1. 颅内动脉瘤手术夹闭与血管内治疗临床对比研究 2. 光动力治疗裸鼠皮下移植的C6胶质瘤对VEGF表达的影响及意义
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摘要
目的:探讨颅内动脉瘤(Intracranial aneurysms,AN)治疗方法的选择、手术和血管内治疗的适应症、安全性及影响预后因素,为动脉瘤性蛛网膜下腔出血患者的临床治疗提供指导性依据。
方法:回顾性分析了沈阳军区总医院和第三军医大学西南医院自2000年1月至2007年12月收治的1537例颅内动脉瘤病例,男性659例,女性878例,年龄17-84岁,平均年龄60.8岁。术前Hunt-Hess分级0级22例,I级207例,II级437例,III级760例,IV级76例,V级35例。377例有高血压病史,221例有糖尿病病史,17例合并脑梗塞。所有患者入院前均行CT检查,1515急性剧烈头痛患者行CT检查或腰穿证实为蛛网膜下腔出血,其中Fisher I级36例,Fisher II级397例,Fisher III级891例,Fisher IV级213例。本组患者1532例行全脑血管连续造影术,并行三维重建明确动脉瘤与载瘤动脉及其分支空间三维关系。所有患者均经有经验的神经外科医生和神经介入医生阅片,根据动脉瘤形态、部位及患者临床状态,并与患者家属及本人交流共同制定治疗计划。本组889例患者采用显微外科手术治疗处理责任病灶,另外3例同侧串联性多发动脉瘤和1例CT及造影无法判断责任病灶的双侧后交通动脉瘤患者同期采用显微外科夹闭动脉瘤,共夹闭893例动脉瘤。621例行血管内治疗:窄颈动脉瘤采用单纯微弹簧圈栓塞,宽颈动脉瘤采用支架辅助微弹簧圈栓塞、球囊辅助微弹簧圈栓塞、单纯支架成形,其中部分多发动脉瘤病例同期栓塞所有动脉瘤;23例行保守(未)治疗(由于经济、技术、风险等原因)。术后随访改良Rankin评分、再出血率,48例显微外科手术患者和35例血管内治疗患者复查脑血管造影。
结果:血管内治疗组术后恢复良好(改良Rankin评分0-2分)589例,功能障碍(改良Rankin评分3-5分)22例,死亡10例;显微外科手术组恢复良好(改良Rankin评分0-2分)796例,功能障碍(改良Rankin评分3-5分)61例,死亡32例。随访血管内治疗组患者349例,再出血7例(脑血管造影显示4例栓塞后动脉瘤复发,2例其他部位再发动脉瘤,1例原因不明);随访显微外科手术组患者571例,再出血9例(脑血管造影显示7例术后动脉瘤复发,2例其他部位再发动脉瘤)。48例显微外科手术患者复查脑血管造影(6m～3Y),显示瘤颈残留2例,动脉瘤复发1例;35例血管内治疗患者复查脑血管造影(6m～27m),显示动脉瘤再通4例。27例未治疗患者中11例因再出血死亡(2w～7m)。
结论:
1.大部分动脉瘤同时适合显微外科手术和血管内治疗,血管内治疗动脉瘤总体上预后优于显微外科手术,在动脉瘤患者既适合血管内治疗又适合显微外科手术时,应首选血管内治疗;
2.动脉瘤在手术后随病情的等级升级,功能障碍比率增大,死亡率提高,风险性较大。但在同等级情况下,血管内治疗优越于显微外科手术治疗。当IV、V级动脉瘤出血形成血肿脑疝时,应采用显微外科手术治疗,并尽量缩短发生脑疝距离手术的时间,如根据出血可判断动脉瘤部位可直接探查手术;
3.动脉瘤在出血3-14d治疗增加死亡率和病残率,因此对于破裂动脉瘤,无论显微外科手术还是血管内治疗,治疗时机应选择在3d以内或14d以后;如需在3-14d治疗,应首选血管内治疗;
4.动脉瘤随着患者年龄的增长,功能障碍增多,手术风险增大,特别是60岁以上年龄组,应首选血管内治疗;
5.动脉瘤大小影响治疗方法的选择,在条件具备的条件下大行动脉瘤应首选血管内治疗,风险性小,成功率高。颅内支架治疗微小动脉瘤具有潜在的优势;
6.动脉瘤在不同部位选择治疗方法存在差异,即在大脑中动脉瘤应采用显微外科手术为佳,其他部位采用血管内治疗为佳,
7.多发动脉瘤和未破裂应首选血管内治疗;
8.后循环远端动脉瘤应用液态非粘附材料血管内治疗有独特的优势;
