伴脑缺血症状的大脑中动脉瘤患者行显微外科夹闭与血管内治疗的对比研究

Comparative study of microsurgical clipping and endovascular treatment in patients with middle cerebral artery aneurysms presenting with cerebral ischemia

目的 比较伴脑缺血症状的大脑中动脉瘤患者行显微外科夹闭与血管内治疗的安全性差异。方法 回顾性连续纳入2014年1月至2022年9月于哈尔滨医科大学附属第一医院就诊的135例伴脑缺血症状的大脑中动脉未破裂动脉瘤患者,并根据治疗方式将所有患者分为血管内治疗组和显微外科夹闭组。收集患者的基线资料和影像学资料并进行组间比较。基线资料包括年龄、性别、高危因素(高血压病、糖尿病、吸烟史、饮酒史)、脑缺血症状类型[短暂性脑缺血发作(TIA)、脑梗死]、末次脑缺血症状至入院时间、术前改良Rankin量表(mRS)评分。影像学资料包括动脉瘤部位、动脉瘤最大径、是否合并血管重度狭窄(狭窄率70%~99%)、合并血管重度狭窄的部位(前循环、后循环)、合并血管狭窄侧别(动脉瘤同侧、动脉瘤对侧)、是否合并多支血管狭窄。分析并比较两组在主要终点事件及次要终点事件发生率上的差异。主要终点事件定义为术后30 d内与治疗相关的严重不良事件(SAEs)的发生率;次要终点事件定义为术后即刻至末次随访期间(≥6个月)与治疗相关的任何神经系统并发症发生率、致残性卒中发生率、病死率及动脉瘤完全闭塞率。随访期间,采用DSA评估患者的动脉瘤完全闭塞情况;采用MRI或CT评估患者的术后神经系统并发症;采用mRS评分评估患者的临床预后。结果 血管内治疗组纳入46例患者共48个动脉瘤,显微外科夹闭组纳入89例患者共100个动脉瘤,两组的术前基线资料差异均无统计学意义(均P>0.05)。术后30 d内共有26例(19.3%)患者出现与治疗相关的SAEs,其中血管内治疗组5例(10.9%),显微外科夹闭组21例(23.6%),差异有统计学意义(P=0.035)。所有患者接受了临床随访,中位随访时间为27.5(12.0,58.5)个月。末次临床随访结果显示,血管内治疗组、显微外科夹闭组术后即刻至末次随访期间与治疗相关的任何神经系统并发症发生率分别为17.4%(8/46)和33.7%(30/89),差异有统计学意义(P=0.022);致残性卒中的发生率分别为8.7%(4/46)和16.9%(15/89),差异无统计学意义(P=0.199);病死率分别为4.3%(2/46)和4.5%(4/89),差异无统计意义(P=0.969);血管内治疗组、显微外科夹闭组末次随访时mRS评分≤2分患者占比分别为91.3%(42/46)和86.5%(77/89),差异无统计学意义(P=0.418)。共有89例(65.9%)患者(90个动脉瘤)完成了DSA随访,其中血管内治疗组37例(38个动脉瘤)、显微外科夹闭组52例(52个动脉瘤),随访中位时间为11.5(6.0,12.0)个月;末次DSA随访结果显示,血管内治疗组、显微外科夹闭组动脉瘤完全闭塞率差异无统计学意义(76.3%比90.4%,P=0.066)。结论 对于伴脑缺血症状的大脑中动脉瘤患者,血管内治疗术后30 d与治疗相关的SAEs的发生率和术后即刻至末次随访期间的任何与治疗相关的神经系统并发症的发生率均低于显微外科夹闭组,结论仍需大型多中心随机对照研究进一步验证。

Objective To compare the safety between microsurgical clipping and endovascular intervention therapy for patients with middle cerebral artery(MCA)aneurysms and presented with cerebral ischemia.Methods We conducted a retrospective and continuous analysis on the clinical data of 135 patients with MCA aneurysms and cerebral ischemia of ischemia treated at the First Affiliated Hospital of Medical University from January 2014 to September 2022.Patients were divided into the microsurgical clipping group and the endovascular treatment group.This study collected the baseline and clinical data of the patients and performed intergroup comparisons.The baseline data includes age,gender,high-risk factors(such as hypertension,diabetes,smoking history,alcohol consumption history),types of cerebral ischemic symptoms(including transient ischemic attack,cerebral infarction),time from the last cerebral ischemic symptom to admission,and preoperative modified Rankin scale(mRS)score.Imaging data includes the location and maximum diameter of the aneurysm,whether there is severe vascular stenosis,the location of severe vascular stenosis(anterior circulation,posterior circulation)if present,the side of vascular stenosis(ipsilateral side as the aneurysm,opposite side),and whether there is concurrent multi-vessel stenosis.The differences in the occurrence rates of primary endpoint events and secondary endpoint events were compared between the two groups.The primary endpoint of this study involves the incidence rate of serious adverse events(SAEs)related to the treatment within 30 days after surgery.The secondary endpoints include the incidence rate of any treatment-related neurological complications from immediately postoperative period to the end of follow-up,rate of disabling strokes,mortality rate,and complete occlusion rate of the aneurysm.At follow-up,the complete occlusion rate of aneurysms in patients will be evaluated through DSA,and postoperative neurological complications will be evaluated through MRI or CT,and the clinical prognosis of patients using mRS score.Results The endovascular treatment group included 46 patients with 48 aneurysms,and the microsurgical clipping group included 89 patients with 100 aneurysms.There was no statistically significant difference in preoperative baseline treatment between the two groups(all P>0.05).A total of 26 patients(19.3%)experienced SAEs within 30 days after surgery related to treatment during the perioperative period,including 5 patients(10.9%)in the endovascular treatment group and 21 patients(23.6%)in the microsurgical clipping group,with a statistically significant difference(P=0.035).During follow-up,the incidence of any treatment-related neurological complications from immediately postoperative period to the end of follow-up in the endovascular treatment and microsurgical clipping groups was 17.4%(8/46)and 33.7%(30/89),respectively,with a statistically significant difference(P=0.022).The incidence rates of disabling strokes were 8.7%(4/46)and 16.9%(15/89)respectively,with no statistically significant difference observed(P=0.199).The mortality rates were 4.3%(2/46)and 4.5%(4/89)respectively,and there was no statistically significant difference between the groups(P=0.969).The mRS score of 2 or less was achieved by 91.3%(42/46)and 86.5%(77/89)of participants,respectively,with no statistically significant difference(P=0.418).A total of 89(65.9%)patients(90 aneurysms)underwent DSA follow-up,with a follow-up time of 11.5(6.0,12.0)months.The final follow-up results showed that the complete occlusion rates in the endovascular treatment and microsurgical clipping groups were not statistically significant(76.3%vs.90.4%,P=0.066).Conclusions For patients with middle cerebral artery aneurysms presenting with cerebral ischemia,the incidence rates of treatment-related SAEs within 30 days after endovascular therapy and any treatment-related neurological complications from immediately postoperative period to the end of follow-up were lower compared to the microsurgical clipping group.However,further validation is required through large-scale multicenter randomized controlled studies to draw conclusive findings.