术。采用改良Rankin评分（mRS）量表评价患者的预后。结果37例患者均获随访，中位随访时间为15个月。37例患者术后并发症的发生率为54．1％（20／37），总体预后良好率为59．5％（22／37），病死率为27．0％（10／37）。Hunt—HessIV级者的预后良好率为67．9％（19／28），病死率为21．4％（6／28）；V级者的预后良好比例为3／9，病死患者比例为4／9。早期手术的19例中，17例行动脉瘤夹闭并减压术，并发症的发生率为73．7％（14／19），预后良好率为42．1％（8／19）；延期手术18例中，单纯动脉瘤夹闭15例，并发症的发生率为33．3％（6／18），预后良好率为77．8％（14／18）。延期手术组与早期手术组比较，并发症少，预后相对较好，差异有统计学意义（P〈0．05）。结论对不合并严重脑内血肿，脑室积血、积水的高分级aSAH患者，延期手术可以相对减少术后并发症，预后相对较好。在临床上应结合病情，在不同时期，采取不同的外科手术方式，可有助于改善患者预后。

The clinical efficacy of microsurgery for treatment of high-grade aneurysmal subarachnoid hemorrhage

Objective To investigate the clinical efficacy of microsurgical treatment of high-grade aneurysmal subarachnoid hemorrhage （aSAH）. Methods The clinical data of 37 patients with high- grade aSAH（ Hunt-Hess grade IV -V on admission） treated with microsurgery were analyzed retrospectively. Early surgery was the operation performed within 72 hours after the onset （ n = 19 ） and delayed surgery was the operation performed 〉 72 h after the onset （n = 18 ）. 20 patients with intracerebral hematoma, severe intraventricular hemorrhage or hydrocephalus were treated with aneurysm clipping and decompression, and simple aneurysm clipping were performed in the remaining 17 patients. The modified Rankin scale （mRS） was used to assess the prognosis of the patients. Results All the 37 patients were followed up, the median follow-up period was 15 months. The incidence of postoperative complications of the 37 patients was 54. 1% （20/37） , the overall good prognosis rate was 59.5% （22/37） , and the mortality rate was 27.0% （10/37）. The good prognosis rate of patients with Hunt-Hess grade IV was 67.9% （19/28） and the mortality rate was 21.4% （6/28） ; the good prognosis rate of patients with grade V was 33.3% （3/9） and the mortality rate was 44.4% （4/9）. In the 19 patients of the early surgery, aneurysm clipping and dccom- pressive surgery were performed in 17 patients. The complication rate was 73.7% （14/19） and the good prognosis rate was 42. 1% （8/19） ; in the 18 patients of delayed surgery, simple aneurysm clipping were performed in 15 patients. The complication rate was 33.3 （6/15） and the good prognosis rate was 77.8% （14/18）. Compared to the early surgery group, the delayed surgery group had fewer complications, the prognosis was relatively better, and there was significant difference （ P 〈 0. 05 ）. Conclusions For patients with high-grade aSAH but not complicating severe intracerebral hematoma, intraventricular hemorrhage, and hydrocephalus, the delayed surgery can relatively decrease the postoperative complications, and the prognosis was relatively better. In clinical practice, different surgical procedures should be taken at different times according to disease conditions, which may help improve the prognosis of patients.