血流导向装置治疗大脑中动脉复杂动脉瘤的初步研究

A preliminary study on the treatment of complex aneurysms of middle cerebral artery with flow diverter

目的探讨血流导向装置(FD)治疗大脑中动脉复杂动脉瘤的安全性和有效性。方法回顾性连续收集2018年7月至2021年4月海军军医大学第一附属医院脑血管病中心行FD治疗的20例大脑中动脉复杂动脉瘤患者的人口学(性别、年龄)、临床资料,其中临床资料包括首发症状和动脉瘤是否破裂、复发、多发以及动脉瘤部位、大小、形态(囊性、梭形、夹层或血泡样动脉瘤)、载瘤动脉是否累及分支等,以及FD治疗相关资料、围手术期并发症发生情况、随访资料。术后≥6个月进行临床和影像学随访,评估患者动脉瘤闭塞情况(完全闭塞、进一步血栓形成、稳定、复发)及临床改良Rankin量表(mRS)评分。结果20例患者中,夹层动脉瘤7例,梭形动脉瘤6例,囊性动脉瘤7例,无血泡样动脉瘤;复发动脉瘤2例,破裂动脉瘤1例,无多发动脉瘤;9例有明显的分支受累,为豆纹动脉或大脑中动脉分支自瘤颈或瘤体发出。瘤体平均最大径为(8.47±4.89)mm,平均瘤颈(囊性)或病变长度(梭形或夹层)为(11.03±6.97)mm。20例患者共释放22枚FD,释放技术成功率为100%,18例置入单枚FD,2例桥接置入双枚FD;14例行单纯FD置入,6例行FD联合弹簧圈治疗。围手术期共3例患者发生出血或缺血并发症;围手术期出院时mRS评分0分19例,1分1例,无死亡病例。20例患者均获得了临床随访,中位随访时间10(6,18)个月,随访期内1例患者有短暂性脑缺血发作,未遗留神经系统症状。末次随访时的mRS评分0分19例,3分1例,总体致残率和致死率分别为5.0%(1/20)和0。18例患者获得DSA影像学随访,中位随访时间9(7,14)个月,其中8例为完全闭塞,9例为进一步血栓形成,1例为稳定,无复发病例;无分支受累动脉瘤和有分支受累动脉瘤完全闭塞比例分别为7/10、1/8。结论FD治疗大脑中动脉复杂动脉瘤技术成功率高,随访临床效果较好,可作为复杂动脉瘤的治疗选择,长期安全性和有效性有待进一步大样本、多中心、长期随访研究验证。

Objective To investigate the safety and effectiveness of flow diverter(FD)in the treatment of complex aneurysms of middle cerebral artery.Methods The demographic(sex and age)and clinical data of 20 patients with complex middle cerebral artery aneurysms treated by FD in the Cerebrovascular Disease Center of the First Affiliated Hospital of Naval Medical University from July 2018 to April 2021 were retrospectively collected.The clinical data included initial symptoms,rupture and recurrence,aneurysm location,size,shape(cystic,fusiform,dissected or blood blister-like aneurysm),parent artery involvement,FD treatment related data,perioperative complications,follow-up data,etc.Clinical and imaging follow-up was performed 6 months after surgery to assess aneurysm occlusion(complete occlusion,further thrombosis,stability,recurrence)and clinically modified Rankin(mRS)score.Results Among the 20 patients,7 were dissected aneurysms,6 were fusiform aneurysms and 7 were cystic aneurysms.There was no blood blister-like aneurysm.There were obvious branch involvement in 9 cases,with the lenticulostriate artery or middle cerebral artery branch deriving from the tumor neck or body.The overall maximum diameter of tumor body was 8.47 mm±4.89 mm,and the length of tumor neck(cystic)or lesion(fusiform/dissected)was 11.03 mm±6.97 mm.A total of 22 FDs was released in 20 patients,and the success rate of the release technique was 100%.18 patients had single FD placement and 2 patients had double FD bridge placement.FD implantation alone was performed in 14 cases,and FD combined with coil was performed in 6 cases.There were 3 cases of hemorrhage or ischemia complications during perioperative period.The mRS score at discharge was 0 in 19 patients and 1 in 1 patient,without any death.All the 20 patients(100%)received clinical follow-up with a median follow-up time of 10(6,18)months.During the follow-up period,1 patient had transient ischemic attack without neurological sequelae.The overall morbidity rate and mortality rate was 5%(1/20)and 0,respectively.Imaging follow-up was obtained for 18 patients with a median follow-up time of 9(7,14)months,including 8 cases of complete aneurysm occlusion,9 cases of further thrombosis,and 1 case of stable aneurysm without recurrence.The proportion of completely occluded aneurysms without branch involvement and with branch involvement was 7/10 and 1/8,respectively.Conclusions FD has a high success rate in the treatment of complex middle cerebral artery aneurysms with satisfactory clinical follow-up.It can be used as a treatment choice for complex aneurysms.Its safety and effectiveness need to be verified by further large-sample,multi-center and long-term follow-up trials.