脑微出血与颅内动脉瘤破裂出血的相关性研究

Correlation of cerebral microbleeds with intracranial aneurysm rupture and hemorrhage

目的探讨脑微出血(CMBs)对颅内动脉瘤破裂出血的影响。方法选择南方医科大学珠江医院神经外科自2010年6月至2018年12月收治、经DSA检查证实的颅内单发动脉瘤患者2023例(其中未破裂动脉瘤994例,破裂动脉瘤1029例)。采用3D-DSA三维重建图像评估动脉瘤大小、位置、形态,判断Willis环变异类型,计算瘤体与瘤颈比(AR)、长轴与载瘤动脉直径比(SR)以及动脉瘤倾斜角等形态学参数;采用头颅MRI检查判断是否存在CMBs,比较合并CMBs组和未合并CMBs组患者的临床资料;随访92例未经治疗的颅内动脉瘤合并CMBs患者,评估CMBs相关颅内动脉瘤破裂出血的潜伏期,并进一步比较未破裂组、破裂组患者的临床特征,采用单因素分析和多因素Logistic回归分析确定颅内动脉瘤破裂出血的危险因素。结果2023例颅内动脉瘤患者中合并CMBs 158例(7.81%)。未合并CMBs组和合并CMBs组患者的年龄,动脉瘤倾斜角,SR,瘤颈为窄颈、动脉瘤形态不规则、破裂出血、吸烟者所占比例,动脉瘤位置、高血压分布差异均有统计学意义(P<0.05)。92例未经治疗的颅内动脉瘤合并CMBs患者中,颅内动脉瘤破裂27例,未破裂65例,发生破裂的时间为(15.07±10.76)个月,范围为3~46个月。与未破裂组比较,破裂组患者动脉瘤形态不规则者所占比例较高,差异有统计学意义(P<0.05)。单因素分析显示合并CMBs,女性,年龄,动脉瘤大小,动脉瘤形态,颈内动脉(ICA)、大脑前动脉(ACA)动脉瘤,AR,Willis环变异,高血压Ⅱ级、Ⅲ级,糖尿病伴空腹血糖≤6.0 mmol/L,高脂血症,冠心病,饮酒是影响颅内动脉瘤破裂的重要因素,差异有统计学意义(P<0.05)。多因素Logistic回归分析显示合并CMBs是颅内动脉瘤破裂出血的独立危险因素,与未合并CMBs患者比较,合并CMBs的颅内动脉瘤患者其动脉瘤破裂风险增加1.75倍。结论年龄较大、动脉瘤倾斜角较小、SR较大、瘤颈为窄颈、动脉瘤形态不规则、破裂出血、吸烟的颅内动脉瘤患者易合并CMBs。合并CMBs的颅内动脉瘤中形态不规则者易破裂出血。CMBs是颅内动脉瘤破裂出血的独立危险因素。

Objective To evaluate the effect of cerebral microbleeds (CMBs) on intracranial aneurysm rupture and hemorrhage. Methods A total of 2023 patients with intracranial single aneurysms (944 un-ruptured aneurysms and 1029 ruptured aneurysms) were enrolled in our study. The 3D-DSA was applied to all patients to evaluate the aneurysm sizes, locations, and morphous features, and to confirm the presence of A1 dominance and variations of Circle of Willis;moreover, aspect ratio (AR), size ratio (SR) and aneurismal inclination angle were measured. The presence of CMBs identified by T2-weighted gradient-recalled-echo sequence on magnetic resonance imaging (MRI) was evaluated;the clinical data of combined with/without CMBs patients were compared. Ninety-two untreated intracranial aneurysms patients combined with CMBs were followed up to evaluate the incubation periods of CMBs-related intracranial aneurysm rupture and hemorrhage;the clinical data of patients with un-ruptured aneurysms and ruptured aneurysms were compared;the risk factors of intracranial aneurysm rupture and hemorrhage were analyzed by univariate and multivariate Logistic regression analyses. Results CMBs confirmed by MR imaging were presented in 158 patients, with 7.81% incidence rate (158/2023). Age, proportion of smokers, aneurysm inclination Angle, SR, narrow neck, irregular aneurysm shape, proportion of rupture and hemorrhage, aneurysm sites, and hypertension showed significant differences between patients without CMBs and patients with CMBs (P<0.05). In the untreated intracranial aneurysms patients combined with CMBs, 27 had intracranial aneurysm rupture and 65 did not appear intracranial aneurysm rupture;the rupture time was 3-46 months, with an average of (15.07±10.76) months. As compared with the un-ruptured group, the ruptured group had a statistically higher proportion of patients with irregular aneurysm morphology (P<0.05). Univariate analysis showed that CMBs, female, age, aneurysm size, aneurysm morphology, ICA and ACA aneurysms, AR, variations of Circle of Willis, hypertension grading II and III, diabetes mellitus with fasting blood glucose≤6.0 mmol/L, hyperlipidemia, coronary heart disease, and drinking alcohol were important factors affecting intracranial aneurysm rupture, and the differences were statistically significant (P<0.05). Multivariate Logistic regression analysis showed that CMB was an independent risk factor for intracranial aneurysm rupture and hemorrhage;as compared with patients without CMBs, patients with CMBs had a 1.75 fold increased risk of aneurysm rupture. Conclusions Patients with intracranial aneurysms with older age, smaller aneurysm inclination Angle and larger SR are more likely to be associated with CMBs. Intracranial aneurysms with CMBs patients with irregular morphology are prone to have rupture and hemorrhage. CMBs is an independent risk factor for intracranial aneurysm rupture and hemorrhage.