中华神经外科杂志
中華神經外科雜誌
중화신경외과잡지
Chinese Journal of Neurosurgery
2012年
1期
27-32
,共6页
张炘%段传志%李铁林%汪求精%龙霄翱%罗斌%Tamrakar Karun%何旭英%李西峰%刘晓平%权涛%顾大群%苏世星%赖凌峰
張炘%段傳誌%李鐵林%汪求精%龍霄翱%囉斌%Tamrakar Karun%何旭英%李西峰%劉曉平%權濤%顧大群%囌世星%賴凌峰
장흔%단전지%리철림%왕구정%룡소고%라빈%Tamrakar Karun%하욱영%리서봉%류효평%권도%고대군%소세성%뢰릉봉
动脉瘤,破裂%术中再破裂%危险因素%处理方法
動脈瘤,破裂%術中再破裂%危險因素%處理方法
동맥류,파렬%술중재파렬%위험인소%처리방법
Aneurysm,ruptured%Intraprocedual rerupture%Risk factors%Management
目的 探讨颅内破裂动脉瘤术中再破裂(IPR)的危险因素、破裂后的处理方法,评估术后临床效果,为今后术前评估IPR的风险提供理论依据,同时为IPR的治疗策略提供经验性指导.方法 回顾性分析1 628例颅内破裂动脉瘤患者的资料,采用Logistic回归分析颅内破裂动脉瘤IPR的危险因素,并总结IPR的治疗策略,术后所有IPR患者定期接受临床及影像学随访,评估该治疗策略的临床疗效.结果 IPR的发生率为0.98％,死亡率为37.50％.存活的10例患者中有8例得益于发生IPR后立即快速完成动脉瘤栓塞以及静脉注射鱼精蛋白中和肝素钠逆转抗凝,2例得益于急诊脑室外引流.但是7例患者遗留有不同程度的残疾,3例完全康复.微小动脉瘤(直径≤3 mm)( OR 21.086,95％ CI 2.009 ～ 221.333,P=0.011)、颅内动脉粥样硬化(OR 39.246,95％ CI 2.949～522.373,P=0.005)、FisherⅢ级(OR 127.139,95％CI 3.340～4 839.744,P=0.009)、脑血管痉挛Ⅰ级(OR 111.888,95％CI 4.154 ～3 013.480,P=0.005)和Ⅱ级(OR 93.024,95％CI 5.256～1 646.527,P=0.002)为颅内破裂动脉IPR的危险因素；颈内动脉分叉近端和基底动脉主干处(OR 0.003,95％ CI 0.000～0.101,P=0.001)以及Hunt - HessⅡ级(OR 0.003,95％ CI 0.000～0.316,P=0.015)为IPR的保护性因素.结论 微小动脉瘤(直径≤3 mm)、颅内动脉粥样硬化、FisherⅢ级以及存在脑血管痉挛(Ⅰ级和Ⅱ级)的患者容易发生IPR；颈内动脉分叉近端和基底动脉主干处以及Hunt - HessⅡ级的动脉瘤较少发生IPR.IPR发生后立即快速完成动脉瘤栓塞,同时予静脉注射鱼精蛋白中和肝素钠逆转抗凝是急诊救治的关键.
目的 探討顱內破裂動脈瘤術中再破裂(IPR)的危險因素、破裂後的處理方法,評估術後臨床效果,為今後術前評估IPR的風險提供理論依據,同時為IPR的治療策略提供經驗性指導.方法 迴顧性分析1 628例顱內破裂動脈瘤患者的資料,採用Logistic迴歸分析顱內破裂動脈瘤IPR的危險因素,併總結IPR的治療策略,術後所有IPR患者定期接受臨床及影像學隨訪,評估該治療策略的臨床療效.結果 IPR的髮生率為0.98％,死亡率為37.50％.存活的10例患者中有8例得益于髮生IPR後立即快速完成動脈瘤栓塞以及靜脈註射魚精蛋白中和肝素鈉逆轉抗凝,2例得益于急診腦室外引流.但是7例患者遺留有不同程度的殘疾,3例完全康複.微小動脈瘤(直徑≤3 mm)( OR 21.086,95％ CI 2.009 ～ 221.333,P=0.011)、顱內動脈粥樣硬化(OR 39.246,95％ CI 2.949～522.373,P=0.005)、FisherⅢ級(OR 127.139,95％CI 3.340～4 839.744,P=0.009)、腦血管痙攣Ⅰ級(OR 111.888,95％CI 4.154 ～3 013.480,P=0.005)和Ⅱ級(OR 93.024,95％CI 5.256～1 646.527,P=0.002)為顱內破裂動脈IPR的危險因素；頸內動脈分扠近耑和基底動脈主榦處(OR 0.003,95％ CI 0.000～0.101,P=0.001)以及Hunt - HessⅡ級(OR 0.003,95％ CI 0.000～0.316,P=0.015)為IPR的保護性因素.結論 微小動脈瘤(直徑≤3 mm)、顱內動脈粥樣硬化、FisherⅢ級以及存在腦血管痙攣(Ⅰ級和Ⅱ級)的患者容易髮生IPR；頸內動脈分扠近耑和基底動脈主榦處以及Hunt - HessⅡ級的動脈瘤較少髮生IPR.IPR髮生後立即快速完成動脈瘤栓塞,同時予靜脈註射魚精蛋白中和肝素鈉逆轉抗凝是急診救治的關鍵.
