大脑中动脉瘤的治疗策略(附111例病例分析)

Strategetic treatment of middle cerebral artery aneurysm:analysis of 111 cases

目的探讨大脑中动脉瘤治疗方法的选择和疗效。方法回顾性分析2005年1月至2011年7月间手术夹闭和血管内介入治疗的111例114个大脑中动脉瘤。分析术前分级、动脉瘤大小、部位、治疗结果。结果手术夹闭88例患者90个动脉瘤,术后15 d～48个月(平均12.7个月)造影随访,夹闭动脉瘤89个,瘤颈残留1个,未见复发。血管内介入治疗23例24个动脉瘤。支架辅助栓塞7个,球囊辅助栓塞3个,单纯微弹簧圈栓塞12个,17个动脉瘤术后1～37个月(平均10.6个月)造影随访,5个(29.4%)复发;单纯支架治疗2个(未破裂夹层动脉瘤),术后3个月造影随访,1个动脉瘤消失,1个无变化。Glasgow预后评分5～4分中夹闭72例(81.8%),介入21例(91.3%)。结论窄颈(浆果样)大脑中动脉瘤,手术夹闭和介入栓塞均不易复发。复杂大脑中动脉瘤手术夹闭不易复发,介入栓塞相对容易复发。大脑中动脉瘤合并血肿(血肿量>30 mL),选择手术夹闭动脉瘤并清除血肿。介入栓塞和手术夹闭大脑中动脉瘤均能有效防止动脉瘤再出血。

Objective To discuss the choice and effectiveness of treatment of middle cerebral artery aneurysms（MCAA）.Methods 111 patients with a total of 114 MCAA from January 2005 to July 2011 who underwent surgical clipping and endovascular interventional therapy were retrospectively analyzed.Factors analyzed included the pre-operation grading,the aneurysm size and location,and the clinical outcomes.Results The angiographic follow-up of the surgical clipping group（88 patients with a total of 90 aneurysms） 15 days to 48 months（mean 12.7 months）after the operation showed that 89 aneurysms were completely clipped and the residual neck appeared in only 1 aneurysm.There was no angiographic recurrence in any the aneurysms.In the endovascular treatment group（23 patients with a total of 24 aneurysms）,7 ruptured aneurysms were treated with stent-assistance,3 with balloon-assistance,and 12 with coil only.The angiographic follow-up of the 17 aneurysms 1 month to 37 months（mean 10.6 months）after the operation showed that 5 recurred（29.4%）.2 un-ruptured dissecting aneurysms were treated with stent only.The angiographic follow-up 3 months after the operation showed that 1 aneurysm was completely occluded and the other stayed the same.Good outcome（Glasgow Outcome Score = 4-5） occurred in 81.8%（72 patients） in the clipping group and 91.3%（21 patients） in the endovascular treatment group.Conclusion ＂Berry-like＂ MCAA is suitable for both surgical clipping and endovascular treatment.Lower recurrence was associated with surgical clipping in the complex MCAA,but higher recurrence was associated with endovascular treatment.Surgical clipping should be considered in MCAA with hematoma（volume of hematoma30 mL）and the hematoma should be cleared.Both endovascular treatment and surgical clipping can effectively prevent MCAA re-bleeding.