血管内介入治疗周围型颅内动脉瘤17例
|
摘要
目的报道血管内介入治疗周围型颅内动脉瘤的效果和临床经验,探讨介入治疗策略。方法 2010年1月至2015年12月采用血管内介入术治疗17例周围型颅内动脉瘤(男7例,女10例,平均年龄52.1岁),1例为偶然发现的血流相关性动脉瘤,16例为蛛网膜下腔出血,其中3例伴有脑实质内血肿,1例伴发脑室内出血,1例为偶然发现的其它部位动脉瘤破裂。动脉瘤位于小脑上动脉1例,脉络膜前动脉1例,大脑前动脉8例,小脑后下动脉4例,大脑后动脉3例。囊性动脉瘤9例,夹层动脉瘤7例,假性动脉瘤1例。所有动脉瘤均为小动脉瘤,2例梭形夹层动脉瘤缺乏明确瘤颈,15例为窄颈,其中5例体-颈比≤2,10例体-颈比>2。结果血管内介入治疗技术成功率为100%。术后即刻,11例弹簧圈栓塞患者中7例囊状动脉瘤完全闭塞,1例囊状动脉瘤和2例夹层囊状动脉瘤不全闭塞,1例夹层囊状动脉瘤瘤颈残留;6例动脉瘤和载瘤动脉同时栓塞患者中5例完全闭塞,1例不全闭塞、载瘤动脉部分闭塞。术后3例出现神经功能缺损,其他患者无新发神经功能缺损。出院时改良Rankin量表(m RS)评分为0分14例,2分1例,4分2例。术后6~9个月血管造影和临床随访显示,11例弹簧圈栓塞患者中7例动脉瘤仍保持完全闭塞,3例不全闭塞,1例瘤颈残留患者复发;6例动脉瘤和载瘤动脉同时栓塞患者中5例动脉瘤仍保持完全闭塞,1例载瘤动脉再通。末次随访显示14例保持m RS评分0分,1例保持4分不变,2例m RS评分有明显改善。结论对于外科手术治疗较困难的周围型颅内动脉瘤,血管内介入治疗是一种安全有效的治疗方法。选择何种血管内介入治疗策略取决于动脉瘤部位、性质、形态、血管入路迂曲程度和载瘤动脉供血区功能重要程度。
Objective To report the clinical results and the experience of endovascular treatment(EVT) for peripheral intracranial aneurysms(IAs) in 17 patients, and to discuss the interventional therapeutic strategy for peripheral IAs. Methods During the period from January 2010 to December 2015, a total of 17 patients with peripheral IAs were treated with EVT at authors' hospital. The patients included 7 males and 10 females with a mean age of 52.1 years. Peripheral IA was an accidental discovery as a blood flow-related aneurysm in one patient and was characterized by subarachnoid hemorrhage(SAH) in 16 patients, among whom concurrent intracerebral hematoma was found in 3, concurrent intraventricular hemorrhage was detected in one, and in another one the aneurysm was an accidental finding because of ruptured aneurysm located at other site. The peripheral IAs were located at superior cerebellar artery(n=1), anterior choroidal artery(n=1), anterior cerebral artery(n=8), posterior inferior cerebellar artery(n=4) and posterior cerebral artery(n =3). Pathologically, cystic aneurysm was seen in 9 patients, dissecting aneurysm was detected in 7 patients and false aneurysm was observed in one patient. All the 17 aneurysms were small in size; two fusiform dissecting aneurysms were lack of clear an eurysm neck; in 15 patients the aneurysm had a narrow neck, among which the dome-to-neck ratio was ≤2 in 5 and was >2 in 10. Results The technical success rate of EVT was 100%. Of the 11 patients who received spring coil embolization, complete occlusion of aneurysm was achieved immediately after the procedure in 7 patients with saccular aneurysms, incomplete occlusion of aneurysm was obtained in one patient with saccular aneurysm and two patients with dissecting saccular aneurysm, and residual neck was seen in one patient with dissecting saccular aneurysm. Of the 6patients whose aneurysm and parent artery were simultaneously embolized, complete occlusion of aneurysm was achieved in 5 and incomplete occlusion of aneurysm with partial occlusion of parent artery in one. After the embolization, three patients developed nerve function defect, while no newly-developed nerve function defect was observed in the other patients. At the time of discharge, the modified Rankin scale(m RS) score was 0 point in 14 patients, 2 points in one patient and 4 points in 2 patients. Follow-up angiography performed at 6-9 months after treatment revealed that among the 11 patients who received spring coil embolization, the aneurysm was still completely obstructed in 7, incomplete occlusion in 3 and aneurysm recurrence in one who had residual neck. Of the 6 patients whose aneurysm and parent artery were simultaneously embolized, the aneurysm remained totally occluded in 5 and re-canalization of parent artery was seen in one. The last followup examination showed that m RS score remained 0 point in 14 patients and 4 points in one patient, and in other two patients the m RS score was obviously improved. Conclusion For the treatment of peripheral IAs that are difficult to be treated with surgery, EVT is safe and effective. The selection of endovascular interventional treatment strategy depends on the location, nature and form of the aneurysm, as well as on the tortuosity degree of vascular path and the important degree of brain function area that gets blood supply from parent artery.
