液态栓塞剂治疗出血性周围型颅内动脉瘤临床分析

Clinical analysis of liquid embolization agent in treatment of hemorrhagic peripheral intracranial aneurysm

目的探讨液态栓塞剂治疗不同类型出血性周围型颅内动脉瘤的方法和效果。方法回顾性分析南京大学医学院附属鼓楼医院神经外科于2018年1月至2019年12月采用液态栓塞剂治疗的23例出血性周围型颅内动脉瘤的一般资料[年龄、性别和出血类型(单纯出血性周围型、烟雾病合并出血性周围型、脑血管畸形合并出血性周围型颅内动脉瘤)]及临床资料(包括动脉瘤分布、大小和治疗方式、结果以及随访时间、方式及随访结果),所有患者使用液态栓塞剂栓塞动脉瘤和(或)载瘤动脉,脑动静脉畸形合并周围型颅内动脉瘤患者同时部分或全部栓塞畸形团。术后3、6个月进行临床随访(门诊就诊或电话形式),并于术后6个月行DSA影像随访。采用改良Raymond-Roy(RR)分级评估动脉瘤DSA随访结果[治愈(RR分级Ⅰ级,动脉瘤完全不显影)、瘤颈残留(RR分级Ⅱ级,仅瘤颈显影)、栓塞不全(RR分级Ⅲ级,动脉瘤残留)]。动脉瘤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23例患者中,单纯出血性周围型颅内动脉瘤5例,烟雾病合并出血性周围型颅内动脉瘤5例,脑动静脉畸形合并出血性周围型颅内动脉瘤13例(根据Redekop分型:Ⅰ型8例,Ⅱ型5例,其中Ⅱa型2例,Ⅱb型3例)。5例单纯出血性周围型颅内动脉瘤患者载瘤动脉和动脉瘤均成功闭塞,无新发神经功能障碍;5例烟雾病合并出血性周围型颅内动脉瘤患者中,1例超选失败,余4例栓塞顺利,术后有2例新发神经功能障碍,其中1例术前危重,术后家属放弃治疗后死亡,1例出现肢体偏瘫;13例脑动静脉畸形合并出血性周围型颅内动脉瘤,目标动脉瘤均顺利栓塞,其中动静脉畸形完全栓塞6例,不完全栓塞7例(其中栓塞后随访3例,栓塞后外科切除4例)。共3例(13.0%)发生手术相关并发症(1例Ⅰ型脑动静脉畸形合并出血性周围型颅内动脉瘤患者微导管超选过程中分支动脉出血,1例Ⅱb型脑动静脉畸形合并出血性周围型颅内动脉瘤患者术毕拔除栓塞微导管时动脉瘤出血,1例顶叶血管畸形患者术后因微导管拔管困难而留置血管内)。23例患者中,1例血管畸形合并出血性周围型颅内动脉瘤患者术后死亡,1例烟雾病合并出血性周围型颅内动脉瘤患者术后放弃治疗,1例血管畸形患者出院后2个月死亡,1例失访。临床随访19例,均无再出血,其中预后良好16例,预后不良3例。DSA随访15例,动脉瘤均未见复发。结论液态栓塞剂治疗出血性周围型颅内动脉瘤是一种有效的治疗方法,但不同类型动脉瘤的安全性不同。对单纯出血性周围型颅内动脉瘤,如载瘤动脉为非重要功能区的供血动脉,栓塞动脉瘤和载瘤动脉是安全的;对脑动静脉畸形合并出血性周围型颅内动脉瘤,尤其动脉瘤位于畸形团内者,栓塞同样可靠,且能同时部分或全部栓塞畸形团;对烟雾病合并出血性周围型颅内动脉瘤患者,应充分评估血管条件后谨慎选择。

