颈内动脉床突上段破裂血泡样动脉瘤治疗效果的初步分析

A preliminary study on the therapeutic effect of ruptured blood blister-like aneurysms of the supraclinoid internal carotid artery

目的初步探讨颈内动脉床突上段破裂血泡样动脉瘤(BBA)采用适宜治疗方式的效果。方法回顾性连续纳入2016年9月至2018年9月首都医科大学三博脑科医院脑血管病病区颈内动脉床突上段BBA患者6例,经DSA明确诊断,头部CT均提示蛛网膜下腔出血。Hunt-Hess分级Ⅰ级3例,Ⅱ级1例,Ⅲ级1例,Ⅳ级1例。根据脑血管造影特点,Hunt-Hess分级Ⅰ~Ⅲ级者选择双支架套叠管腔重建术或覆膜支架腔内隔绝术,出血急性期同时行动脉瘤腔弹簧圈栓塞,Ⅳ级采用显微外科手术缝合动脉瘤。术后6个月经DSA或MR血管成像或CT血管成像行影像学随访;采用改良Rankin量表(mRS)评分评价患者术后神经功能恢复情况,0~2分为预后良好,3~6分为预后不良,其中6分为死亡。结果6例患者中,5例采用血管内治疗,1例采用手术治疗。5例血管内治疗患者,术后即刻造影显示,Raymond Ⅰ级3例,Raymond Ⅱ级1例,Raymond Ⅲ级1例,均未发生术中破裂出血。1例手术患者术后四肢肌力Ⅴ级,无神经功能障碍,术后3个月行颅骨成形术。术后随访3~27个月,中位随访时间13.6个月。mRS评分0分4例,1分1例,2分1例,均预后良好,影像学随访未见复发,开颅手术者显示载瘤动脉轻度狭窄(狭窄率约20%)。结论颈内动脉床突上段BBA,Hunt-Hess分级Ⅰ~Ⅲ级时可考虑血管内治疗,根据脑血管造影特征选择覆膜支架腔内隔绝术或双支架套叠管腔重建术,出血急性期同时行瘤腔弹簧圈致密栓塞;Hunt-Hess分级更高时可首选显微外科手术,选择合适的治疗方式可取得较好的效果。

Objective To investigate the therapeutic effect of choosing reasonable treatment modality for ruptured blood blister-like aneurysms (BBA) of the supraclinoid internal carotid artery.Methods From September 2016 to September 2018,six patients with ruptured BBA of the supraclinoid internal carotid artery admitted to the Department of Neurosurgery of Sanbo Brain Hospital,Capital Medical University were consecutively and retrospectively recruited.DSA were performed to confirm the aneurysms and head CT showed subarachnoid hemorrhage in all patients.There were 3 cases in Hunt-Hess Grade Ⅰ,1 case in Grade Ⅱ,1 case in Grade Ⅲ and 1 case in Grade Ⅳ.Endovascular treatments were performed in Hunt-Hess grade Ⅰ-Ⅲ patients by double overlapping stents or covered stent according to the characteristics of cerebral angiography.Simultaneous coil embolization was applied in the acute stage of subarachnoid hemorrhage.Microsurgical suture for aneurysms was performed in Hunt-Hess grade Ⅳ patients.All patients were followed up by DSA,MR angiography (MRA) or CT angiography (CTA) 6 months after operation.A modified Rankin Scale (mRS) was used for postoperative recovery measurement of neurological function (good outcome,mRS 0 - 2;bad outcome,mRS 3 - 6;and death,mRS 6 ).Results Among the 6 patients,5 underwent endovascular treatment and 1 underwent microsurgical treatment.Immediate postoperative angiography showed 3 cases of Raymond grade Ⅰ,1 case of Raymond gradeⅡ and 1 case of Raymond grade Ⅲ.No intraoperative rupture of the aneurysms occurred.After the operation,the limb muscle strength was grade Ⅴ and there was no neurological dysfunction.Cranioplasty was performed 3 months after the operation.The mean follow-up time was 13.6 months (range 3 to 27 months).MRS score was 0 in 4 cases,1 in 1 case and 2 in 1 case.All patients recovered well without recurrence.The parent artery was mild stenosis(stenosis rate was about 20%) in surgical patients.Conclusions For ruptured blood blister-like aneurysms(BBA) of the supraclinoid internal carotid artery,endovascular treatment is preferred in Hunt-Hess grade Ⅰ-Ⅲ patients by double overlapping stents or covered stent according to angiographic features,and simultaneous dense coil embolization can be performed in the acute stage of hemorrhage;Microsurgery may be the first choice in higher Hunt-Hess grade.Choosing appropriate treatment modality could achieve satisfactory therapeutic effect.