Objective To report the clinical results and the experience of endovascular treatment(EVT) for peripheral intracranial aneurysms(IAs) in 17 patients, and to discuss the interventional therapeutic strategy for peripheral IAs. Methods During the period from January 2010 to December 2015, a total of 17 patients with peripheral IAs were treated with EVT at authors' hospital. The patients included 7 males and 10 females with a mean age of 52.1 years. Peripheral IA was an accidental discovery as a blood flow-related aneurysm in one patient and was characterized by subarachnoid hemorrhage(SAH) in 16 patients, among whom concurrent intracerebral hematoma was found in 3, concurrent intraventricular hemorrhage was detected in one, and in another one the aneurysm was an accidental finding because of ruptured aneurysm located at other site. The peripheral IAs were located at superior cerebellar artery(n=1), anterior choroidal artery(n=1), anterior cerebral artery(n=8), posterior inferior cerebellar artery(n=4) and posterior cerebral artery(n =3). Pathologically, cystic aneurysm was seen in 9 patients, dissecting aneurysm was detected in 7 patients and false aneurysm was observed in one patient. All the 17 aneurysms were small in size; two fusiform dissecting aneurysms were lack of clear an eurysm neck; in 15 patients the aneurysm had a narrow neck, among which the dome-to-neck ratio was ≤2 in 5 and was >2 in 10. Results The technical success rate of EVT was 100%. Of the 11 patients who received spring coil embolization, complete occlusion of aneurysm was achieved immediately after the procedure in 7 patients with saccular aneurysms, incomplete occlusion of aneurysm was obtained in one patient with saccular aneurysm and two patients with dissecting saccular aneurysm, and residual neck was seen in one patient with dissecting saccular aneurysm. Of the 6patients whose aneurysm and parent artery were simultaneously embolized, complete occlusion of aneurysm was achieved in 5 and incomplete occlusion of aneurysm with partial occlusion of parent artery in one. After the embolization, three patients developed nerve function defect, while no newly-developed nerve function defect was observed in the other patients. At the time of discharge, the modified Rankin scale(m RS) score was 0 point in 14 patients, 2 points in one patient and 4 points in 2 patients. Follow-up angiography performed at 6-9 months after treatment revealed that among the 11 patients who received spring coil embolization, the aneurysm was still completely obstructed in 7, incomplete occlusion in 3 and aneurysm recurrence in one who had residual neck. Of the 6 patients whose aneurysm and parent artery were simultaneously embolized, the aneurysm remained totally occluded in 5 and re-canalization of parent artery was seen in one. The last followup examination showed that m RS score remained 0 point in 14 patients and 4 points in one patient, and in other two patients the m RS score was obviously improved. Conclusion For the treatment of peripheral IAs that are difficult to be treated with surgery, EVT is safe and effective. The selection of endovascular interventional treatment strategy depends on the location, nature and form of the aneurysm, as well as on the tortuosity degree of vascular path and the important degree of brain function area that gets blood supply from parent artery.
引文
[1]Nussbaum ES,Madison MT,Goddard JK,et al.Peripheral intracranial aneurysms:management challenges in 60 consecutive cases[J].J Neurosurg,2009,110:7-13.
[2]Lubicz B,Leclerc X,Gauvrit JY,et al.Endovascular treatment of peripheral cerebellar artery aneurysms[J].AJNR Am J Neuroradiol,2003,24:1208-1213.
[3]Puri AS,Massari F,Hou SY,et al.Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms[J].J Neurointerv Surg,2015,pii:neurintsurg-2014-011622.
[4]Chalouhi N,Tjoumakaris S,Gonzalez LF,et al.Endovascular treatment of distal intracranial aneurysms with onyx 18/34[J].Clin Neurol Neurosurg,2013,115:2528-2532.
[5]Saravanan M,Clifton A,Johnson D.Onyx embolization of distal aneurysms of the posterior circulation[J].AJNR Am J Neuroradiol,2009,30:e69.
