942例颅内动脉瘤患者血管内治疗围术期出血并发症分析及防治

Analysis of perioperative hemorrhagic complications on 942 cases of intracranial aneurysms undergoing endovascular treatment

目的:分析942例颅内动脉瘤患者行血管内治疗的围术期出血并发症发生情况,并探讨其处理措施。方法:收集2011年1月至2019年4月复旦大学附属华山医院收治的942例颅内动脉瘤患者(1 055个动脉瘤),分析围术期出血并发症发生原因,探讨围术期用药方案,总结防治措施。结果:本组942例患者发生出血性并发症共12例(1.27%),其中术中出血9例、术后出血3例。9例术中出血无一例致死致残,其中因弹簧圈损伤瘤腔致动脉瘤破裂6例,微导管损伤瘤腔致动脉瘤破裂2例,微导丝损伤远端小分支导致出血1例。9例患者均预后良好,出院前mRS评分较入院时未增加。术后出血3例均死亡,其中2例蛛网膜下腔出血可能与瘤腔栓塞不全或术后肝素化有关,1例基底节区血肿可能与术后血压一过性增高有关。结论:术前不常规应用抗血小板聚集药物及肝素化可降低术中出血导致的致死率,及时识别并处理后多数患者预后良好。术后出血发生率低,但预后差,病死率高。术前充分评估危险因素,术中致密填塞瘤腔,术后慎用抗凝治疗,可改善出血患者的预后。

Objective:To analyze preoperative hemorrhagic complications and management on endovascular treatment of intracranial aneurysms in 942 cases.Methods:From January 2011 to April 2019,942 patients with intracranial aneurysms(1 055 aneurysms)in our center were collected to investigate the clinical perioperative hemorrhagic complications and their management.Results:Among the 942 patients 12(1.27%)experienced preoperative hemorrhagic complications,consisting of intraoperative hemorrhage in 9 aneurysms(9/942,0.96%)and postoperative hemorrhagic complications in 3 patients(3/942,0.32%).Nine intraoperative hemorrhages with no mortality and disability,of which 6 cases due to coil injury in the aneurysm wall,2 cases due to microcatheter injury in the aneurysm wall,1 case due to micro-guide wire injury in distal small arterial branch.Nine patients had a good prognosis,and the mRS score before discharge was not increased compared with admission.3 patients with postoperative hemorrhagic complications were fatal,of which two cases were related to incomplete embolization or postoperative general heparinization,and one case might due to the acute fluctuation of blood pressure.Conclusions:No preoperative heparinization and dual antiplatelet medicine can reduce the fatal intraoperative hemorrhage.Intraoperative rupture complications can achieve favorable prognosis via timely screening and reasonable treatment.Although the low incidence rate of postoperative hemorrhagic complications,the outcome will be fatal.Preoperative prevention measures,densely embolization and prudent anticoagulation usage can improve the prognosis.