基层医院大脑中动脉瘤的临床鉴别及救治体会(附116例报道)

Clinical identification and treatment strategies of middle cerebral artery aneurysm in primary hospitals

目的探讨大脑中动脉瘤的发病类型及诊治方法,以期提高基层医院大脑中动脉瘤的临床识别准确率,减少误诊误治,提高治愈率。方法回顾2007年1月至2019年1月兴安盟人民医院收治的116例大脑中动脉瘤患者临床资料,87例动脉瘤因破裂形成颅内出血而入院,29例无症状偶然发现。在出血病例中,蛛网膜下腔出血41例,24例脑内血肿、硬膜下血肿,7例出血破入脑室铸型;仅为脑内血肿15例。动脉瘤位于M1段123例、M2段1例、M3段1例。结果对大脑中动脉走行区附近出血或疑似动脉瘤的占位病变患者均进行血管成像检查或术中探查,116例患者共发现125个大脑中动脉瘤,有76例手术治疗用一个或多个动脉瘤夹夹闭,5例有血栓性动脉瘤同时摘除血栓并切除部分瘤体。术后恢复MRS评分0分35例,1分11例,2分12例,3~4分8例,5分3例。7例救治无效死亡。结论大脑中动脉瘤是一种较为常见的颅内动脉瘤,未破裂的大脑中动脉瘤普通临床体格检查不易察觉,需与脑膜瘤相鉴别;破裂型不仅表现为蛛网膜下腔出血,也可表现为侧裂池血肿,或脑内血肿、硬膜下血肿、脑室铸型等,临床应与高血压脑出血相鉴别,以免漏诊误诊。

Objective To discuss different onset patterns of middle cerebral aneurysm so as to enhance its clinical diagnostic accuracy in hospitals at primary level,and reduce misdiagnosis and mistreatment.Methods The clinical data of 116 cases of patients with middle cerebral artery aneurysm(MCAA)hospitalized and treated in Xing’an League People’s Hospital from January 2007 to January 2019 was reviewed,in which 87 patients were hospitalized for aneurysm rupture-caused intracranial hemorrhage,the other 29 discovered by accident asymptomatically.Among cases with hemorrhage,41 were with subarachnoid hemorrhage,24 accompanied by intracerebral or subdural hematoma,7 with cerebroventricular hemorrhage,and 15 intracerebral hematoma only.The aneurysms were located in 123 cases of M1 segment,1 case of M2 segment and 1 case of M3 segment.Results A total of 125 MCAA were found in 116 patients,of which 76 received surgical treatment clamped by one or more aneurysm clips;5 with thrombosis aneurysm were removed of the thrombus and part of the tumor body.After surgery,modified Rankin score was 0 of 35 cases,1 in 11 cases,2 in 12 cases,3~4 in 8 cases,5 in three cases.Seven patients died despite all rescue measures.Conclusion MCAA is a common intracranial aneurysm.Unruptured MCAA can be easily neglected in general clinical examination.We need to distinguish it from meningioma.The ruptured type takes the form of not only subarachnoid hemorrhage,but also hematoma in lateral fissure pool,intracerebral hematoma,subdural hematoma,total intraventricular hemorrhage,etc,which should be differentiated carefully with hypertensive intracerebral hemorrhage in clinical practice to avoid misdiagnosis and missed diagnosis.