[6]Wu Q,Wang HD,Zhang QR,et al.Parent artery occlusion with Onyx for distal aneurysms of posterior inferior cerebellar artery:a single-centre experience in a series of 15 patients[J].Neurol India,2013,61:265-269.
[7]Li H,Li XF,He XY,et al.Endovascular treatment of dissecting aneurysms of the posterior inferior cerebellar artery and predictors of outcome[J].J Stroke Cerebrovasc Dis,2015,24:2134-2142.
[8]Bradac GB,Bergui M.Endovascular treatment of the posterior inferior cerebellar artery aneurysms[J].Neuroradiology,2004,46:1006-1011.
[9]Eckard DA,O’boynick PL,Mc Pherson CM,et al.Coil occlusion of the parent artery for treatment of symptomatic peripheral intracranial aneurysms[J].AJNR Am J Neuroradiol,2000,21:137-142.
[10]陈左权,张桂运,顾斌贤,等.颅内后循环远端动脉瘤的介入治疗[J].中华神经外科杂志,2007,23:837-839.
[11]李吻,赵瑞,洪波,等.血管内治疗大脑后动脉动脉瘤的疗效[J].中华神经外科杂志,2015,31:436-439.
[12]纪文军,康慧斌,孙立倩,等.未破裂大脑后动脉夹层动脉瘤的血管内治疗[J].中国卒中杂志,2015,10:918-922.
[13]Andreou A,Ioannidis I,Mitsos A.Endovascular treatment of peripheral intracranial aneurysms[J].AJNR Am J Neuroradiol,2007,28:355-361.
[14]Peluso JP,van Rooij WJ,Sluzewski M,et al.Distal aneurysms of cerebellar arteries:incidence,clinical presentation,and outcome of endovascular parent vessel occlusion[J].AJNR Am J Neuroradiol,2007,28:1573-1578.
[15]Biondi A,Jean B,Vivas E,et al.Giant and large peripheral cerebral aneurysms:etiopathologic considerations,endovascular treatment,and long-term follow-up[J].AJNR Am J Neuroradiol,2006,27:1685-1692.
[16]李佑祥,刘爱华,吕明,等.大脑后动脉动脉瘤的血管内治疗[J].中华医学杂志,2006,86:2033-2036.
[17]Gao X,Liang G,Li Z,et al.Intra-aneurysmal onyx embolization for distal aneurysms of the cerebellar arteries[J].Neurol Res,2012,34:211-216.
[18]Cognard C,Weill A,Tovi M,et al.Treatment of distal aneurysms of the cerebellar arteries by intraaneurysmal injection of glue[J].AJNR Am J Neuroradiol,1999,20:780-784.
[19]Suh SH,Kim DJ,Kim DI,et al.Management of anterior inferior cerebellar artery aneurysms:endovascular treatment and clinical outcome[J].AJNR Am J Neuroradiol,2011,32:159-164.
[20]Cavalcanti DD,Abla AA,Martirosyan NL,et al.Endovascular management of distal ACA aneurysms:single-institution clinical experience in 22 consecutive patients and literature review[J].AJNR Am J Neuroradiol,2013,34:1593-1599.
[21]Waldenberger P,Petersen J,Chemelli A,et al.Endovascular therapy of distal anterior cerebral artery aneurysms:an effective treatment option[J].Surg Neurol,2008,70:368-377.
[22]Sturiale CL,Brinjikji W,Murad MH,et al.Endovascular treatment of distal anterior cerebral artery aneurysms:single-center experience and a systematic review[J].AJNR Am J Neuroradiol,2013,34:2317-2320.
[23]Vora N,Thomas AJ,Gupta R,et al.Endovascular treatment of distal anterior cerebral artery aneurysms:technical results and review of the literature[J].J Neuroimaging,2010,20:70-73.
[24]Kashiwazaki D,Ushikoshi S,Asano T,et al.Endovascular treatment for aneurysms of the posterior cerebral artery:12 years’experience with 21 cases[J].Acta Neurochir(Wien),2011,153:2151-2158.
[25]Ciceri EF,Klucznik RP,Grossman RG,et al.Aneurysms of the posterior cerebral artery:classification and endovascular treatment[J].AJNR Am J Neuroradiol,2001,22:27-34.
[2]Lubicz B,Leclerc X,Gauvrit JY,et al.Endovascular treatment of peripheral cerebellar artery aneurysms[J].AJNR Am J Neuroradiol,2003,24:1208-1213.
[3]Puri AS,Massari F,Hou SY,et al.Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms[J].J Neurointerv Surg,2015,pii:neurintsurg-2014-011622.
