老年颅内未破裂动脉瘤的治疗及预后分析

Treatment and prognosis of unruptured intracranial aneurysms in elderly patients

目的:比较老年颅内未破裂动脉瘤(unruptured intracranial aneurys,UIA)患者随访观察、介入栓塞及开颅夹闭3种治疗方式的远期预后,并分析其危险因素。方法:回顾性分析重庆医科大学附属第一医院神经外科2012年1月至2018年8月收治的177例老年(≥65岁)UIA患者临床资料。其中观察组74例,介入组65例,夹闭组38例。以改良Rankin评分量表(modified Rankin scale,mRS)评估患者远期(≥1年)预后,比较各组预后,并分析影响患者预后及动脉瘤破裂的独立危险因素。结果:观察组(12.16%)、介入组(6.15%)及夹闭组(5.26%)远期预后不良率无统计学差异(P=0.324),但观察组死亡率(9.46%)明显高于介入组(3.08%)及夹闭组(0.00%)(P=0.031);观察组患者动脉瘤年破裂率为3.3%,动脉瘤大小(P=0.022,OR=0.111,95%CI=0.017~0.731)及形态(P=0.021,OR=10.032,95%CI=1.417~71.035)是预后不良的独立危险因素;动脉瘤大小(P=0.047,OR=17.867,95%CI=1.041~306.749)及症状性脑梗死(P=0.022,OR=64.750,95%CI=1.834~2 286.561)是手术组(介入组+夹闭组)预后不良的独立危险因素。结论:高风险的老年未破裂动脉瘤应积极手术治疗,介入栓塞及开颅夹闭术均是安全有效的手术方式,年龄不应作为手术禁忌。

Objective:To compare the long-term prognosis of the elderly patients with unruptured intracranial aneurys(UIA),treated by observation,cliping or coiling,and analyze the risk factors. Methods:The clinical data of 177 cases of patients(≥65 years old)with unruptured intracranial aneurysms admitted in our hospital from January,2012 to August,2018 were retrospectively analyzed. In all,65 patients were treated with coiling,and 38 patients were treated with clipping. The remaining 74 patients were placed under conservative observation. The modified Rankin scale(mRS) was used to assess prognosis (≥1 year). Risk factors were explored through univariable and multivariable logistic regression analysis. Results:There was no significant difference of long-term prognosis in patients with UIA among observed(12.16%),coiling(6.15%) and clipping group(5.26%,P =0.324). However the mortality of observed group was significantly higher than others(9.46% vs. 3.08% vs. 0.00%,P=0.031). The annual rupture rate of observation group was 3.3%. The multivariate analysis showed that aneurysm size(P=0.022,OR=0.111,95%CI=0.017-0.731)and morphology(P=0.021,OR=10.032,95%CI=1.417-71.035)were independent risk factors for unfavorable outcome of UIA in observed group Symptomatic cerebral infarction(P=0.022,OR=64.750,95%CI=1.834-2 286.561)and aneurysm size(P=0.047,OR=17.867,95%CI=1.041-306.749)were also significantly associated with unfavorable outcome of UIA managed with operation. Conclusion:Aggressive treatment of high-risk unruptured aneurysms in elderly patients should be considered positively. Coiling and clipping are both safe and effective treatment methods,and age is not the contraindication.