临床及影像学表现不典型的颅内动脉瘤误诊分析

Misdiagnosis of Intracranial Aneurysm with Atypical Clinical Manifestations and Imaging Findings

背景正常人群颅内动脉瘤发生率较高(发生率为3%~7%),而部分颅内动脉瘤患者临床及影像学表现不典型,极易误导临床诊治。目的分析临床及影像学表现不典型的颅内动脉瘤患者误诊情况,以提高此类患者诊断效率。方法川北医学院附属医院2013-2018年共收治诊断明确的颅内动脉瘤患者1138例,选取其中首诊误诊患者25例作为研究对象。回顾性分析25例误诊患者一般资料、入院情况、首诊误诊情况,并结合相关文献分析临床及影像学表现不典型的颅内动脉瘤特点、诊断策略及治疗策略。结果25例患者中男12例,女13例;年龄41~71岁,平均年龄(56.5±7.2)岁;门诊入院3例,急诊入院15例,院外转入10例(3例先转入门诊)。1例首诊误诊为短暂性脑缺血发作,行颅脑CT血管造影(CTA)检查发现右侧后交通动脉瘤并行动脉瘤夹闭术,术后恢复良好。3例首诊误诊为颅脑创伤,行颅脑CTA或数字减影血管造影(DSA)确诊为前循环动脉瘤并行开颅手术夹闭动脉瘤,术后恢复良好。4例首诊误诊为颅内肿瘤,其中1例术中发现颅内动脉瘤破裂并大出血,行动脉瘤夹闭术,术后出现后组颅神经功能障碍及轻偏瘫;1例明确诊断后放弃治疗;2例术前发现颅内动脉瘤,行动脉瘤夹闭术,术后恢复良好。17例首诊误诊为高血压脑出血,除1例因动脉瘤再次破裂、病情迅速加重而放弃手术外,其余16例均行动脉瘤夹闭术,术后2例因并发症而死亡,其余14例患者中术后改良Rankin量表(m RS)评分为5分者2例、4分者3例、3分者3例、2分者6例。结论颅内动脉瘤发生率较高,且部分颅内动脉瘤患者临床及影像学表现不典型,极易导致漏诊、误诊(如短暂性脑缺血发作、颅脑创伤、颅内肿瘤、高血压脑出血等),临床医师及影像学医师应加强对此类患者的认识,提高诊断效率,并在条件允许的情况下建议患者积极行手术治疗。

Background Incidence of intracranial aneurysm is relatively high in general population(is about 3%to 7%),however there are a few intracranial aneurysm patients with atypical clinical manifestations and imaging findings,which is easily misleading clinical diagnosis and treatment.Objective To analyze the misdiagnosis of intracranial aneurysm with atypical clinical manifestations and imaging findings,and to improve its diagnostic efficiency.Methods A total of 1138 patients were definitely diagnosed in the Affiliated Hospital of North Sichuan Medical College from 2013 to 2018,of them 25 cases with misdiagnosis were selected as the objects.General information,condition of hospitalization and misdiagnosis at the first diagnosis were retrospectively analyzed in the 25 patients,meanwhile characteristics,diagnostic and therapeutic strategy of intracranial aneurysm with atypical clinical manifestations and imaging findings were summarized by combining with pertinent literatures.Results Of the 25 patients,12 cases were males,the other 13 cases were females;the average age was(56.5±7.2)years old,which ranged from 41 to 71 years old;3 cases firstly admitted in the Department of Outpatient Service,15 cases firstly admitted in the Department of Medical Emergency,10 cases firstly admitted in other hospitals(including 3 cases firstly admitted in the Department of Outpatient Service).Only 1 case firstly misdiagnosed as transient ischemic attack,who confirmed as right posterior communicating aneurysm by craniocerebral CTA and underwent intracranial aneurysmal clipped operation,with good postoperative prognosis.A total of 3 cases firstly misdiagnosed as craniocerebral trauma,who confirmed as right posterior communicating aneurysm by craniocerebral CTA or DSA and underwent intracranial aneurysmal clipped operation,with good postoperative prognosis.A total of 4 cases firstly misdiagnosed as intracranial tumors,thereinto 1 case found ruptured intracranial aneurysm complicated with massive haemorrhage during operation and underwent intracranial aneurysmal clipped operation,with postoperative cranial nerve dysfunction and hemiparesis;1 case abandoned treatment after confirmation of intracranial aneurysm;2 cases confirmed as intracranial aneurysm before operation and underwent intracranial aneurysmal clipped operation,with good postoperative prognosis.A total of 17 cases firstly misdiagnosed as hypertensive cerebral hemorrhage,thereinto 1 case abandoned operation due to once again ruptured intracranial aneurysm and rapid progression of illness;all of the other 16 cases underwent intracranial aneurysmal clipped operation,but 2 cases died because of complications,however mRS score was five in cases,four in 3 cases,three in 3 cases,and two in 6 cases.Conclusion Incidence of intracranial aneurysm is relatively high,however clinical manifestations and imaging findings may be atypical in some patients with intracranial aneurysm,which is very easily lead to missed diagnosis and misdiagnosis(such as transient ischemic attack,intracranial tumors,intracranial tumors and hypertensive cerebral hemorrhage),thus clinicians and imaging doctors should enhance the awareness to such patients and improve the diagnostic efficiency,moreover suggest the active surgical treatment if conditions permit.