颅内破裂动脉瘤的出血特征和治疗(附632例报告)

Characteristics and treatment of hematoma caused by intracranial ruptured aneurysms:A report of 632 cases

目的探讨颅内动脉瘤破裂后的出血特征和治疗方法。方法回顾性分析2007年7月至2019年1月内蒙古兴安盟人民医院神经外科收治的632例颅内破裂动脉瘤患者(共678个动脉瘤)的临床资料。678个动脉瘤中,位于前交通动脉259个,大脑中动脉197个,后交通动脉136个,颈内动脉63个,基底动脉23个。139个(135例)予保守治疗;539个(497例)行手术治疗,其中开颅夹闭手术427个,血管内治疗112个。患者的临床预后采用格拉斯哥预后评级(GOS)评估,行影像学随访评估动脉瘤有无复发。结果632例患者中,610例表现为蛛网膜下腔出血,其中合并颞叶血肿52例,伴脑池血肿368例,伴胼胝体血肿25例,伴脑室积血69例,伴额叶血肿15例,伴脑积水73例,伴硬膜下血肿6例;仅表现为硬膜下血肿1例;仅以颞叶出血发病21例。随访时间为6个月至3年。行手术治疗的497例患者中,术后发生迟发脑梗死13例,其中大面积脑梗死6例,死亡2例;植物生存6例。行保守治疗的135例患者中,发生动脉瘤再次破裂出血3例,死亡2例。末次随访的GOS:Ⅴ级347例,Ⅳ级253例,Ⅲ级20例,Ⅱ级7例,Ⅰ级5例。行影像学随访426例(526个动脉瘤),其中524个动脉瘤未复发,2个动脉瘤复发。结论颅内动脉瘤破裂出血的形式多样,血肿位置有助于定位动脉瘤。根据患者的具体情况采用个性化的治疗方案,总体可获得较好的预后。

Objective To explore the characteristics and treatment of hematoma caused by intracranial ruptured aneurysms.Methods A retrospective analysis was conducted to investigate the clinical data of 632 patients with a total of 678 intracranial aneurysms who were admitted to Department of Neurosurgery,Xing′an League People′s Hospital from July 2007 to January 2019.The 678 aneurysms included 259 anterior communicating artery aneurysms,197 middle cerebral artery aneurysms,136 posterior communicating artery aneurysms,63 internal carotid artery aneurysms,and 23 basilar artery aneurysms.In this series,135 cases(139 aneurysms)underwent conservative treatment,while the remaining 497 cases(539 aneurysms)underwent surgical treatment(surgical clipping in 427 aneurysms and endovascular treatment in 112 aneurysms).The outcomes of patients were assessed using the Glasgow outcome score(GOS).Imaging follow-up was performed to evaluate the recurrence of aneurysms.Results Among the 610 patients with subarachnoid hemorrhage(SAH),temporal lobe hematoma coexisted in 52 cases,intracisternal hematoma in 368 cases,corpus callosum hematoma in 25 cases,intraventricular hemorrhage in 69 cases,frontal lobe hematoma in 15 cases,hydrocephalus in 73 cases and subdural hematoma in 6 cases.Among the remaining 22 patients,1 case had subdural hematoma only,and 21 cases only presented with temporal lobe hemorrhage.The follow-up period was 0.5-3.0 years.Among the 497 patients who underwent surgery,delayed cerebral infarction occurred in 13 cases after operation(including massive cerebral infarction in 6 cases and death in 2 cases),while persistent vegetative state occurred in 6 cases.In the group with conservative treatment,rebleeding caused by aneurysm rupture occurred in 3 cases,death occurred in 2 cases.GOS score was gradeⅤin 347 cases,Ⅳin 253 cases,Ⅲin 20 cases,Ⅱin 7 cases andⅠin 5 cases.426 cases(526 aneurysms)underwent imaging follow-up and recurrence was only reported in 2 aneurysms.Conclusions Ruptured intracranial aneurysms lead to a variety of types of hemorrhage.The location of hematoma can help locate the intracranial aneurysms.Individualized treatment regimens can be applied in accordance with specific conditions which could lead to a favorable prognosis.