9.无论显微外科还是血管内治疗,均无法完全避免血管痉挛及缺血性损害的发生,并且发生率与治疗方法无明确相关,应在术后积极进行抗血管痉挛的治疗;应根据患者年龄、临床分级、动脉瘤部位、形态学特点和医院、医生经验等综合因素选择治疗策略,必要时联合两种治疗手段。
目的
分析应用国产血卟啉衍生物(Hematoporphyrin Derivative,HpD)的光动力学疗法(Photodynamic Therapy,PDT)对裸鼠皮下C6胶质瘤细胞的杀伤效应,观察血管内皮细胞生长因子(vascular endothelial growth factor , VEGF)的变化情况,探讨血管生成在PDT治疗后在肿瘤复发中可能起的作用,为临床PDT联合抗血管生成治疗脑胶质瘤提供实验基础。
方法
大鼠C6胶质瘤细胞常规体外培养后,进行C6胶质瘤的裸鼠皮下移植,于l5d时取出肿瘤制成1×1×lmm3大小的组织块,分别接种于裸小鼠的四个部位(双侧腋窝和腹股沟皮下)。待肿瘤大直径长至7mm左右开始PDT治疗,每小组裸小鼠都以同侧治疗,对侧作为对照。使用Lumacare-051光动力学治疗仪在波长628 nm、照光强度20 mW/cm2、照光时间5 min条件下,给与不同的HpD浓度(5 mg/kg、10 mg/kg、20 mg/kg和30 mg/kg)进行PDT治疗。测定肿瘤体积并计算抑瘤率,然后处死裸鼠行HE染色组织病理观察,TUNEL法检测不同HpD浓度组C6胶质瘤细胞经PDT治疗后的细胞凋亡率,采用Sp法进行免疫组织化学染色检查经PDT治疗后VEGF蛋白含量及变化。
结果
1.C6胶质瘤裸鼠皮下移植瘤各治疗组的对侧对照肿瘤体积逐渐增大;经不同浓度PDT治疗的各组肿瘤在第2-3天明显增大,3天后出现瘤区皮下出血,在3-10天治疗组肿瘤无明显增大,10天时与对照组相比抑瘤明显。镜下可见治疗组肿瘤细胞死亡及间质内陈旧性出血。
2.VEGF蛋白表达结果免疫组化检查裸小鼠皮下移植瘤组织可见呈较弥散的VEGF表达,呈阳性。阳性反应位于瘤细胞胞质,部分位于血管。单纯光照射对照组与加药后对照组VEGF表达无差异。在HpD治疗组VEGF在治疗后1天达到表达的高峰(图1,2),治疗组与各自对照组间差异显著(P<0.01),在3天时表达明显降低与对照组差异不明显。并且HpD 5mg/kg组与10mg/kg、20mg/kg、30mg/kg组只在治疗后1天存在组间差异(P<0.01),而HpD 10mg/kg、20mg/kg、30mg/kg组间VEGF表达差异不明显(P>0.05)。
3.TUNEL测定细胞凋亡率:HpD 5mg/kg、10mg/kg、20mg/kg与30mg/kg浓度组C6胶质瘤裸鼠皮下移植瘤经PDT后TUNEL染色可见:部分细胞出现细胞缩小、染色质边集呈新月形、分叶状及不规则形、凋亡小体形成、细胞核内棕黄色颗粒等改变,凋亡率为35.5%,52.8%,56.4%,63.2%。只加光敏剂不照光的C6胶质瘤细胞经TUNEL染色后可见细胞形态良好,有极少量凋亡样细胞存在。
结论
1、PDT在裸鼠皮下移植瘤模型中对C6胶质瘤细胞有明确杀伤效应;
2、PDT能够引起C6胶质瘤细胞出现细胞凋亡,并且与HPD的浓度相关。
3、裸鼠皮下移植瘤模型中对C6胶质瘤经PDT治疗后在24小时后出现VEGF蛋白表达高峰,3天后VEGF蛋白表达减少与对照组无差异。PDT治疗杀伤胶质瘤后的VEGF的表达,可能有肿瘤自我保护的作用,可能是肿瘤复发的关键因素。
Objective: To investigate the factors influenced decision-making in the treatment of intracranial aneurysms, indication of microsurgery and endovascular therapy, security, and the relevant factors to the prognosis for aneurysmal subarachnoid hemorrhage patients within the clinical treatment.
