颅内动脉瘤治疗十年回顾(附1372例治疗及随访)

目的 总结十年颅内动脉瘤治疗经验,以提高其治疗效果.方法 2000年1月至2009年12月收治颅内动脉瘤1 372例,采用血管内栓塞治疗632例(697枚动脉瘤),显微手术夹闭740例(805枚动脉瘤).结果 按GOS评分,栓塞组Hunt-Hess 0～Ⅲ级564例患者中,良好536例(95.0%),死亡6例(1.1%);手术夹闭组Hunt-Hess 0～Ⅲ级患者566例,良好542例(95.8%),重残18例(3.2%),死亡6例(1.1%).栓塞组Hunt-HessⅣ～Ⅴ级68例患者中,良好32例(47.1%),重残18例(26.5%),死亡18例(26.5%);手术夹闭组Hunt-HessⅣ～Ⅴ级174例患者中,良好84例(48.3%),重残55例(31.6%),植物生存7例(4.0%),死亡28例(16.1%)死亡.两组Hunt-Hess 0～Ⅲ级患者的预后没有显著差别(P>0.05).本组Hunt-HessⅤ级26例,重残4例,植物生存3例,死亡19例.栓塞组DSA复查167例,动脉瘤仍致密填塞138例,不完全栓塞24例,复发5例;夹闭组DSA复查136例,安全夹闭129例,部分瘤颈残留7例.结论 血管内栓塞治疗和显微手术夹闭均是治疗颅内动脉瘤的有效方法,治疗应根据病人动脉瘤的部位、大小及经济状况等进行选择,前循环动脉瘤两种皆可,后循环动脉瘤应首选血管内栓塞.Hunt-Hess 0～Ⅲ级尽早诊断和治疗,Hunt-Hess Ⅳ级在出血3 d以后血管痉挛严重者应待其缓解后再行治疗,Ⅴ级疗效极差.

Management of intracranial aneurysms: review of ten years experience

Objective To summarize ten years experience in treating intracranial aneurysms (ICAN) in order to enhance the curative effect on them. Methods The clinical data of 1 372 patients with ICAN, of whom, 632 with 697 ICAN were treated by endovascular embolization (EVE) and 740 with 805 ICAN by microsurgery from January, 2000 to December, 2009, were analyzed retrospectively. Results The prognoses were assessed by GOS in all the patients. Of 564 patients with Hunt-Hess grades 0~ Ⅲ treated by EVE, 536 (95.0%) had good prognoses, 22 (3.9%) were severely disabled and 6 (1.1%) died. Of 566 patients with Hunt-Hess grades 0~ Ⅲ treated by the microsurgery, 542 (95.8%) had good prognoses, 18 (3.2%) were severely disabled and 6 (1.1%) died. Of 68 patients with Hunt-Hess grades Ⅳ ~ Ⅴ treated by EVE, 32 (47.1%) had good prognoses, 18 (26.5%) were severely disabled and 18 (26.5%) died. Of 174 patients with Hunt-Hess grades Ⅳ ~ Ⅴ treated by the microsurgery, 84 (48.3%) had good prognoses, 55 (31.6%) were severely disabled, 7 (4.0%) vegetatively survived and 28 (16.1%) died. There was insignificant difference in the rates of good prognoses between both the EVE and microsurgical treatment groups ( P >0.05). Of 26 patients with Hunt-Hess grade Ⅴ , 4 were severely disabled, 3 survived vegetatively and 19 died. DSA re-examination showed that of 167 patients treated by EVE, 138 had densely occluded aneurysms, 24 incompletely and 5 suffered from recurrence of aneurysms, and of 136 patients treated by the microsurgery, 129 received complete clipping of the aneurysms and 7 received incomplete. Conclusions The EVE and microsurgical clipping are the effective methods to treat ICAN. The methods to treat ICAN should be selected according to the aneurysmal region and size, and patient ’ s economic conditions. The anterior circulation aneurysms may be treated by both the EVE and microsurgical clipping. The EVE should be selected first for the posterior circulation aneurysms. The diagnosis and treatment should be made as early as possible in the ICAN patients with Hunt-Hess grades 0~ Ⅲ . If severe cerebral vasospasm occurred in the patients with Hunt-Hess grade Ⅳ 3 days after the bleeding, the endovascular or microsurgical treatment should be not performed until the vasospasm was relieved. The prognoses of the ICAN patients with Hun-Hess grade Ⅴ are very poor.