血流导向装置治疗大脑中动脉动脉瘤的临床疗效以及缺血性并发症的影响因素分析

Clinical efficacy and risk factor analysis of ischemic complications following flow diverter treatment for middle cerebral artery aneurysms

目的探讨血流导向装置(FD)治疗大脑中动脉(MCA)动脉瘤的临床疗效以及围手术期发生缺血性并发症的影响因素。方法回顾性分析郑州大学第一附属医院神经介入科2016年4月至2021年12月采用FD治疗的86例MCA动脉瘤患者的临床及影像学资料。于术后3、6、12个月对患者进行临床及影像学随访。采用改良Rankin量表评分(mRS)评估临床预后。采用O′Kelly-Marotta(OKM)分级标准评估动脉瘤的闭塞情况。观察围手术期和随访期间的手术相关并发症,根据围手术期有无缺血性并发症将患者分为缺血性并发症组与无缺血性并发症组。比较两组患者的临床资料并采用单因素logistic回归分析法判断FD治疗MCA动脉瘤围手术期发生缺血性并发症的影响因素。结果86例患者(90个动脉瘤)共成功置入90枚FD。围手术期并发症的发生率为12.8%(11/86),包括缺血性脑血管病9例,蛛网膜下腔出血1例,其他并发症1例。82例患者获得临床随访,中位随访时间为8个月(3~40个月)。随访期并发症的发生率为4.9%(4/82),均为缺血性并发症。至末次随访,mRS 0分75例,1分5例,3分2例。53例患者行数字减影血管造影随访,中位时间为7个月(2~28个月);末次随访时MCA动脉瘤的完全闭塞率为67.9%(36/53)。缺血性并发症组(9例)与无缺血性并发症组(77例)仅围手术期抗血小板聚集治疗方案的差异有统计学意义(χ^(2)=9.33,P=0.004)。单因素logistic回归分析结果显示,以阿司匹林+氯吡格雷方案为参照,阿司匹林+替格瑞洛、阿司匹林+替罗非班+氯吡格雷(或替格瑞洛)对围手术期缺血性并发症的发生具有保护作用(OR值均为0.09,均P<0.05)。结论FD治疗MCA动脉瘤的临床预后较好,抗血小板聚集治疗方案可能是围手术期发生缺血性并发症的影响因素。

Objective To evaluate the clinical efficacy and risk factors of ischemic complications following flow diverter(FD)treatment of middle cerebral artery(MCA)aneurysms.Methods A retrospective analysis was performed on the clinical and imaging data of 86 patients with MCA aneurysms treated with FD from April 2016 to December 2021 in the Department of Interventional Neurology of the First Affiliated Hospital of Zhengzhou University.Clinical and imaging follow-up was conducted at 3,6 and 12 months after surgery.Clinical outcomes were assessed using the modified Rankin scale(mRS).Aneurysm occlusion was assessed using O′Kelly-Marotta(OKM)grading criteria.Surgery-related complications were observed during perioperative and follow-up periods,and patients were divided into group of ischemic complications and that of non-ischemic complications according to the presence or absence of ischemic complications during the perioperative period.Clinical data from the two groups were compared.Univariate logistic regression analysis were used to determine the influencing factors of ischemic complications in the perioperative period of FD treatment of MCA aneurysm.Results A total of 90 FDs were successfully placed in 86 patients(90 aneurysms).The incidence of perioperative complications was 12.8%(11/86),including 9 cases of ischemic cerebrovascular disease,1 case of subarachnoid hemorrhage,and 1 case of other complication.Eighty-two patients received clinical or telephone follow-up,with a median follow-up time of 8 months(3-40 months).The follow-up complication rate was 4.9%(4/82),all of which were ischemic complications.At the last follow-up,the mRS score was 0 in 75 cases,1 in 5 cases and 3 in 2 cases.Fifty-three patients underwent digital subtraction angiography follow-up,with a median time of 7 months(2-28 months).The complete occlusion rate for MCA aneurysms at last follow-up was 67.9%(36/53).There was significant difference in perioperative antiplatelet regimen between the group of ischemic complications(9 cases)and that of non-ischemic complications(77 cases)(χ^(2)=9.33,P=0.004).The results of univariate logistic regression analysis showed that compared with aspirin+clopidogrel,the regimens of aspirin+ticagrelor and aspirin+tirofiban+clopidogrel(or ticagrelor)had a protective effect on the occurrence of perioperative ischemic complications(both OR=0.09,both P<0.05).Conclusions The clinical outcome of MCA aneurysms treated by FD seems relatively good,and antiplatelet regimen may be a factor influencing the development of ischemic complications in the perioperative period.