血流导向装置Pipeline治疗前循环大型和巨大型颅内动脉瘤的中长期疗效

Medium and long-term effects of Pipeline embolization device for the treatment of large and giant intracranial anterior circulation aneurysms

目的探讨应用血流导向装置Pipeline(PED)治疗前循环大型和巨大型颅内动脉瘤的中长期疗效及安全性。方法回顾性分析2014年12月至2016年12月冬雷脑科医生集团连续纳入采用PED治疗的36例36个颅内大型和巨大型动脉瘤的资料。瘤径为12~33 mm,平均(16.6±4.5)mm;瘤颈为4~10 mm,平均(6.1±1.5)mm。动脉瘤位于颈动脉海绵窦段8例,颈内动脉眼动脉段22例,颈内动脉后交通段5例,大脑中动脉M1段1例。单纯PED治疗7例,PED联合弹簧圈治疗28例,双枚PED治疗1例。采用Raymond分级评价动脉瘤栓塞程度,采用改良Rankin量表(mRS)评分评价患者预后。结果 (1)患者临床预后采用电话和门诊随访,随访6~33个月,DSA随访25例,动脉瘤完全闭塞(RaymondⅠ级)23例(92%),近全闭塞(RaymondⅡ级)2例(8%)。(2)7例接受单纯PED治疗者,6个月随访完全治愈4例,1例次全闭塞,2例未愈;到最后一次随访(33个月)治愈6例,1例动脉瘤逐步缩小;28例PED联合弹簧圈治疗者,17例接受DSA随访,随访6~8个月,动脉瘤均已完全闭塞(RaymondⅠ级);双枚PED治疗1例术后8个月DSA访可见微小动脉瘤样显影,15个月随访动脉瘤基本闭塞。(3)手术后经MRI证实,发生无症状性散在斑点状缺血灶10例,脑实质出血4例,其中1例死亡,1例经治疗恢复良好(mRS 1分),另外2例为无症状脑出血。24例患者的占位效应消失,8例有明显改善,3例无明显变化。结论 PED治疗颅内大型和巨大型动脉瘤闭塞率高,中期随访结果显示PED结合弹簧圈治疗动脉瘤的闭塞率高于单纯PED治疗;长期随访结果显示,单纯PED(包括单枚或多枚)治疗者闭塞率随着时间的延长逐步升高。手术的安全性尚需大样本研究进一步证实。

Objective To investigate the medium-and long-term effects and safty of Pipeline embolization device（ PED） for the treatment of large and giant intracranial anterior circulation aneurysms.Methods From December 2014 to December 2016,the data of 36 consecutive patients with large and giant aneurysm（ 36 large and giant intracranial anterior circulation aneurysms） treated with PED in Donglei Brain Doctor Group were analyzed retrospectively. The diameter of the aneurysms was 12-33 mm,（ mean16. 6 ± 4. 5 mm）,and the neck size was 4-10 mm（ mean 6. 1 ± 1. 5 mm）. Eight aneurysms were located in the carotid cavernous sinus segment,22 in the ophthalmic artery segment,5 in the internal carotid artery posterior communicating segment,and 1 in the M1 segment of middle cerebral artery. Seven aneurysms were only treated by PED,2 8 aneurysms were treated by PED in combination with coil embolization,and 1 aneurysm was treated by double PEDs. The modified Rankin scale（ mRS） score was used to evaluate the prognosis of the patients. Results（ 1） The clinical prognosis of the patients was followed up by telephone and outpatient department for 6-33 months. Twenty-five patients were followed up by DSA,23 aneurysms（ 92%） were occluded totally（ Raymond gradeⅠ） and 2（ 8%） were occluded near totally（ Raymond grade Ⅱ）.（ 2） Seven patients were treated with PED alone. Four patients were cured totally after 6 months follow-up,1 was occluded subtotally,2 were not cured; 6 were cured in the last follow-up（ 33 months）,and the other aneurysm was gradually reduced; 17 of 28 patients treated with PED in combination with coils received DSA follow-up. They were followed up for 6-8 months. All the aneurysms were totally occluded（ Raymond grade Ⅰ）. 1 aneurysm was treated by 2 PEDs,DSA revealed micro-aneurysm-like development at 8 months after procedure. The aneurysms were basically occluded after 15-month follow-up.（ 3） MRI confirmed after operation that 10 patients had asymptomatic scattered spotted ischemic foci,4 had cerebral parenchymal hemorrhage,1 of them died,1 recovered well after treatment（ mRS 1）,and the other2 were asymptomatic cerebral hemorrhage. The occupying effect of 24 cases disappeared,8 had obvious improvement,and 3 did not have any obvious change. Conclusions The occlusion rate of the treatment of large and giant intracranial aneurysms with PED was high. The results of medium-term follow-up showed that the occlusion rate of PED in combination with coils in the treatment of aneurysms was higher than that of PED alone. The long-term follow-up results showed that the occlusion rate of patients treated with PED alone（ including one or more） was gradually increased with time. The safety of the surgery needs to be further confirmed by a large sample study.