手术夹闭和血管内介入治疗颅内破裂动脉瘤的疗效分析

Outcomes of surgical versus endovascular treatment for ruptured cerebral aneurysms

目的对手术夹闭和血管内介入治疗颅内破裂动脉瘤的疗效作初步分析。方法2004年6月至2006年6月共治疗符合入选标准的113例颅内动脉瘤病人。手术夹闭61例病人共62个动脉瘤,血管内介入栓塞52例病人共54个动脉瘤。病人术前状态采用Hunt-Hess分级,颅脑CT采用Fisher分级,术后1个月和6个月行改良Rankin评分。全部数据采用Wilcoxon秩和检验。结果手术夹闭组术前Hunt-HessⅠ～Ⅲ级53例,39例预后好,Ⅳ～Ⅴ级8例,3例预后好;术前CT Fisher分级Ⅰ～Ⅱ级35例,30例预后好,Ⅲ～Ⅳ级26例,13例预后好,术前Hunt-Hess分级和CT Fisher分级与mRS评分呈正相关。介入栓塞组术前Hunt-HessⅠ～Ⅲ级42例,33例顶后好,Ⅳ～Ⅴ级10例,2例预后好;术前CT Fisher分级Ⅰ～Ⅱ级37例,32例预后好,Ⅲ～Ⅳ级15例,7例预后好,术前Hunt-Hess分级和CT Fisher分级与mRS评分呈正相关。同一术前Hunt-Hess分级及CT Fisher分级在手术组和介入组病人中mRS评分差异无统计学意义。结论对于手术夹闭和血管内介入均适合的动脉瘤,处于同一术前Hunt-Hess分级或CT Fisher分级的病人,不论手术夹闭还是介入治疗,术后短期疗效差异无统计学意义。对于高龄、术前Hunt-Hess分级差的病人首选介入治疗。两种治疗办法的长期疗效对比仍有待于研究。

Objectives To compare the effects of neurosurgical clipping versus endovascular coiling in patients with aneurysmal subarachnoid hamorrhage in a single center. Methods Patients and aneurysm characteristics, procedural complications and clinical results were compared retrospectively in 61 patients treated by clipping and 52 by coiling. Modified Rankin Scale （mRS） was assessed at 1 and 6 months after treatment. All the data were analyzed by using Ridit-test, figures were made with SPSS 12.0. Results In the surgical groups, the number of patients with good outcome was 39 （53 with Hunt-Hess Ⅰ - Ⅱ ） , 3 （8 with Hunt-Hess Ⅳ- Ⅴ）, 30 （35 with CT fisher Ⅰ - Ⅱ）, 13 （26 with CT fisher Ⅲ - Ⅳ）. In the endovascular treatment groups, the number of patients with good outcome was 33 （42 with Hunt-Hess Ⅰ - Ⅱ）, 2 （10with Hunt-Hess Ⅳ- Ⅴ）, 32 （37 with CT fisher Ⅰ -Ⅲ）, 7 （15 with CTfisher Ⅲ -Ⅳ）. Hunt-Hess grade and CT fisher grade were associated with mRS positively （ P 〈 0. 0001 , P = 0. 0002 ）. Modified Rankin Scale in the surgical and endovascular treatment groups, who were in the same grade of Hunt-Hess and CT fisher, did not differ significantly （ P 〉 0.05 ）. Conclusions If the aneurysm is considered suitable for both surgical clipping and endovascular treatment, coiling is associated with a better outcome. Endovascular treatment has changed the management of poor-grade SAH in elderly patients, most of whom are high-risk surgical candidates. The long-term effect of surgical clipping and endovascular treatment need further investigation.