颅内椎动脉夹层动脉瘤血管内治疗策略及效果分析

Endovascular treatment strategy and effect analysis of intracranial vertebral artery dissecting aneurysm

目的初步分析颅内椎动脉夹层动脉瘤血管内治疗的安全性及临床效果。方法回顾性连续纳入2016年1月至2019年12月在苏州大学附属第一医院神经外科接受血管内治疗[载瘤动脉闭塞术和保留载瘤动脉通畅的重建性手术(单纯支架置入术、支架辅助弹簧圈栓塞术)]的颅内椎动脉夹层动脉瘤患者41例。收集患者的一般资料以及临床资料,一般资料包括年龄、性别和血管危险因素等;临床资料包括动脉瘤的基本特征(动脉瘤的长径、是否位于椎动脉优势侧、与同侧小脑后下动脉的关系)、治疗结果、随访资料等。动脉瘤分型:(1)根据椎动脉夹层动脉瘤与小脑后下动脉的毗邻关系分为小脑后下动脉近端型、小脑后下动脉累及型、小脑后下动脉远端型;(2)根据优势侧椎动脉与载瘤动脉的关系分为对侧优势型、同侧优势型、共同优势型;(3)根据形态学表现分为偏侧型、全周型。治疗的安全性以死亡、围手术期并发症(动脉瘤破裂出血、脑梗死)进行评估。影像学随访采用MR血管成像(MRA)和(或)DSA,临床预后采用门诊或电话随访。术后6个月行DSA随访,此后每1~2年行MRA及临床随访。DSA随访治愈(改良Raymond分级Ⅰ级)为动脉瘤不显影,改善(改良Raymond分级Ⅱ级)为动脉瘤显影小于1/3,栓塞不全(改良Raymond分级Ⅲ级)为动脉瘤显影大于1/3。复发为动脉瘤显影较术后即刻增多。临床预后采用改良Rankin量表(mRS)评分进行评估,mRS评分≤2分为预后良好,3~6分为预后不良,其中6分为死亡。结果41例椎动脉夹层动脉瘤患者中采用载瘤动脉闭塞治疗9例,2例采用单纯支架置入术,采用支架辅助栓塞治疗30例。围手术期并发症发生率为7.3%(3/41),其中2例为支架辅助弹簧圈栓塞患者,于术后1周内因动脉瘤再次破裂而致死亡,病死率为4.9%(2/41);1例患者为右侧舌回新发脑梗死。41例椎动脉夹层动脉瘤患者有39例完成了术后6个月的DSA随访,影像学随访时间6~24个月,中位随访时间8个月。DSA结果显示,动脉瘤治愈28例(68.3%),改善7例(17.1%),栓塞不全4例(9.8%);复发3例(7.3%),为小脑后下动脉累及型,且均为行支架辅助弹簧圈栓塞术者。闭塞载瘤动脉或单纯支架置入术患者随访期间未出现破裂或复发。术后6个月,41例患者完成了临床随访,预后良好37例(90.2%),预后不良4例(9.8%)。结论初步分析显示,椎动脉夹层动脉瘤患者采用血管内治疗方案安全、有效,但该结论尚需进一步验证。

Objective To preliminarily analyze the safety and clinical effect of endovascular treatment of intracranial vertebral artery dissecting aneurysm.Methods From January 2016 to December 2019,41 patients with intracranial vertebral artery dissecting aneurysms and received endovascular treatment(parent artery occlusion and reconstructive surgery for parent artery patency[simple stent placement,stent-assisted coiling embolization])in Department of Neurosurgery,the First Hospital Affiliated to Soochow University were included.General data and clinical data of these patients were collected.General data included age,gender and vascular risk factors;clinical data included basic characteristics of aneurysm(length,location on dominant side of vertebral artery or not,and relationship with ipsilateral posterior inferior cerebellar artery[PICA]),treatment outcome and follow-up outcome.Classification of aneurysms:(1)According to the relationship between vertebral artery dissection and PICA,aneurysms can be divided into PICA proximal type,PICA involvement type,and PICA distal type.(2)According to relationship between dominant side of vertebral artery and parent artery,aneurysms can be divided into contralateral dominant type,ipsilateral dominant type and co-dominant type.(3)According to morphological manifestations,aneurysms can be divided into lateral type and circumferential type.The safety of treatment was assessed by death and perioperative complications(ruptured aneurysm hemorrhage,cerebral infarction).Imaging follow-up was performed using MR angiography(MRA)and/or DSA.Clinical prognosis was evaluated by outpatient or telephone follow-up.DSA follow-up was performed 6 months after surgery,and MRA and clinical follow-up were performed every 1-2 years thereafter.In DSA follow-up,complete obliteration of aneurysm(modified Raymond classificationⅠ)was defined as no contrast filling;improved embolization(modified Raymond classificationⅡ)was defined as contrast filling less than 1/3;incomplete embolization(modified Raymond classificationⅢ)was defined as contrast filling greater than 1/3;recurrent aneurysms was defined contrast filling more than that immediately after operation.Clinical prognosis was evaluated by modified Rankin scale(mRS)score.Good prognosis was defined as mRS score≤2 and poor prognosis as mRS score3-6.Death was mRS score 6.Results In 41 cases with vertebral artery dissection,9 cases were treated with parent artery occlusion,2 cases with stent implantation alone,and 30 cases with stent-assisted coiling embolization.The incidence of perioperative complications was 7.3%(3/41),among which 2 patients with stent-assisted coil embolization died of aneurysm recurrent rupture within 1 week after surgery,and the fatality rate was 4.9%(2/41).One patient had a new cerebral infarction in the right lingual gyrus.Among 41 patients,39 patients completed DSA follow-up 6 months after surgery,and imaging follow-up lasted from 6 to 24 months,with median follow-up time of 8 months.DSA results showed that 28 cases(68.3%)of aneurysms were completely obliterated;7 cases(17.1%)were improved;4 cases(9.8%)were incomplete embolized;3 cases(7.3%)had recurrence as PICA involvement type,and all of them were treated with stent-assisted coiling embolization.During the follow-up period,there was no rupture of recurrence after parent artery occlusion or simple stent placement.6 months after surgery,41 patients completed clinical follow-up,with good prognosis in 37 cases(90.2%)and poor prognosis in 4 cases(9.8%).Conclusion Preliminary analysis shows that endovascular therapy is safe and effective for patients with vertebral artery dissecting aneurysms,but this conclusion needs to be further verified.