Methods: We retrospectively analysis 1537 intracranial aneurysm patients of the General Hospital of Shenyang Military and the Southwest Hospital of the Third Military Medical University from January 2000 to December 2007, 659 cases of male, 878 cases of female, aged 17-84 years old , the average age of 60.8 years old. Preoperative Hunt-Hess grade 0 22 cases, grade I 207 cases, 437 cases of grade II and grade III 760 cases, 76 cases of grade IV, V-35 cases. 377 cases have a history of hypertension, 221 patients with a history of diabetes, 17 patients with cerebral infarction. CT scans were performed before patients were admitted to hospital, 1515 patients with acute severe headache or lumbar puncture confirmed subarachnoid hemorrhage, which Fisher grade I-36 cases, Fisher grade II-397 cases, 891 cases of Fisher grade III, Fisher grade IV - 213 cases. The 1532 patients performed routine cerebral vascular angiography, three-dimensional reconstruction clear parallel aneurysm and the parent artery and its branches in 3D space relations. All data were reviewed by experienced neurosurgeons and interventional neuroradiology doctors, the treatment plan was decided according to aneurysm shape, location and clinical status, with patients and their families willings. Of whom 621 patients were treated with endovascular therapy,893 patients were treated with microsurgery,23 patients underwent expectant treatment. Three cases of ipsilateral series of multiple aneurysms and one case of CT and angiography to determine the responsibility of the bilateral lesions of the posterior communicating artery with the same period a microsurgical clipping of aneurysms, and the remaining Surgical Treatment of patients with lesions responsibility. In endovascular treatment group: narrow-necked aneurysms using simple micro-coil embolization, a wide-necked aneurysm stent-assisted coil embolization, balloon-assisted coil embolization alone stent forming part of multiple cases of aneurysm embolization over the same period; 27 conservative routine (non) treatment (due to the economic, technical, risk and other reasons). Follow-up modified Rankin score, rebleeding rate, 48 cases of micro-surgery patients and 35 patients in the treatment of patients with vascular review cerebral angiography.Mortality, morbidity, recurrence rate and rebleeding rate were concerned.
RESULTS: In patients treated with endovascular therapy, 589 patients received good recovery(modified Rankin score 0-2),22patients received dysfunction (modified Rankin score 3-5),10 patients died. In patients treated with microsurgery, 796 patients received good recovery(Rankin score 0-2),61 patients received bad recovery(Rankin score 3-5),32 patients died. 11 patients died of rebleeding in expectant treatment group. 349 cases of endovascular treatment group were followed-up with 7 cases of rebleeding (Cerebral angiography revealed that four cases of aneurysms after embolization recurrence, two cases to other parts of the aneurysm, one case of unknown cause); 571 cases of patients Microsurgery were followed-up, nine cases of rebleeding (cerebral angiography showed that after seven cases of aneurysm recurrence, two cases to other parts of the aneurysm). Microsurgery 48 cases of patients performed cerebral angiography review (6 m ~ 3Y), revealed that two cases of residual neck, one case of recurrent aneurysms; 35 cases of endovascular treatment group followed up with cerebral angiography (6 m ~ 27m), indicating that further aneurysm - 4 cases.
Conclusion:
1. Most of the intracranial aneurysms were suitable to both microsurgery and endovascular therapy. The prognosis is better in Endovascular Therapy than microsurgery. Endovascular therapy should be the first choice in most of intracranial aneurysms.