목적 탐토로내파렬동맥류술중재파렬(IPR)적위험인소、파렬후적처리방법,평고술후림상효과,위금후술전평고IPR적풍험제공이론의거,동시위IPR적치료책략제공경험성지도.방법 회고성분석1 628례로내파렬동맥류환자적자료,채용Logistic회귀분석로내파렬동맥류IPR적위험인소,병총결IPR적치료책략,술후소유IPR환자정기접수림상급영상학수방,평고해치료책략적림상료효.결과 IPR적발생솔위0.98％,사망솔위37.50％.존활적10례환자중유8례득익우발생IPR후립즉쾌속완성동맥류전새이급정맥주사어정단백중화간소납역전항응,2례득익우급진뇌실외인류.단시7례환자유류유불동정도적잔질,3례완전강복.미소동맥류(직경≤3 mm)( OR 21.086,95％ CI 2.009 ～ 221.333,P=0.011)、로내동맥죽양경화(OR 39.246,95％ CI 2.949～522.373,P=0.005)、FisherⅢ급(OR 127.139,95％CI 3.340～4 839.744,P=0.009)、뇌혈관경련Ⅰ급(OR 111.888,95％CI 4.154 ～3 013.480,P=0.005)화Ⅱ급(OR 93.024,95％CI 5.256～1 646.527,P=0.002)위로내파렬동맥IPR적위험인소；경내동맥분차근단화기저동맥주간처(OR 0.003,95％ CI 0.000～0.101,P=0.001)이급Hunt - HessⅡ급(OR 0.003,95％ CI 0.000～0.316,P=0.015)위IPR적보호성인소.결론 미소동맥류(직경≤3 mm)、로내동맥죽양경화、FisherⅢ급이급존재뇌혈관경련(Ⅰ급화Ⅱ급)적환자용역발생IPR；경내동맥분차근단화기저동맥주간처이급Hunt - HessⅡ급적동맥류교소발생IPR.IPR발생후립즉쾌속완성동맥류전새,동시여정맥주사어정단백중화간소납역전항응시급진구치적관건.
Objective To identify the risk factors of intraprocedual rerupture ( IPR) of ruptured intracranial aneurysm,and illustrate the prevention and management on this event as well as its postembolization outcomes evaluation.Method Endovascular treatment was performed in l,628 ruptured intracranial aneurysms.The clinical records and images,risk factors of IPR were studied by using multivariate logistic regression to summanze the treatment strategy.Results The morbidity of IPR was 0.98% and mortality was 37.50％.8 patients survived from rapid completion of coiling with immediate reversal of heparin anticoagulation with protamine sulfate,and 2 from emergent extemal ventricular drainage ( EVD).However,7 0f them presented with different degrees of disability and 3 were fully recovered.Small aneurysms ( diameter≤ 3.0 mm,OR 21.086,95％ CI 2.009 - 221.333, P =0.011),cerebral atherosclerosis ( OR 39.246,95 ％ CI 2.949 - 522.373, P =0.005 ),Fisher grade Ⅲ ( OR 127.139,95％ CI 3.340 -4 839.744, P =0.009),cerebral vasospasm ( grade Ⅰ ) ( OR 111.888,95％ CI 4. 154 - 3 013.480, P =0.005) and vasospasm ( grade Ⅱ ) ( OR 93.024,95％ CI 5.256 - 1 646.527,P =0.002) were risk factors of IPR.Aneurysms at proximal part of intemal carotid artery ( ICA) bifurcation and basilar artery ( BA) stem ( OR 0.003,95％ CI 0.000 -0.101,P =0.001) and Hunt - Hess Grade Ⅱ ( OR 0.003,95％CI 0.000 -0.316,P =0.015) were identified as protective factors.Conclusions Small aneurysms,cerebral atherosclerosis,Fisher grade of SAH and cerebral vasospasm are risk factors for IPR.Aneurysms at proximal part of ICA bifurcation and BA stem and Hunt - Hess Grade Ⅱ are less associated with IPR.Rapid completion of coiling combined with immediate reversal of heparin anticoagulation is confirmed to be the best management strategy.
