血管内治疗高级别动脉瘤性蛛网膜下腔出血的早期预后和长期随访

Endovascular treatment of high-grade aneurysmal subarachnoid hemorrhage:early prognosis and long-term follow-up

目的评价血管内治疗高级别(Hunt-Hess Ⅳ～Ⅴ级)的急性动脉瘤性蛛网膜下腔出血(aSAH)的早期疗效和长期随访结果。方法选取2001年1月—2009年12月行血管内栓塞治疗的44例高级别aSAH患者,进行回顾性分析。其中37例为Hunt-HessⅣ级,7例为Hunt-Hess Ⅴ级。对术中、术后并发症、出院时临床预后(mRS评分)及平均12.4个月的长期随访结果进行综合评价。结果①44例中,39例动脉瘤完全闭塞,2例动脉瘤栓塞率≥90%,3例动脉瘤栓塞率为70%～90%。②3例(6.8%)出现术中并发症,其中2例为动脉瘤破裂出血,1例术中弹簧圈脱出。③术后14d连续行TCD监测,显示26例出现严重血管痉挛,其中11例死亡。④出院时,15例(34.1%)死亡,29例(65.9%)存活,其中2例(4.5%)预后良好,27例(61.4%)均残留有中、重度的神经功能障碍,27例中24例(24/37,64.9%)为Hunt-Hess Ⅳ级患者,3例(3/7)为Ⅴ级患者,两组比较预后差异无统计学意义。⑤29例存活患者中,27例获得长期随访,平均随访时间为38个月(6～71个月)。27例中,18例(66.7%)预后良好,6例(22.2%)遗留有中、重度残疾,3例(11.1%)出院后死亡。长期预后良好率、病死率均为42.96%(18/42)。27例中,20例行影像学复查,均未见动脉瘤复发。结论对高级别aSAH患者,血管内治疗的有效性仍有待于进一步研究。

Objective To assess the early efficacy and long-term results of the patients with highgrade （Hunt-Hess IV-V ） acute aneurysmal subaraehnoid hemorrhage （aSAH） treated by endovascular methods. Methods Forty-four patients with high-grade aSAH （37 with Hunt-Hess grade IV and 7 with Hunt-Hess grade V ） diagnosed and treated from January 2001 to December 2009 were analyzed retrospec- tively. A comprehensive evaluation was performed for the complications of treatment , the clinical condition at discharge, and the long-term （ mean 12.4 months） follow-up results of the patients. Results （1）In the 44 patients, the aneurysms of 39 patients were obliterated completely. The obliterate degree was ≥90% in 2 cases and 70% -90% in 3 cases . （2）Three cases （6. 8% ） had intraoperative complications, two of them had aneurysm rupture, and one had protruding of coil. （3）The postoperative continuous TCD monitoring for 14 days showed that 26 patients had severe vasospasm, and 11 of them died. （4）Final results, 15 patients （34. 1% ） died; 29 （65.9%） survived, two of them （4. 5% ） had good prognosis, 27 （61.4%） were left with moderate to severe neurological dysfunction, 24 of the 27 patients were in the Hunt-Hess IV and 3 were in the Hunt-Hess V grading after aSAH. （5）Among the 29 survivors, 27 obtained long-term follow-up data, and the mean follow-up period was 38 months （range, 6 to 71 ）. Of the 27 patients, 18 （66.7%） had good prognosis, 6 （22. 2% ） left with moderate to severe disability, and 3 （ 11.1% ） died after discharge. Both the long-term good prognosis rate and mortality rates were all 42. 86% （ 18/42 ）. Twenty of the 27 patients were reexamined, no recurrence of aneurysm was found. Conclusion The effectiveness of endovaseular treatment remains to be further studied for patients with high-grade aSAH.