颅内多发动脉瘤的诊治

The diagnosis and treatment of patients with multiple intracranial aneurysms

目的探讨颅内多发动脉瘤（MIA）的诊治及手术时机选择。方法回顾性分析广州军区武汉总医院自2000—2010年收治的214例MIA的诊断及治疗情况，其中显微手术夹闭119例245枚动脉瘤，血管内栓塞治疗95例198枚动脉瘤。结果夹闭组119例中，Hunt—Hess分级Ⅰ～Ⅲ级98例，Ⅳ级18例，Ⅴ级3例；GOS5分96例，4分12例，3分8例，2分1例，1分2例。栓塞组95例中0～Ⅲ级86例，Ⅳ级9例；GOS5分79例，4分5例，3分6例，2分3例，1分2例。DSA随访复查：夹闭组60例（126枚），118枚动脉瘤夹闭完全，8枚动脉瘤瘤颈残留；栓塞组63例（130枚），119枚动脉瘤栓塞完全，11枚栓塞不完全。结论CT为确定MIA责任动脉瘤提供了重要信息，3D—DSA是MIA诊断的金标准，提高了MIA的诊断率，CTA为诊断提供了良好的补充。MIA明确诊断后应尽早治疗，首先治疗责任动脉瘤，争取一次性治疗未出血动脉瘤，根据患者的病情、动脉瘤部位、大小以及经济状况酌情选择显微手术夹闭或血管内栓塞治疗。后循环动脉瘤首选血管内治疗，Hunt—HessV级者效果极差。

Objective To investigate the methods to diagnose and treat multiple intracranial aneurysms （MIAs） and the choices of their surgical timings. Methods The clinical data of 214 patients with MIAs, of whom, 119 patients with 245 aneurysms were treated by microsurgical clipping and 95 patients with 198 aneurysms were treated by endovascular embolization from 2000 to 2010, were analyzed retrospectively. Results Of 119 patients （ Hunt - Hess grades, Ⅰ - Ⅲ, 98 patients ; IV, 18 patients ; V, 3 patients） treated by microsurgical clipping, 96 belonged in GOS 5 scores, 12 in 4, 8 in 3, 1 in 2, and 2 in 1. Of 95 patients （Hunt -Hess grade, 0 - Ⅲ, 86 patients; Ⅳ, 9 patients） treated by endovascular embolization, 79 belonged in GOS 5 scores, 5 in 4, 6 in 3, 3 in 2, and 2 in 1. Sixty patients with 126 aneurysms treated by microsurgical clipping were followed up by DSA and the outcomes showed that the necks of 118 aneurysms were completely clipped and 8 aneurysms had residue necks. Sixty - three patients with 130 aneurysms treated by endovascular embolization were followed up by DSA and the outcomes showed that the complete occlusion was in 119 aneurysms and incomplete in 11 aneurysms. Conclusions CT scan is very important to predicating the responsible aneurysm of ruptured MIAs. The diagnostic accuracy of MIAs can be enhanced by 3D - DSA, which is the gold standard of MIAs diagnosis. The treatment should begin as soon as a definitive diagnosis is made and the responsible aneurysms for bleeding should be treated firstly. It should also be tried to treat all the non - bleeding aneurysms at one time. The treatment methods （microsurgical clipping and endovascular embolization） should be chosen according to the patient ＇s economical condition and the location and size of the aneurysm. The endovascular embolization should be selected firstly in patients with posterior circulation aneurysms. The prognosis of aneurysms patient with Hunt -Hess grade V is very poor.