[4]Chalouhi N,Tjoumakaris S,Gonzalez LF,et al.Endovascular treatment of distal intracranial aneurysms with onyx 18/34[J].Clin Neurol Neurosurg,2013,115:2528-2532.
[5]Saravanan M,Clifton A,Johnson D.Onyx embolization of distal aneurysms of the posterior circulation[J].AJNR Am J Neuroradiol,2009,30:e69.
[6]Wu Q,Wang HD,Zhang QR,et al.Parent artery occlusion with Onyx for distal aneurysms of posterior inferior cerebellar artery:a single-centre experience in a series of 15 patients[J].Neurol India,2013,61:265-269.
[7]Li H,Li XF,He XY,et al.Endovascular treatment of dissecting aneurysms of the posterior inferior cerebellar artery and predictors of outcome[J].J Stroke Cerebrovasc Dis,2015,24:2134-2142.
[8]Bradac GB,Bergui M.Endovascular treatment of the posterior inferior cerebellar artery aneurysms[J].Neuroradiology,2004,46:1006-1011.
[9]Eckard DA,O’boynick PL,Mc Pherson CM,et al.Coil occlusion of the parent artery for treatment of symptomatic peripheral intracranial aneurysms[J].AJNR Am J Neuroradiol,2000,21:137-142.
[10]陈左权,张桂运,顾斌贤,等.颅内后循环远端动脉瘤的介入治疗[J].中华神经外科杂志,2007,23:837-839.
[11]李吻,赵瑞,洪波,等.血管内治疗大脑后动脉动脉瘤的疗效[J].中华神经外科杂志,2015,31:436-439.
[12]纪文军,康慧斌,孙立倩,等.未破裂大脑后动脉夹层动脉瘤的血管内治疗[J].中国卒中杂志,2015,10:918-922.
[13]Andreou A,Ioannidis I,Mitsos A.Endovascular treatment of peripheral intracranial aneurysms[J].AJNR Am J Neuroradiol,2007,28:355-361.
[14]Peluso JP,van Rooij WJ,Sluzewski M,et al.Distal aneurysms of cerebellar arteries:incidence,clinical presentation,and outcome of endovascular parent vessel occlusion[J].AJNR Am J Neuroradiol,2007,28:1573-1578.
[15]Biondi A,Jean B,Vivas E,et al.Giant and large peripheral cerebral aneurysms:etiopathologic considerations,endovascular treatment,and long-term follow-up[J].AJNR Am J Neuroradiol,2006,27:1685-1692.
[16]李佑祥,刘爱华,吕明,等.大脑后动脉动脉瘤的血管内治疗[J].中华医学杂志,2006,86:2033-2036.
[17]Gao X,Liang G,Li Z,et al.Intra-aneurysmal onyx embolization for distal aneurysms of the cerebellar arteries[J].Neurol Res,2012,34:211-216.
[18]Cognard C,Weill A,Tovi M,et al.Treatment of distal aneurysms of the cerebellar arteries by intraaneurysmal injection of glue[J].AJNR Am J Neuroradiol,1999,20:780-784.
[19]Suh SH,Kim DJ,Kim DI,et al.Management of anterior inferior cerebellar artery aneurysms:endovascular treatment and clinical outcome[J].AJNR Am J Neuroradiol,2011,32:159-164.
[20]Cavalcanti DD,Abla AA,Martirosyan NL,et al.Endovascular management of distal ACA aneurysms:single-institution clinical experience in 22 consecutive patients and literature review[J].AJNR Am J Neuroradiol,2013,34:1593-1599.
[21]Waldenberger P,Petersen J,Chemelli A,et al.Endovascular therapy of distal anterior cerebral artery aneurysms:an effective treatment option[J].Surg Neurol,2008,70:368-377.
[22]Sturiale CL,Brinjikji W,Murad MH,et al.Endovascular treatment of distal anterior cerebral artery aneurysms:single-center experience and a systematic review[J].AJNR Am J Neuroradiol,2013,34:2317-2320.
[23]Vora N,Thomas AJ,Gupta R,et al.Endovascular treatment of distal anterior cerebral artery aneurysms:technical results and review of the literature[J].J Neuroimaging,2010,20:70-73.
[24]Kashiwazaki D,Ushikoshi S,Asano T,et al.Endovascular treatment for aneurysms of the posterior cerebral artery:12 years’experience with 21 cases[J].Acta Neurochir(Wien),2011,153:2151-2158.
[25]Ciceri EF,Klucznik RP,Grossman RG,et al.Aneurysms of the posterior cerebral artery:classification and endovascular treatment[J].AJNR Am J Neuroradiol,2001,22:27-34.