烟雾病合并颅内动脉瘤的血管内栓塞治疗

Endovascular embolization of intracranial aneurysms in patients with moyamoya disease

目的探讨血管内栓塞治疗烟雾病合并颅内动脉瘤的疗效及策略。方法收集2013年3月至2019年9月在解放军总医院第五医学中心行血管内栓塞治疗的烟雾病合并颅内动脉瘤的患者共25例(25个动脉瘤)。对于主干型动脉瘤,如果为窄颈动脉瘤直接予以单纯弹簧圈栓塞,若为宽颈动脉瘤则采用双微导管、球囊辅助及支架辅助等技术手段进行栓塞。对于外周型动脉瘤,若为真性动脉瘤则采用弹簧圈进行栓塞,若考虑为假性动脉瘤则采用液态栓塞剂(Onyx-18)栓塞,观察手术效果并进行术后随访。采用Fisher精确概率法比较真性动脉瘤和假性动脉瘤并发症发生率的差异。结果有7例采用了支架辅助弹簧圈栓塞;9例采用单纯弹簧圈栓塞,其中有1例动脉瘤术中破裂出血,术后有轻度头痛症状;9例假性动脉瘤采用了液态栓塞剂(Onyx-18)栓塞,其中有5例患者术后出现不同程度的神经功能障碍。假性动脉瘤术后并发症发生率明显高于真性动脉瘤[55.6%(5/9)vs 6.3%(1/16)],差异具有统计学意义(P=0.012)。18例患者在术后3~26个月(平均12.6个月)进行了全脑血管造影复查显示动脉瘤均已治愈,无复发及残留。7例采用支架辅助弹簧圈栓塞治疗的患者在术前1周至术后3个月服用双抗药物期间均未发生颅内出血,全脑血管造影复查时也未见支架内再狭窄。结论血管内栓塞是治疗烟雾病合并颅内动脉瘤的重要手段之一。短时间内服用双抗类药物并未明显增加烟雾病合并颅内动脉瘤发生颅内出血的风险。假性动脉瘤血管内栓塞术后并发症发生率高于真性动脉瘤。

Objective To explore the therapeutic effect and strategy of endovascular embolization in the treatment of moyamoya disease complicated with intracranial aneurysm.Methods 25 cases(25 aneurysms)of moyamoya disease with intracranial aneurysms were collected at the Fifth Medical Center of PLA General Hospital from March 2013 to September 2019.For trunk aneurysms,simple coil embolization was directly performed for narrow-neck aneurysms.Double microcatheter,balloon-assisted and stent-assisted embolization was performed for wide neck aneurysms.For peripheral aneurysms,coil embolization was used for true aneurysms and liquid embolic agent(Onyx-18)was used for pseudoaneurysms.The effects of operations were observed and followed up after operation.Fisher accurate probability method was used to compare the incidence of complications between true aneurysms and pseudoaneurysms.Results Stentassisted coil embolization was used in 7 cases,simple coil embolization in 9 cases with one case complicated with ruptured hemorrhage and mild headache after operation.The 9 cases of pseudoaneurysms were embolized by liquid embolic agent(Onyx-18),and 5 of them had different degree of neurological dysfunction after operation.The incidence of postoperative complications of pseudoaneurysm was significantly higher than that of true aneurysm(55.6%[5/9]vs 6.3%[1/16],P=0.012).After 3~26 months(mean 12.6 months),the aneurysms were all cured without recurrence and residual.No intracranial hemorrhage occurred in 7 patients treated with stent-assisted coils embolization during the period of taking clopidogrel plus aspirin from one week before operation to 3 months after operation,and no stent restenosis was observed during whole cerebral angiography.Conclusion Endovascular embolization is an important method to treat moyamoya disease with intracranial aneurysm.There was no significant increase in the risk of intracranial hemorrhage in moyamoya disease and intracranial aneurysm when shortly taking clopidogrel plus aspirin.The incidence of complications after endovascular embolization of pseudoaneurysm was higher than that of true aneurysm.