2. The prognosis become worse in high grade aneurysms, especially in patients older than 60 years old,endovascular therapy is better than microsurgery in old patients,it should be the first choice. In high grade patients with cerebral hernia,microsurgery should be the first choice, and surgery should be performed as soon as ossible.
3. The prognosis is worse in patients who were treated 0-14 days after SAH either microsurgery or endovascular therapy, treatment should be performed in 3 days or 14 days later after SAH. When a patient need to be treated in 3-14 days after SAH,endovascular therapy should be the first choice.
4. Age is a important factor in the choice of treatment methods,the prognosis would be worse in elder patients,endovascular therapy should be the first choice in patients older than 60.
5. The size of aneurysms also influenced treatment choice,endovascular therapy should be the first choice in giant intracranial aneurysm;intracranial stent has potential superiority in small aneurysms;
6. The location is also important,middle cerebral aneurysms should be treated with microsurgery,endovascular therapy should be the first choice in other locations.
7. Multiple aneurysms and unruptured aneurysms should be treated with endovascular therapy;
8. Onyx has superiority in the treatment of aneurysms located in distal posterior circulation .
9. Neither microsurgery nor endovascular therapy can avoid vasospasm and ischemic disease,and the occurrence has nothing with the method of treatment,anti-spasm treatment should be performed as soon as possible;
10. Clinical decision should be made according to aneurysm location, shape, size aneurysm, clinical grade, whether or not the merger aneurysm thrombosis, calcification, narrow, whether involved or branch perforator blood vessels, aneurysms and multiple single and doctors experience a variety of factors to consider Individualized treatment options.
Objectives: To evaluate the effect of hepatoprophyrin derivative(HpD) mediated photodynamic therapy (PDT) on the expression change of vascular endothelial growth factors(VEGF) in C6 gliomas of nude mice so as to discuss the meaning of neovascularization after PDT and provide the further evidence for the clinical application.
Methods: The suspension of C6 glioma cells was injected into subcutaneousness of the nude mice, after 15 days the glioma was took out and divided into1×1×lmm3 which was implanted in double armpit and groin subcutaneousness of the nude mice. When the volume of implantation tumor was grown to 5-7 mm, the implantation tumors in one side of the nude mice were begun to PDT(HpD), and all of the contralateral implantation tumors were set up as control groups. C6 glioma cells were irradiated by Lumacare-051 irradiator at 628 nm, 20 mW/cm2 for 5 min afrer being given different concentration of HpD (5, 10, 20 and 30 mg/kg) respectively.The tumor suppressive rate was calculated and HE staining were observed after the nude mice sacrificed. Apoptosis of C6 glioma cells were detected by terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) assay in differernt groups. VEGF was observed by immunohistostaining.
Results:
1. The tumor volume of therapy group was obviously increased in 2-3 days and has a slight change in 3-10 days after PDT. The control group has a stabile increase after PDT. Subcutaneousness hemorrhage could be examined in the therapy group at PDT 3 days.
2. The expression of VEGF which reached the peak in C6 gliomas in 5 mg/kg group 24 hours after PDT was significantly higher than that in the control group 1,3,7 and 10 days after the treatment and in 5 mg/kg group3,7 and 10 days after PDT(P<0.01).The expression of VEGF which also reached the peak in the other dose groups 24 hours after PDT was insignicantly higher than that 3,7 and 10 days after PDT(P>0.05).
3. TUNEL detection showed: Some rather typical apoptotic cells(cell shrinkage, Butty granulas in cell nucleus, chromatin margination as luniform、lubiform as well as irregular shape, apoptotic bodies formation and so on) were observed in all grops with a proportionate of 33.5%, 52.8%, 56.4% and 63.2% in different concentration of HpD (5, 10, 20 and 30 mg/kg) group respectively . No obvious morphologic changes of the C6 glioma cells was found in the control group.
Conclusions:
1. HpD-PDT has lethal effective on C6 glioma cells, and this effect was correlated with the concentration of HpD.
2.The peak of VEGF expression is reached 24 hours afeter PDT,the expression of VEGF may have self-protect function and play important point in tumor recurrence.
