出血性椎动脉颅内段夹层动脉瘤的急诊血管内治疗  

Emergency endovascular treatment of hemorrhagic vertebral artery dissecting aneurysm

作　　者：郑峥[1,2] 汪银洲[1,2] 程琼[1,2] 李永坤[1,2] 刘君鹏[1,2] ZHENG Zheng;WANG Yin-zhou;CHENG Qiong;LI Yong-kun;LIU Jun-peng(Department of Neurology, Fujian Provincial Hospital, Fuzhou 350001, China;Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou 350001, China)

机构地区：[1]福建医科大学省立临床医学院,福州350001 [2]福建省立医院神经内科,福州350001

出　　处：《创伤与急诊电子杂志》2017年第4期166-170,174,共6页Journal of Trauma and Emergency(Electronic Version)

基　　金：福建省自然科学基金卫生联合面上项目(2017J01176)

摘　　要：目的探讨出血性椎动脉颅内段夹层动脉瘤(intracranial vertebral artery dissecting aneurysm,IVADA)急诊血管内治疗方法的选择和临床疗效。方法回顾32例破裂导致蛛网膜下腔出血(subarachnoid hemorrhage,SAH)的IVADA患者临床资料,均通过脑血管数字减影血管造影(digital subtraction angiography,DSA)检查证实IVADA的诊断,于就诊后24小时内根据载瘤椎动脉(vertebral artery,VA)是否为优势侧、IVADA与小脑后下动脉(posterior inferior cerebellar artery,PICA)开口的位置关系选择不同的急诊血管内治疗方法。术后观察并记录再出血、脑梗死等并发症发生情况,术后6个月复查脑血管造影,并评估改良的Rankin评分(modified Rankinscale,mRS),mRS 0~2分为预后良好,mRS>2为预后不良。结果 32例IVADA患者均成功实施血管内治疗,术中和术后均未发生再出血,27例(84.4%)预后良好,5例(15.6%)预后不良,其中2例(6.3%)死亡。18例接受动脉瘤栓塞并近端VA闭塞术治疗,14例预后良好(77.8%),2例死亡,2例术后并发小脑、延髓梗死,mRS5分;12例接受支架辅助栓塞术,11例预后良好(91.7%),仅1例术后并发小脑、延髓梗死,mRS 3分;2例接受经健侧VA逆行PICA支架植入联合动脉瘤栓塞及近端VA闭塞术,均预后良好。27例完成影像学随访,均未见IVADA复发。结论急诊实施血管内治疗是防止出血性IVADA再出血的一项安全有效的治疗方法。Objective To investigate the selection and clinical efficacy of endovascular treatment in patients with hemorrhagic intracranial vertebral artery dissecting aneurysm(IVADA). Methods Thirty-two patients with subarachnoid hemorrhage(SAH) resulting from ruptured IVADA were reviewed. The diagnosis of IVADA was confirmed through the cerebral DSA examination. Within 24 hours after the visit, different methods of emergency endovascular treatment were selected depending on whether the responsible vertebral artery(VA) is the superior side and correlation between the position of IVADA and the posterior inferior cerebellar artery(PICA) opening. The complications such as rebleeding and cerebral infarction were observed and recorded after operation. Cerebral angiography and evaluation of modified Rankin scale(mRS) were performed 6 months after the operation(mRS 0~2 was defined as good prognosis, and mRS2 was defined as poor prognosis). Results In 32 patients with IVADA, endovascular treatment was successfully performed without rebleeding. Twenty-seven patients(84.4%) had a favorable prognosis, 5(15.6%) had poor prognosis, and 2 of them(6.3%) died. Among 18 cases undergoing aneurysm embolization and proximal VA occlusion, 14 cases had good prognosis(77.8%), 2 cases died, and 2 cases were complicated with cerebellum and bulbar infarction with mRS 5 points. Of 12 patients who underwent stent assisted embolization, 11 patients had favorable prognosis(91.7%), and only 1 patient with mRS 3 points suffered from cerebellar and bulbar infarction after surgery. Two patients received stent placement from the PICA to VA through the contralateral VA combined with coil embolization of the dissected segment and proximal VA, and the prognosis was good in these 2 cases. No recurrence of IVADA was observed in 27 cases. Conclusion Endovascular treatment is an effective and safe way to prevent rebleeding for hemorrhagic IVADA.

关 键 词：椎动脉 夹层动脉瘤 蛛网膜下腔出血 血管内治疗 预后 

分 类 号：R651.12[医药卫生—外科学]