重症前循环动脉瘤破裂患者115例疗效分析

Analysis on curative effects of ruptured anterior circulation aneurysms with severe SAH in 115 cases

目的探讨对于破裂前循环动脉瘤重症患者积极实施探查夹闭手术的必要性及手术的策略及技巧。方法回顾性分析2010年10月-2013年3月收治的115例破裂前循环动脉瘤重症患者的临床资料及手术策略及技巧。其中72例给予探查手术治疗,43例给予输液及栓塞治疗。根据格拉斯哥预后评分对两组治疗结果进行分级评定并比较。结果手术治疗组发现后交通动脉瘤32个,脉络膜前动脉瘤6个;大脑中动脉瘤18个,其中位于M1段4个,M2分叉部13个,M3段1个;前交通动脉瘤16个。动脉瘤直径〈5 mm 35例,5-15 mm26例,15-25 mm 9例,〉25 mm 2例,均予以完全夹闭,并保持载瘤动脉通畅,去除骨瓣减压。根据格拉斯哥预后评分（GOS）结果评定：死亡14例（GOS 1分）,差21例（GOS 2-3分）,良好37例（GOS 4-5分）。非手术治疗组择期行CTA检查证实为前循环动脉瘤破裂,其中颈内动脉瘤18例,大脑中动脉瘤16例,前交通动脉瘤9例,39例给予栓塞治疗。治疗结果评定：死亡25例（GOS 1分）,差16例（GOS 2-3分）,良好2例（GOS 4-5分）。两组死亡率及良好率均差异有统计学意义（P〈0.05）。结论对于重症前循环动脉瘤破裂患者,通过积极的探查手术治疗,可使患者的生存率大大提高,预后明显改善。而科学正确的手术策略、精巧细致的分离暴露方法则对于探查手术的成功至关重要。

【Objective】To analyze the necessity of emergent exploratory surgeries on ruptured anterior circulation aneurysms with severe SAH and to summarize the experience of surgical strategies and operational skills.【Methods】115 cases of ruptured anterior circulation aneurysms with severe SAH from October 2010 to March 2013 were analyzed retrospectively, in which 72 cases were under exploratory surgeries and 43 cases under expectant or embolism treatment.【Results】72 anterior circulation aneurysms were identified during surgeries, 32 of which were located at posterior communicating arteries, 6 were at anterior choroidal arteries, 4 were at M1 segment, 13 at bifurcation of M1, 3 at M3 segment and 16 at anterior communicating arteries. The diameters of aneurysms were shorter than 5 mm in 35 cases, between 5 and 15 mm in 26 cases, between 15 and 25 mm in 9 cases and longer than25 mm in 2 cases. All aneurysms were clipped successfully and the feeding arteries kept patent. Bone flaps were removed for decompression. According to Glasgow outcome scale, the curative effects were poor in 21 cases, good in37 cases and 14 patients died. In the expectant or embolism treatment group, ruptured anterior circulation aeurysms were confirmed by CTA, 18 of which were located at internal carotid arteries, 16 at middle cerebral arteries and 9 at anterior communicating arteries, of which 39 aneurysms were embolized. The curative effects were poor in 16 cases,good in 2 cases and 25 patients died. The curative effects were significantly different between two groups（P〈0.05）.【Conclusion】Exploratory surgeries could greatly improve the prognosis of patients with ruptured anterior circulation aneurysms with severe SAH. The reasonable surgical strategies and delicate surgical skillsare critical to the successof exploratory surgeries.