3. Anti-neovascularization therapy may enganced the effect of PDT, Anti-neovascularization cooperate with PDT in cure glioma may become a new strategy of anti-glioma therapy.
方法:回顾性分析了沈阳军区总医院和第三军医大学西南医院自2000年1月至2007年12月收治的1537例颅内动脉瘤病例,男性659例,女性878例,年龄17-84岁,平均年龄60.8岁。术前Hunt-Hess分级0级22例,I级207例,II级437例,III级760例,IV级76例,V级35例。377例有高血压病史,221例有糖尿病病史,17例合并脑梗塞。所有患者入院前均行CT检查,1515急性剧烈头痛患者行CT检查或腰穿证实为蛛网膜下腔出血,其中Fisher I级36例,Fisher II级397例,Fisher III级891例,Fisher IV级213例。本组患者1532例行全脑血管连续造影术,并行三维重建明确动脉瘤与载瘤动脉及其分支空间三维关系。所有患者均经有经验的神经外科医生和神经介入医生阅片,根据动脉瘤形态、部位及患者临床状态,并与患者家属及本人交流共同制定治疗计划。本组889例患者采用显微外科手术治疗处理责任病灶,另外3例同侧串联性多发动脉瘤和1例CT及造影无法判断责任病灶的双侧后交通动脉瘤患者同期采用显微外科夹闭动脉瘤,共夹闭893例动脉瘤。621例行血管内治疗:窄颈动脉瘤采用单纯微弹簧圈栓塞,宽颈动脉瘤采用支架辅助微弹簧圈栓塞、球囊辅助微弹簧圈栓塞、单纯支架成形,其中部分多发动脉瘤病例同期栓塞所有动脉瘤;23例行保守(未)治疗(由于经济、技术、风险等原因)。术后随访改良Rankin评分、再出血率,48例显微外科手术患者和35例血管内治疗患者复查脑血管造影。
结果:血管内治疗组术后恢复良好(改良Rankin评分0-2分)589例,功能障碍(改良Rankin评分3-5分)22例,死亡10例;显微外科手术组恢复良好(改良Rankin评分0-2分)796例,功能障碍(改良Rankin评分3-5分)61例,死亡32例。随访血管内治疗组患者349例,再出血7例(脑血管造影显示4例栓塞后动脉瘤复发,2例其他部位再发动脉瘤,1例原因不明);随访显微外科手术组患者571例,再出血9例(脑血管造影显示7例术后动脉瘤复发,2例其他部位再发动脉瘤)。48例显微外科手术患者复查脑血管造影(6m～3Y),显示瘤颈残留2例,动脉瘤复发1例;35例血管内治疗患者复查脑血管造影(6m～27m),显示动脉瘤再通4例。27例未治疗患者中11例因再出血死亡(2w～7m)。
结论:
1.大部分动脉瘤同时适合显微外科手术和血管内治疗,血管内治疗动脉瘤总体上预后优于显微外科手术,在动脉瘤患者既适合血管内治疗又适合显微外科手术时,应首选血管内治疗;
2.动脉瘤在手术后随病情的等级升级,功能障碍比率增大,死亡率提高,风险性较大。但在同等级情况下,血管内治疗优越于显微外科手术治疗。当IV、V级动脉瘤出血形成血肿脑疝时,应采用显微外科手术治疗,并尽量缩短发生脑疝距离手术的时间,如根据出血可判断动脉瘤部位可直接探查手术;
3.动脉瘤在出血3-14d治疗增加死亡率和病残率,因此对于破裂动脉瘤,无论显微外科手术还是血管内治疗,治疗时机应选择在3d以内或14d以后;如需在3-14d治疗,应首选血管内治疗;
4.动脉瘤随着患者年龄的增长,功能障碍增多,手术风险增大,特别是60岁以上年龄组,应首选血管内治疗;
5.动脉瘤大小影响治疗方法的选择,在条件具备的条件下大行动脉瘤应首选血管内治疗,风险性小,成功率高。颅内支架治疗微小动脉瘤具有潜在的优势;
6.动脉瘤在不同部位选择治疗方法存在差异,即在大脑中动脉瘤应采用显微外科手术为佳,其他部位采用血管内治疗为佳,
7.多发动脉瘤和未破裂应首选血管内治疗;
8.后循环远端动脉瘤应用液态非粘附材料血管内治疗有独特的优势;
