脑外伤性与医源性颅内假性动脉瘤的临床特点及其血管内治疗的效果分析(附7例报道)

Clinical characteristics of brain traumatic and iatrogenic intracranial pseudoaneurysms and the related endovascular treatment

目的探讨脑外伤性与医源性颅内假性动脉瘤的临床特点以及血管内治疗的方法及其效果。方法回顾性分析南昌大学附属赣州医院神经外科2012年10月至2020年3月收治的6例脑外伤性与1例医源性颅内假性动脉瘤患者的临床特点以及血管内治疗的方法、效果、复发情况、并发症和随访情况。结果6例脑外伤性颅内假性动脉瘤,外伤后均有颅底骨折及蛛网膜下腔出血,动脉瘤与骨折关系密切,6例外伤性颅内假性动脉瘤中2例为颈内动脉海绵窦段假性动脉瘤,4例为床突旁假性动脉瘤,1例为脑膜中动脉颅内段的假性动脉瘤。6例均行血管内治疗,其中瘤腔内单纯弹簧圈栓塞1例,采用多支架辅助栓塞3例,ONYX栓塞1例;1例医源性颅内假性动脉瘤,创伤后动态复查,采用多支架辅助栓塞;所有7例患者血管内治疗术后即刻达到动脉瘤完全不显影,Raymond分级1级。术后复发2例,其中1例为单纯弹簧圈栓塞者,术后反复发生鼻腔大出血,复发后再次支架辅助弹簧圈栓塞,达到治愈,Raymond分级1级。另1例为支架辅助栓塞术后3个月复查数字剪影血管造影(DSA)发现复发,再次用弹簧圈补充填塞治愈。7例血管内治疗仅1例发生手术后脑梗死,为动脉瘤侧的颞顶叶梗死,出院时轻度偏瘫,改良Rankin量表(mRS)评分3分。6例外伤性假性动脉瘤出院时mRS评分,0分4例;3分2例,其中1例康复2年后mRS评分由3分变为1分,可以正常工作,另1例康复半年后mRS评分由3分变为2分,目前仍在继续康复中。医源性颅内假性动脉瘤出院时mRS评分为0分。本组无死亡病例。本组病例术后随访6个月~8年,1年后DSA复查2例,1年后门诊CTA或MRA复查4例,未见复发,电话随访6例,未见明显复发表现,1例3个月后失访。结论脑外伤性和医源性颅内假性动脉瘤,早期发现早期处理至关重要,根据患者的具体病情以及医院的现有条件和材料的可获得性,选择合适的血管内治疗方法,可以取得较好的效果。

Objective To investigate the clinical characteristics of traumatic and iatrogenic intracranial pseudoaneurysms,and the methods and effects of endovascular treatment.Methods The clinical features of both six cases of traumatic brain injury and one case of iatrogenic intracranial pseudoaneurysm,who were hospitalized in the department of neurosurgery in Ganzhou hospital affiliated to Nanchang University from October 2012 to March 2020,were retrospectively analyzed.The related endovascular treatment was also evaluated,including the methods,the effects,the recurrence,the complications,and the follow-up.Results All the six cases of traumatic intracranial pseudoaneurysm suffered skull base fractures and subarachnoid hemorrhage after trauma, showing a relationship betweenpseudoaneurysm and fractures. Among six cases of traumatic intracranial pseudoaneurysm, there were twocases of internal carotid artery cavernous segment pseudoaneurysm, three cases of paraclinoidpseudoaneurysm, and one case of a pseudoaneurysm which was located in the intracranial segment of themiddle meningeal artery. All these six cases were treated with endovascular treatment, including one casewith coil embolization, three cases with multi stent assisted embolization, one case with Onyx embolization,and one case with iatrogenic intracranial pseudoaneurysm, who was treated with multi-stent assistedembolization after dynamic reexamination after trauma. All seven cases with endovascular treatmentimmediately achieved no aneurysm development (Raymond grade 1). Two cases recurred after operation,including one case with simple coil embolization, recurrent nasal bleeding, and stent assisted coilembolization again after recurrence;the other case with stent assisted embolization was found recurrent threemonths after DSA, therefore with spring coil filling again. Among the seven patients treated withendovascular treatment, only one patient had cerebral infarction after operation, which was temporal parietallobe infarction on the aneurysm side, with 3 points of mRS (modified Rankin scale) and mild hemiplegia atdischarge. The mRS of six patients with traumatic pseudoaneurysms were 0 in 4 cases and 3 in 2 cases. Oneof the latter was able to work normally, with a decrease from 3 points to 1 point after 2 years of rehabilitation,and the other one was still recovering, with a slight decrease from 3 points to 2 points half a year later. ThemRS of iatrogenic intracranial pseudoaneurysm was 0 at discharge. There were no deaths. The patients werefollowed up from 6 months to 8 years. Two cases were reexamined by DSA 1 year later, the other four casesby CTA or MRA in the outpatient one year later. No recurrence was found. Six cases were followed up bytelephone, and the other one was lost 3 months later. Conclusion Early detection and early treatment arevery important for traumatic and iatrogenic intracranial pseudoaneurysms. Based on both the patient'sspecific condition and the equipment accessibility and the technical feasibility of the hospital, the appropriateendovascular treatment method can achieve good results.