数字减影血管造影首次阴性蛛网膜下腔出血患者的病因及诊治对策

Analysis of etiology and treatment of subarachoid hemerrhage patients with initial normal DSA

目的探讨首次数字减影血管造影(DSA)阴性蛛网膜下腔出血的病因及临床诊治对策。方法回顾性分析26例首次DSA阴性蛛网膜下腔出血患者的临床表现、影像学表现、治疗转归。结果所有患者于发病6h～7d内行首次DSA检查,结果均为阴性,发病10～24d后全部复查DSA,11例发现动脉瘤(其中前交通动脉4例,后交通动脉4例,小脑上动脉瘤1例,颈内动脉眼动脉段1例,多发小动脉瘤1例)。15例仍未发现动脉瘤,其中1例行头颅MRI考虑隐匿性脑血管畸形,1例手术探查发现大脑中动脉瘤1例,其余患者最终诊断为中脑周围非动脉瘤性蛛网膜下腔出血。发现动脉瘤者行弹簧圈填塞术或手术探查并行动脉瘤夹闭术后病情好转,隐匿性脑血管畸形者经手术切除后预后较好,其余患者经内科常规治疗后好转出院,随访均未再出血。结论临床中筛查SAH患者的病因很重要,首次DSA阴性的SAH患者必要时仍需进一步检查如DSA、CTA、MRI等明确病因,针对病因治疗,有效改善SAH患者的预后。

Objective To analyze the etiology of subarachoid hemorrhage patients with initial normal DSA and discuss the treatment strategies.Methods Clinical features and image data and treatment outcomes of 26 cases of subarachoid hemorrhage patients with initial normal DSA were analyzed retrospectively.Results All the cases had undergone DSA in 6 hours^7 days after onset and no abnormal findings were obtained.The second DSA examinations had been performed in 10~24 days after onset in the cases with normal initial DSA.Aneurysms were found in 11 cases including anterior communicating artery aneurysm（4 cases）,posterior communicating artery aneurysm（4 cases）,superior cerebellar artery aneurysm（1 case）,the carotid-ophthalmic aneurysm（1 case） and multiple small aneurysms（1 case）.After the second DSA,the negative outcomes were found in 15 cases again,but occuitcerebral vascular malformation was found in one case after MRI later and a middle cerebral artery aneurysm was found in one case after operations research.The other 13 cases were diagnosed perimesencephalic nonaneurysmal subarachnoid hemorrhage.The patients with aneurysm were performed with tamping vascular spring coil or clapping of aneurism in the course of the operations research.The patients with occuitcerebral vascular malformation were treated by excision,and other patients were treated by normal medical therapy.All patients were discharged with a better health condition.During a follow-up period,no rebleeding occurred.Conclusion It is important to looking up the etiology for SAH patients.Subarachnoid hemorrhage patients with initial normal DSA have the necessities of performing examinations such as DSA,MRI or CTA.The treatment aiming at etiology is the best approach to improving the outcomes for these patients.