9.无论显微外科还是血管内治疗,均无法完全避免血管痉挛及缺血性损害的发生,并且发生率与治疗方法无明确相关,应在术后积极进行抗血管痉挛的治疗;应根据患者年龄、临床分级、动脉瘤部位、形态学特点和医院、医生经验等综合因素选择治疗策略,必要时联合两种治疗手段。
目的
分析应用国产血卟啉衍生物(Hematoporphyrin Derivative,HpD)的光动力学疗法(Photodynamic Therapy,PDT)对裸鼠皮下C6胶质瘤细胞的杀伤效应,观察血管内皮细胞生长因子(vascular endothelial growth factor , VEGF)的变化情况,探讨血管生成在PDT治疗后在肿瘤复发中可能起的作用,为临床PDT联合抗血管生成治疗脑胶质瘤提供实验基础。
方法
大鼠C6胶质瘤细胞常规体外培养后,进行C6胶质瘤的裸鼠皮下移植,于l5d时取出肿瘤制成1×1×lmm3大小的组织块,分别接种于裸小鼠的四个部位(双侧腋窝和腹股沟皮下)。待肿瘤大直径长至7mm左右开始PDT治疗,每小组裸小鼠都以同侧治疗,对侧作为对照。使用Lumacare-051光动力学治疗仪在波长628 nm、照光强度20 mW/cm2、照光时间5 min条件下,给与不同的HpD浓度(5 mg/kg、10 mg/kg、20 mg/kg和30 mg/kg)进行PDT治疗。测定肿瘤体积并计算抑瘤率,然后处死裸鼠行HE染色组织病理观察,TUNEL法检测不同HpD浓度组C6胶质瘤细胞经PDT治疗后的细胞凋亡率,采用Sp法进行免疫组织化学染色检查经PDT治疗后VEGF蛋白含量及变化。
结果
1.C6胶质瘤裸鼠皮下移植瘤各治疗组的对侧对照肿瘤体积逐渐增大;经不同浓度PDT治疗的各组肿瘤在第2-3天明显增大,3天后出现瘤区皮下出血,在3-10天治疗组肿瘤无明显增大,10天时与对照组相比抑瘤明显。镜下可见治疗组肿瘤细胞死亡及间质内陈旧性出血。
2.VEGF蛋白表达结果免疫组化检查裸小鼠皮下移植瘤组织可见呈较弥散的VEGF表达,呈阳性。阳性反应位于瘤细胞胞质,部分位于血管。单纯光照射对照组与加药后对照组VEGF表达无差异。在HpD治疗组VEGF在治疗后1天达到表达的高峰(图1,2),治疗组与各自对照组间差异显著(P<0.01),在3天时表达明显降低与对照组差异不明显。并且HpD 5mg/kg组与10mg/kg、20mg/kg、30mg/kg组只在治疗后1天存在组间差异(P<0.01),而HpD 10mg/kg、20mg/kg、30mg/kg组间VEGF表达差异不明显(P>0.05)。
3.TUNEL测定细胞凋亡率:HpD 5mg/kg、10mg/kg、20mg/kg与30mg/kg浓度组C6胶质瘤裸鼠皮下移植瘤经PDT后TUNEL染色可见:部分细胞出现细胞缩小、染色质边集呈新月形、分叶状及不规则形、凋亡小体形成、细胞核内棕黄色颗粒等改变,凋亡率为35.5%,52.8%,56.4%,63.2%。只加光敏剂不照光的C6胶质瘤细胞经TUNEL染色后可见细胞形态良好,有极少量凋亡样细胞存在。
结论
1、PDT在裸鼠皮下移植瘤模型中对C6胶质瘤细胞有明确杀伤效应;
2、PDT能够引起C6胶质瘤细胞出现细胞凋亡,并且与HPD的浓度相关。
3、裸鼠皮下移植瘤模型中对C6胶质瘤经PDT治疗后在24小时后出现VEGF蛋白表达高峰,3天后VEGF蛋白表达减少与对照组无差异。PDT治疗杀伤胶质瘤后的VEGF的表达,可能有肿瘤自我保护的作用,可能是肿瘤复发的关键因素。
Objective: To investigate the factors influenced decision-making in the treatment of intracranial aneurysms, indication of microsurgery and endovascular therapy, security, and the relevant factors to the prognosis for aneurysmal subarachnoid hemorrhage patients within the clinical treatment.
