颅内动脉瘤破裂诊疗的抉择

Decision making in diagnosis and treatment for ruptured intracranial aneurysm

目的探讨颅内动脉瘤诊断方法和治疗策略的抉择。方法 2008年1月至2011年12月收治的210例颅内动脉瘤患者。所有患者入院时均行头颅CT检查,通过CTA/3D-CTA或DSA/3D-DSA确诊。治疗:动脉瘤夹闭术92例,其中因介入治疗失败而转开颅4例;血管内介入治疗113例,全部采用GDC栓塞手术和/或支架辅助。结果统计Hunt-Hess分级Ⅰ-Ⅲ级前循环动脉瘤治疗效果。手术治疗72例患者出院时情况:良好53例(73.2%),轻度残疾7例(9.8%),重度残疾6例(8.9%),植物生存2例(2.8%),死亡4例(5.3%);介入治疗83例患者出院时情况:良好63例(75.3%),轻度残疾13例(15.1%),重度残疾4例(5.4%),植物生存0例,死亡3例(4.2%)。结论 CTA/3D-CTA和DSA/3D-DSA均可以观察动脉瘤的大小、部位、供血动脉,并依此指导手术,两种诊断方法各有优缺点。血管内栓塞治疗和直接开颅夹闭手术均是有效的方法并且各有其适应证,Hunt-Hess分级Ⅰ-Ⅲ级的前循环动脉瘤两种方法均可采用,而后循环动脉瘤则首选血管内栓塞。Ⅳ-Ⅴ级患者行介入治疗并行脑内血肿清除术或去骨瓣减压术、脑室外引流术、腰大池引流术。血管痉挛、颅内高压、巨大动脉瘤的患者应果断早期进行手术。

Objective To explore the selection of diagnosis and treatment for ruptured intracranial aneurysms .Methods 210 patients suffered from intracranial aneurysms between January 2008 to December 2011 were reviewed .All cases were confirmed by CTA/3D-CTA or DSA/3D-DSA. 92 patients were underwent microsurgical treatment , 4 of them were failure of endovascular embolization .113 patients were underwent endovascular therapy , all of them were embolized by guglielmi detachable coil （ GDC） or stent-assisted coiling .Results The anterior circulation aneurysms with Hunt-Hess gradesⅠ-Ⅲ,the prognoses were assessed by GOS in all pations .After the discharge , in the surgical group ,53 cases（73.2%） had good prognoses ,7（9.8%） were mild disabled,6（8.9%） were severely disabled ,2（2.8%） were vegetatively survived and 4（5.3%） died.In the endovascular treatment group,63 cases（75.3%） had good prognoses,13（15.1%） were mild disabled,4（5.4%） were severely disabled ,0 （0%） were vegetatively survived and 3 （4.2%） died.Conclusions The size,form,relationship with parent arteries , and even the ruptured point of aneurysms can be clearly demonstrated by CTA/3D-CTA or DSA/3D-DSA, which can be used to guide the treatment for intracranial aneurysms directly , both have advantages and disadvantages .Endovascular therapy and aneurysm clipping are the effective methods to treat intracranial aneurysms .The patients with intracranial aneurysm need individual treatment .The anterior circulation aneurysms or intracranial aneurysms with Hunt-Hess gradesⅠ-Ⅲmay be treated by both methods .The endovascular embolization should beselected first for the posterior circulation aneurysms .Patients of Ⅳ-Ⅴgrade intracranial ruptured ameurysm should be treated by endovascular intervention ;and also with external ventricular drainage ,lumbar puncture and drainage as well as hematoma removal as the subsequent treatment in an emergent state , The patients with severe cerebral vasosasm or intracranial hypertention or giant ameurysm should choose surgery .