Objective To evaluate the methods and efficacy of liquid embolization agent in treating different hemorrhagic peripheral intracranial aneurysms.Methods From January 2018 to December 2019,the data of 23 patients with hemorrhagic intracranial peripheral aneurysms and treated by liquid embolization agent was retrospectively analyzed.General information(age,sex,type of bleeding[sole peripheral aneurysm,Moyamoya disease with peripheral aneurysm,arteriovenous malformation with peripheral aneurysm])and clinical data(aneurysm distribution,size,treatment modality and results,follow-up time,way and results)were reviewed.All patients used liquid embolization agents for aneurysm and/or parent artery embolization.Patients with arteriovenous malformation accompanied with peripheral aneurysm had simultaneous partial or total embolization of the malformation.Clinical follow-up(outpatient or telephone)was performed 3 and 6 months after operation,and DSA imaging follow-up was performed 6 months after operation.The follow-up results of DSA were classified according to modified Raymond-Roy(RR)classification(Cured[RR classificationⅠ,complete obliteration of aneurysm],residual aneurysm neck[RR classificationⅡ,residual aneurysm neck only],and incomplete embolization[RR classificationⅢ,residual aneurysm]).The recurrent aneurysm was defined as development of aneurysm compared with the immediate angiography after operation.Clinical prognosis was assessed by the modified Rankin scale(mRS):mRS score≤2 as good prognosis and mRS score 3-6 as poor prognosis(6 stands for death).Results Among the 23 patients,there were 5 cases of sole peripheral intracranial aneurysm,5 cases of Moyamoya disease with peripheral intracranial aneurysm,and 13 cases of arteriovenous malformation with peripheral intracranial aneurysm(according to Redekop classification:8 cases of typeⅠ,5 cases of typeⅡ,including 2 cases of typeⅡa and 3 cases of typeⅡb).All 5 cases of sole peripheral aneurysm were successfully embolized without new complications;Among the 5 cases of Moyamoya disease accompanied with peripheral aneurysm,1 case failed in superselective angiography,and the remaining 4 cases were successfully embolized.There were 2 cases of new neurological dysfunction after operation,among which 1 case was critically ill before operation and died after family members giving up further treatment after operation,and 1 case was hemiplegia;Among the 13 cases of arteriovenous malformation with peripheral aneurysm,target aneurysms were all successfully embolized.There were 6 cases of complete embolization of arteriovenous malformations and 7 cases of incomplete embolization(3 cases were followed up after embolization and 4 cases were surgically removed after embolization).Three cases(13.0%)presented operation related complications(branch artery hemorrhage occurred during superselective angiography in 1 case of typeⅠarteriovenous malformation with peripheral intracranial aneurysm,aneurysm bleeding during tube withdrawal after operation in 1 case of typeⅡb arteriovenous malformation with peripheral intracranial aneurysm,and microcatheter indwelling in 1 patient with parietal vascular malformation due to difficulty in withdrawal).Among the 23 patients,1 patient with arteriovenous malformation and peripheral intracranial aneurysm died after operation,1 patient with Moyamoya disease and peripheral intracranial aneurysm abandoned treatment after surgery,1 patient with arteriovenous malformation died 2 months after discharge,and 1 patient was lost to follow-up.Clinical follow-up of 19 patients showed no further bleeding,including 16 patients with good prognosis and 3 patients with poor prognosis.Fifteen patients were followed up by DSA and no recurrence was found.Conclusions Liquid embolization agent treatment is an efficient therapy for hemorrhagic peripheral intracranial aneurysms,but the safety differs in different subtypes of aneurysms.For sole peripheral aneurysms,embolization is safe for aneurysms or parent arteries when parent arteries do not feed the functional area.In cases of arteriovenous malformation with peripheral aneurysms,especially aneurysms located within malformation,embolization is safe as well.Meanwhile,the accompanied malformations could be partially or totally embolized.As for hemorrhagic peripheral aneurysms in Moyamoya disease,prudent evaluation of the angioarchitecture must be carried out before embolization.