Methods: We retrospectively analysis 1537 intracranial aneurysm patients of the General Hospital of Shenyang Military and the Southwest Hospital of the Third Military Medical University from January 2000 to December 2007, 659 cases of male, 878 cases of female, aged 17-84 years old , the average age of 60.8 years old. Preoperative Hunt-Hess grade 0 22 cases, grade I 207 cases, 437 cases of grade II and grade III 760 cases, 76 cases of grade IV, V-35 cases. 377 cases have a history of hypertension, 221 patients with a history of diabetes, 17 patients with cerebral infarction. CT scans were performed before patients were admitted to hospital, 1515 patients with acute severe headache or lumbar puncture confirmed subarachnoid hemorrhage, which Fisher grade I-36 cases, Fisher grade II-397 cases, 891 cases of Fisher grade III, Fisher grade IV - 213 cases. The 1532 patients performed routine cerebral vascular angiography, three-dimensional reconstruction clear parallel aneurysm and the parent artery and its branches in 3D space relations. All data were reviewed by experienced neurosurgeons and interventional neuroradiology doctors, the treatment plan was decided according to aneurysm shape, location and clinical status, with patients and their families willings. Of whom 621 patients were treated with endovascular therapy,893 patients were treated with microsurgery,23 patients underwent expectant treatment. Three cases of ipsilateral series of multiple aneurysms and one case of CT and angiography to determine the responsibility of the bilateral lesions of the posterior communicating artery with the same period a microsurgical clipping of aneurysms, and the remaining Surgical Treatment of patients with lesions responsibility. In endovascular treatment group: narrow-necked aneurysms using simple micro-coil embolization, a wide-necked aneurysm stent-assisted coil embolization, balloon-assisted coil embolization alone stent forming part of multiple cases of aneurysm embolization over the same period; 27 conservative routine (non) treatment (due to the economic, technical, risk and other reasons). Follow-up modified Rankin score, rebleeding rate, 48 cases of micro-surgery patients and 35 patients in the treatment of patients with vascular review cerebral angiography.Mortality, morbidity, recurrence rate and rebleeding rate were concerned.
RESULTS: In patients treated with endovascular therapy, 589 patients received good recovery(modified Rankin score 0-2),22patients received dysfunction (modified Rankin score 3-5),10 patients died. In patients treated with microsurgery, 796 patients received good recovery(Rankin score 0-2),61 patients received bad recovery(Rankin score 3-5),32 patients died. 11 patients died of rebleeding in expectant treatment group. 349 cases of endovascular treatment group were followed-up with 7 cases of rebleeding (Cerebral angiography revealed that four cases of aneurysms after embolization recurrence, two cases to other parts of the aneurysm, one case of unknown cause); 571 cases of patients Microsurgery were followed-up, nine cases of rebleeding (cerebral angiography showed that after seven cases of aneurysm recurrence, two cases to other parts of the aneurysm). Microsurgery 48 cases of patients performed cerebral angiography review (6 m ~ 3Y), revealed that two cases of residual neck, one case of recurrent aneurysms; 35 cases of endovascular treatment group followed up with cerebral angiography (6 m ~ 27m), indicating that further aneurysm - 4 cases.
Conclusion:
1. Most of the intracranial aneurysms were suitable to both microsurgery and endovascular therapy. The prognosis is better in Endovascular Therapy than microsurgery. Endovascular therapy should be the first choice in most of intracranial aneurysms.
2. The prognosis become worse in high grade aneurysms, especially in patients older than 60 years old,endovascular therapy is better than microsurgery in old patients,it should be the first choice. In high grade patients with cerebral hernia,microsurgery should be the first choice, and surgery should be performed as soon as ossible.
