Hunt-Hess Ⅳ～Ⅴ级蛛网膜下腔出血的早期病因诊断及治疗

The early etiological diagnosis and endovascular embolization therapy of Hunt-Hess Ⅳ—Ⅴ grade subarachnoid hemorrhage

目的：探讨Hunt-HessⅣ～Ⅴ级蛛网膜下腔出血（SAH）的早期病因诊断方法及治疗原则，并客观评价其治疗效果。方法：对31例SAH患者发病后7d内进行CT及DSA检查，寻找SAH的原因，明确SAH均为脑动脉瘤破裂所致。明确病因后，即刻采用电解可脱性弹簧圈（GDC）进行动脉瘤囊内栓塞，术后早期处理出血并行有效的对症治疗。对于动脉瘤直径和瘤颈宽度不同患者的疗效和病死率进行比较，结果经X^2检验。结果：31例患者经CT、DSA检查，均明确诊断。SAH均为脑动脉瘤破裂所致，所有动脉瘤均经栓塞治疗。其中动脉瘤腔100％闭塞26例、95％闭塞者3例、90％闭塞者2例。术中并发脑血管痉挛5例，1例动脉瘤复发并经第2次补充GDC栓塞而治愈。29．0％（9／31）出现与SAH有关的永久性后遗症。治疗结果根据Glasgow预后评分：Ⅰ级6例、Ⅱ级9例、Ⅲ级4例、Ⅳ级2例、Ⅴ级10例；病死率32．3％（10／31）。术后随访3～68个月均无再出血。动脉瘤直径11～25mm组7例，死亡5例；5～10mm组21例，死亡4例，2组比较差异有统计学意义（r=6．60，P〈0．05）。瘤颈≤4mm组24例，动脉瘤完全栓塞23例，死亡5例；瘤颈〉4mm组7例，动脉瘤完全栓塞3例，死亡5例，2组动脉瘤完全栓塞率和病死率差异均有统计学意义（分别X^2=11．24、P〈0．01，X^2=6．35、P〈0．05）。结论：CT及DSA可对Hunt-HessⅣ～Ⅴ级SAH进行早期病因诊断；对已破裂的动脉瘤早期采用电解可脱性弹簧圈囊内栓塞，术后早期处理出血并有效的对症治疗，是提高动脉瘤性SAH治愈率和降低病死率及致残率的有效方法。

Objective To explore the methods of early etiological diagnosis and principles of endovascular embolization in Hunt-HessⅣ-Ⅴ grade subarachnoid hemorrhage （SAH）, and to evaluate the therapeutic efficacy. Methods Thirty-one patients underwent imaging examinations such as CT and DSA to make the early diagnosis of SAH. Meanwhile, Guglielmi detachable microcoil （GDC） was used to applying aneurysmal intracapsular embolization in the ruptured aneurysms, and efficient symptomatic treatment was adopted early postoperatively. The results were tested by X^2 test. Results All 31 cases were diagnosed early and operated successfully. Among them, the aneurysm lumen was 100% occluded in 26 cases, 95% occluded in 3 cases; 90% occluded in 2 cases. There were 5 cases complicating with cerebral vasospasm. One case recurrent was cured with secondary complementary GDC embolization. Nine cases （29. 0% ） had permanent sequelae associated with SAH. According to the Glasgow prognosis score, the therapeutic efficacy was as following： 6 patients were in grade Ⅰ , 9 in grade Ⅱ , 4 in grade Ⅲ, 2 in grade Ⅳ, and 10 in grade Ⅴ ; 10 patients died, and the morality rate was 32. 3%. None of them exhibited re-bleeding with follow-up period of 3 to 68 months postoperatively. Morality rates were significantly different between the group with aneurysmal diameter of 11-25 mm and the group of 5-10 mm （ X^2 = 6. 60, P 〈 0. 05）. There was significant difference in 100% occluded rate between the group with aneurysmal neck smaller than 4 mm and the group of more than 4 mm （ X^2 = 11.24, P 〈 0. 01 ）, so was the case for morality rate （ X^2 = 6. 35, P 〈 0. 05）. Conclusions CT and DSA can Make the early etiological diagnosis of the Hunt-Hess Ⅳ-Ⅴgrade aneurysmal SAH, and GDC can be used early to perform the aneurysmal intraeapsular embolization. Dealing with hemorrhage and using efficient symptomatic treatment earlier postoperatively are important methods to improve the curative rate and reduce the mortality rate and mutilation rate.