伴脑内血肿形成的颅内动脉瘤破裂患者的早期手术治疗

Early surgical treatment of patients with intracerebral hematoma from ruptured intrac ranial aneurysms

目的 探讨颅内动脉瘤破裂伴有脑内血肿形成患者早期显微外科手术治疗的临床效果以及转归的影响因素.方法 回顾性纳入新余市人民医院神经外科2010年至2016年收治的伴有脑内血肿形成的颅内动脉瘤破裂患者,收集人口统计学资料、Hunt-Hess分级、格拉斯哥昏迷量表（Glasgow Coma Scale,GCS）评分、影像学资料和手术相关并发症,应用格拉斯哥转归量表（Glasgow Outcome Score,GOS）进行转归评价,4～5分定义为转归良好,1～3分定义为转归不良.将Hunt-HessⅡ～Ⅲ级作为低分级组,Ⅳ～Ⅴ级为高分级组,按照GOS评分比较两组患者的生存率和生存质量.结果 研究期间共纳入36例患者,其中蛛网膜下腔出血伴脑内血肿32例,单纯脑内血肿4例;Hunt-Hess分级为Ⅱ级2例、Ⅲ级18例、Ⅳ级14例、Ⅴ级2例;责任动脉瘤分布：大脑中动脉18例,前交通动脉9例,大脑前动脉6例,后交通动脉3例,其中多发动脉瘤4例.全部患者均在发病36 h内在全身麻醉下行动脉瘤夹闭＋血肿清除术,其中24例行偏侧颅骨切除减压术.术中动脉瘤再次破裂致术后严重脑肿胀死亡1例,术后大面积脑梗死死亡1例,因严重肺部感染合并糖尿病放弃进一步治疗后死亡1例.对生存的33例患者随访1年,转归良好29例（80.5％）,转归不良7例（19.5％）.Hunt-Hess低分级组生存率和生活质量与高分级组存在显著统计学差异（P=0.001）.转归良好组Hunt-Hess分级、基线GCS评分和接受偏侧颅骨切除减压术的患者比例与转归不良组差异有统计学意义.结论Hunt-Hess分级、基线GCS评分和偏侧颅骨切除减压术是颅内动脉瘤破裂伴脑内血肿形成患者转归的影响因素.应尽早行血肿清除＋动脉瘤夹闭术,必要时偏侧颅骨切除减压术.

Objective To investigate the clinical effects and influencing factors of the outcomes of early microsurgical treatment in patients with intracerebral hematoma from ruptured intracranial aneurysm. Methods From 2010 to 2016, patients with intracerebral hematoma from ruptured intracranial aneurysm admitted to the Department of Neurosurgery, Xinyu People＇s Hospital were enrolled retrospectively. The demographic data, Hunt-Hess grade,Glasgow coma scale（GCS）score,imaging data,and procedure-related complications were collected. Glasgow outcome scale （GOS） score was used to evaluate the outcomes. Four to 5 were defined as good outcome and 1 to 3 were defined as poor outcome. The Hunt-Hess gradesⅡ-Ⅲ were used as the low-grade group and the Ⅳ-Ⅴ grades were used as the high-grade group. The survival rate and quality of life of both groups of patients were compared according to the GOS scores. Results A total of 36 patients were enrolled during the study, including 32 with subarachnoid hemorrhage and intracerebral hematoma and 4 with simple intracerebral hematoma. Hunt-Hess grade was grade Ⅱ in 2 cases, Ⅲ in 18 cases, Ⅳ in 14 cases, and Ⅴ in 2 cases. Distribution of responsible aneurysms：18 patients in middle cerebral artery, 9 in anterior communicating artery, 6 in anterior cerebral artery, 3 in posterior communicating artery, including 4 patients with multiple aneurysms. All patients underwent aneurysm clipping＋hematoma removal under the general anesthesia within 36 h after onset,24 of them were treated with decompressive craniectomy. One patient died of severe brain swelling after intraoperative reruptureof the aneurysm,1 died of postoperative massive cerebral infarction, and 1 died of severe pulmonary infection and diabetes after giving up further treatment. Thirty-three survivors were followed up for 1 year, 29 had good outcome（80.5%） and 7 had poor outcome （19.5%）. There were significant differences in survival rate and quality of life between the low-grade group and the high-grade group （P=0.001）. There were significant differences in the Hunt-Hess grade, baseline GCS score, and proportion of patients receiving decompressive craniectomy between the good outcome group and the poor outcome group.Conclusion The Hunt-Hess grade, baseline GCS score, and decompressive craniectomy were the influencing factors of the outcomes in patients with intracerebral hematoma from ruptured intracranial aneurysm. Removal of hematoma and aneurysm clipping should be performed as early as possible,and decompressive craniectomy should be performed if necessary.