3. The prognosis is worse in patients who were treated 0-14 days after SAH either microsurgery or endovascular therapy, treatment should be performed in 3 days or 14 days later after SAH. When a patient need to be treated in 3-14 days after SAH,endovascular therapy should be the first choice.
4. Age is a important factor in the choice of treatment methods,the prognosis would be worse in elder patients,endovascular therapy should be the first choice in patients older than 60.
5. The size of aneurysms also influenced treatment choice,endovascular therapy should be the first choice in giant intracranial aneurysm;intracranial stent has potential superiority in small aneurysms;
6. The location is also important,middle cerebral aneurysms should be treated with microsurgery,endovascular therapy should be the first choice in other locations.
7. Multiple aneurysms and unruptured aneurysms should be treated with endovascular therapy;
8. Onyx has superiority in the treatment of aneurysms located in distal posterior circulation .
9. Neither microsurgery nor endovascular therapy can avoid vasospasm and ischemic disease,and the occurrence has nothing with the method of treatment,anti-spasm treatment should be performed as soon as possible;
10. Clinical decision should be made according to aneurysm location, shape, size aneurysm, clinical grade, whether or not the merger aneurysm thrombosis, calcification, narrow, whether involved or branch perforator blood vessels, aneurysms and multiple single and doctors experience a variety of factors to consider Individualized treatment options.
Objectives: To evaluate the effect of hepatoprophyrin derivative(HpD) mediated photodynamic therapy (PDT) on the expression change of vascular endothelial growth factors(VEGF) in C6 gliomas of nude mice so as to discuss the meaning of neovascularization after PDT and provide the further evidence for the clinical application.
Methods: The suspension of C6 glioma cells was injected into subcutaneousness of the nude mice, after 15 days the glioma was took out and divided into1×1×lmm3 which was implanted in double armpit and groin subcutaneousness of the nude mice. When the volume of implantation tumor was grown to 5-7 mm, the implantation tumors in one side of the nude mice were begun to PDT(HpD), and all of the contralateral implantation tumors were set up as control groups. C6 glioma cells were irradiated by Lumacare-051 irradiator at 628 nm, 20 mW/cm2 for 5 min afrer being given different concentration of HpD (5, 10, 20 and 30 mg/kg) respectively.The tumor suppressive rate was calculated and HE staining were observed after the nude mice sacrificed. Apoptosis of C6 glioma cells were detected by terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) assay in differernt groups. VEGF was observed by immunohistostaining.
Results:
1. The tumor volume of therapy group was obviously increased in 2-3 days and has a slight change in 3-10 days after PDT. The control group has a stabile increase after PDT. Subcutaneousness hemorrhage could be examined in the therapy group at PDT 3 days.
2. The expression of VEGF which reached the peak in C6 gliomas in 5 mg/kg group 24 hours after PDT was significantly higher than that in the control group 1,3,7 and 10 days after the treatment and in 5 mg/kg group3,7 and 10 days after PDT(P<0.01).The expression of VEGF which also reached the peak in the other dose groups 24 hours after PDT was insignicantly higher than that 3,7 and 10 days after PDT(P>0.05).
3. TUNEL detection showed: Some rather typical apoptotic cells(cell shrinkage, Butty granulas in cell nucleus, chromatin margination as luniform、lubiform as well as irregular shape, apoptotic bodies formation and so on) were observed in all grops with a proportionate of 33.5%, 52.8%, 56.4% and 63.2% in different concentration of HpD (5, 10, 20 and 30 mg/kg) group respectively . No obvious morphologic changes of the C6 glioma cells was found in the control group.
Conclusions:
1. HpD-PDT has lethal effective on C6 glioma cells, and this effect was correlated with the concentration of HpD.
2.The peak of VEGF expression is reached 24 hours afeter PDT,the expression of VEGF may have self-protect function and play important point in tumor recurrence.
3. Anti-neovascularization therapy may enganced the effect of PDT, Anti-neovascularization cooperate with PDT in cure glioma may become a new strategy of anti-glioma therapy.
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