破裂性小脑后下动脉远端动脉瘤的个体化治疗策略  

Individualized treatment strategy for ruptured distal posterior inferior cerebellar artery aneurysm

作　　者：庄宗 祝琦 那世杰[1] 刘涛[1] 凌海平 张玉华 曹博强 杭春华 张庆荣 Zhuang Zong;Zhu Qi;Na Shijie;Liu Tao;Ling Haiping;Zhang Yuhua;Cao Boqiang;Hang Chunhua;Zhang Qingrong(Department of Neurosurgery,the Affiliated Drum Tower Hospital,School of Medicine,Nanjing University,Nanjing 210000,China;Department of Neurosurgery,Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University,Nanjing 210000,China)

机构地区：[1]南京大学医学院附属鼓楼医院神经外科,210000 [2]南京医科大学鼓楼临床医学院神经外科,210000

出　　处：《中华脑血管病杂志（电子版）》2023年第3期200-206,共7页Chinese Journal of Cerebrovascular Diseases(Electronic Edition)

基　　金：国家自然科学基金面上项目(81971127);南京市卫生科技发展专项资金项目(ZKX20013)。

摘　　要：目的分析破裂性小脑后下动脉远端动脉瘤介入治疗的安全性和有效性,以及伴随的血管畸形的处理策略。方法回顾性纳入南京大学医学院附属鼓楼医院神经外科2015年1月至2021年3月收治的33例破裂性小脑后下动脉远端动脉瘤患者的临床资料,术后6个月行脑血管造影复查,术后6个月、12个月分别进行临床随访。结果33例破裂性小脑后下动脉远端动脉瘤中,多发动脉瘤5例,夹层动脉瘤2例,假性动脉瘤3例,合并动静脉畸形(AVM)者11例,首次造影动脉瘤假阴性者2例。所有患者介入栓塞术均成功,其中单纯弹簧圈栓塞20例,Onyx/Glubran胶栓塞9例,弹簧圈加Onyx胶栓塞4例。微导管血管超选过程中诱发出血1例,拔除打胶导管出血1例,拔管困难1例。栓塞术中出血1例,遂行生物胶闭塞出血点后急诊开颅减压。术后小脑梗死6例,1例术后5 d行后颅凹开颅减压,1例术后意识变差,一侧肢体肌力下降,1例突发脑疝死亡,余3例患者无新增症状。脑干梗死1例,出现延髓麻痹及面瘫。合并AVM的患者中,同期栓塞5例,其中行弹簧圈闭塞AVM供血动脉者1例,二期栓塞AVM者1例,栓塞后开颅手术切除AVM者1例,1例动脉瘤合并幼稚型AVM,未予栓塞,选择随访,1例患者术后第2天突发脑疝死亡。所有动脉瘤栓塞术后即刻造影均显示动脉瘤完全闭塞。6个月造影复查28例,1例动脉瘤复发,余动脉瘤均不显影。临床随访30例,无新发神经功能缺损,改良Rankin量表评分0~2分者27例(90.0%),3~4分者3例(10%)。结论介入栓塞治疗小脑后下动脉远端破裂性动脉瘤安全有效,但应根据动脉瘤具体特点选择栓塞材料。对合并小脑血管畸形者,大都可同期栓塞,但应根据畸形团的特点及其与动脉瘤关系选择治疗策略。Objective To analyze the safety and efficacy of interventional therapy for ruptured aneurysms of the distal posterior inferior cerebellar artery,and discuss the treatment strategies for the parent artery and accompanying vascular malformations.Methods The clinical data of 33 patients with hemorrhagic distal posterior inferior cerebellar artery aneurysm treated in the Department of Neurosurgery,Drum Tower Hospital,Nanjing University School of Medicine from January 2015 to March 2021 was collected.The patients were followed up upon 6 and 12 months postoperatively and received the cerebral angiography 6 months after the operation.Results Thirty-three patients were confirmed with ruptured Distal-posterior inferior cerebellar artery(PICA)aneurysms.Among the 33 patients,5 had multiple aneurysms at the distal end of PICA,2 dissecting aneurysms,3 pseudoaneurysms,11 arteriovenous malformations(AVM),and 2 had a negative result by the first angiogram.Interventional embolization was successful in all patients,including 20 cases with coil embolization,9 with Onyx/GLUBRAN biological glue,and 4 with coil plus Onyx.Bleeding was induced in 1 case during vascular superselection,another bleeding occurred when the catheter was removed.Extubation failed in 1 case with GLUBRAN embolization.One case had bleeding during embolization;hence,an emergency craniotomy was performed for decompression after hemostasis with Onyx embolization.There were 6 cases with cerebellar infarction after the operation:one case underwent decompression of the posterior fovea craniotomy 5 days after the operation;one case became mentally worse after the operation and limb muscle strength decreased;one case died of sudden brain herniation;and the remaining 3 cases did not have new symptoms.One case of brainstem infarction presented with bulbar palsy and facial paralysis.Among the patients with AVM,5 cases were embolized simultaneously,of which,one case was treated by coil occlusion of the blood supply artery of AVM.1 case had secondary AVM embolization,and 2 ca

关 键 词：蛛网膜下腔出血 小脑后下动脉 动脉瘤 介入栓塞 血管畸形 

分 类 号：R743.4[医药卫生—神经病学与精神病学]