CTA在大脑中动脉动脉瘤破裂伴侧裂血肿的外科治疗中的应用
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摘要
目的：探讨CTA辅助下重症大脑中动脉瘤破裂后伴发侧裂血肿的外科治疗结果。
方法：30例患者接受血肿清除术，同时行夹闭治疗、去骨瓣减压。对这种病例的治疗效果进行分析、总结
结果：预后采用KPS评分判定，随访一年。30例中KPS评分，90-100分2例、60-80分8例、40-50分10例、10-30分6例、0分4例。Hunt-HessⅣ组中18例KPS评分：90-100分2例、60-80分6例、40-50分6例、10-30分4例。Hunt-HessⅤ组中12例KPS评分：60-80分2例、40-50分4例、10-30分2例、0分（死亡）4例。
结论：对于Hunt-Hess分级Ⅳ及Ⅴ级的危重病例，积极的外科治疗可以获得较好的效果，早期手术是提高预后的关键，而头部CTA检查能在短时间内明确诊断，为治疗提供充分的影像依据。
Abstract： Objective This study was conducted to investigate the result ofmicrosurgical treatment of poor-grade ruptured middle cerebral arteryaneurysms with intrasylvian hematomas assisted by CT angiography.
Mehtods：Between Jun2008and Jun2010,30cases with poor-graderuptured middle cerebral artery aneurysms with intrasylvian hematomas weretreated under the assistance of CTA. All of the patients underwent microsugicalclipping aneurysms and decompressive craniotomy after evacuatingintrasylvian homotomas. Results of the treatment for these cases were analyzedto summarize the experience.
Results: The prognoses were assessed according to Karnofskyperformance scale (KPS) and the clinical follow-up period is1year. In30cases:2were90-100scores of KPS,8was60-80scores of KPS,10was40-50scoresof KPS,6was10-30scores of KPS,4was0score of KPS. In group Ⅳ:2were90-100scores of KPS,6were60-80scores of KPS,6was40-50scores of KPS,4was10-30scores of KPS. In groupⅤ:2was60-80scores of KPS,4was40-50scores of KPS,2was10-30scores of KPS,4was0score of KPS.
Conclusion: For ruptured middle cerebral artery aneurysms ofHunt-Hess grade Ⅳ and Ⅴ with intrasylvian hematomas. CT angiography canprovide adequate imaging information in a short time for the operation. werecommend immediate microsugical clipping aneurysms and decompressivecraniotomy after evacuating intrasylvian.
方法：30例患者接受血肿清除术，同时行夹闭治疗、去骨瓣减压。对这种病例的治疗效果进行分析、总结
结果：预后采用KPS评分判定，随访一年。30例中KPS评分，90-100分2例、60-80分8例、40-50分10例、10-30分6例、0分4例。Hunt-HessⅣ组中18例KPS评分：90-100分2例、60-80分6例、40-50分6例、10-30分4例。Hunt-HessⅤ组中12例KPS评分：60-80分2例、40-50分4例、10-30分2例、0分（死亡）4例。
结论：对于Hunt-Hess分级Ⅳ及Ⅴ级的危重病例，积极的外科治疗可以获得较好的效果，早期手术是提高预后的关键，而头部CTA检查能在短时间内明确诊断，为治疗提供充分的影像依据。
Abstract： Objective This study was conducted to investigate the result ofmicrosurgical treatment of poor-grade ruptured middle cerebral arteryaneurysms with intrasylvian hematomas assisted by CT angiography.
Mehtods：Between Jun2008and Jun2010,30cases with poor-graderuptured middle cerebral artery aneurysms with intrasylvian hematomas weretreated under the assistance of CTA. All of the patients underwent microsugicalclipping aneurysms and decompressive craniotomy after evacuatingintrasylvian homotomas. Results of the treatment for these cases were analyzedto summarize the experience.
Results: The prognoses were assessed according to Karnofskyperformance scale (KPS) and the clinical follow-up period is1year. In30cases:2were90-100scores of KPS,8was60-80scores of KPS,10was40-50scoresof KPS,6was10-30scores of KPS,4was0score of KPS. In group Ⅳ:2were90-100scores of KPS,6were60-80scores of KPS,6was40-50scores of KPS,4was10-30scores of KPS. In groupⅤ:2was60-80scores of KPS,4was40-50scores of KPS,2was10-30scores of KPS,4was0score of KPS.
Conclusion: For ruptured middle cerebral artery aneurysms ofHunt-Hess grade Ⅳ and Ⅴ with intrasylvian hematomas. CT angiography canprovide adequate imaging information in a short time for the operation. werecommend immediate microsugical clipping aneurysms and decompressivecraniotomy after evacuating intrasylvian.
引文
[1] Rinne J, Hernesniemi J, Niskanen M. Analysis of561patients with690middle cerebral artery aneurysms: anatomic and clinical features ascorrelatedto management outcome. Neurosurgery,1996,38:2-11.
[2] Prat R, Galeano I. Early surgical treatment of middle cerebral arteryaneurysms associated with intracerebral haematoma. Clin NeurolNeurosurg,2007,109(5):431-5.
[3] Gene H Barnett. High-Grade Gliomas Diagnosis and Treatment. NewJersey: Humana Press,2007,66-67.
[4] Abbed KM, Ogilvy CS. Intracerebral hematoma from aneurysm rupture.Neurosurg Focus,2003,15(4):165-8.
[5] Heiskanen O, Poranen A, Kuurne T. Acute surgery for intracerebralhaematomas caused by rupture of an intracranial arterial aneurysm. ActaNeurochir (Wien),1988,(90)81-83.
[6] Nowak G, Schwachenwald D, Schwachenwald R. Intracerebral hematomascaused by aneurysm rupture. Experience with67cases. Neurosurg Rev,1998,21(1):5-9.
[7] Velat, G.J., et al., Surgical Management of Giant Posterior CommunicatingArtery Aneurysms. Neurosurgery[J],2012.
[8] Uysal E, Yanbulo lu B, Ertürk M. Spiral CT angiography in diagnosis ofcerebral aneurysms of cases with acute subarachnoid hemorrhage. DiagnInterv Radiol,2005,11(2):77-82.
[9]郭新宾,赵丛海,田宇.去骨瓣减压术在Ⅳ、Ⅴ级动脉瘤破裂患者早期手术后的应用.中国神经医学杂志.2005,4(9):967-9.1
[10]潘先文,江晓春,李真保,等.颅内动脉瘤的显微手术治疗.中国神经医学杂志.2005,4(4):397-8.
[11]郄福忠,王智,肖玉强,等.显微神经外科手术和血管内介入治疗Ⅳ、Ⅴ级颅内动脉瘤对比研究.中国神经医学杂志.2003,4(2):155-7.
[12]丰育功,刘滨,侯晓群,等. CT在诊断动脉瘤性蛛网膜下腔出血中的临床应用研究（附140例研究报道）.中国神经医学杂志.2003,2(5):343-5.
[13] Macdonald RL. Lumbar drainage after subarachnoid hemorrhage: does itreduce vasospasm and delayed hydrocephalus?. Neurocrit Care,2007,7(1):1-2.
[14]王忠诚.脑外伤神经外科学.科技出版社,北京,1998,279-386.
[15] Baskaya MK,Menendez JA,Yuceer N,et al.Results of surgical treatment ofintrasylvian hematomas due to ruptured intracranial aneurysms[J].ClinicalNeurology and Neurosurgery,2001,103(1):23-28
[16]刘翼，游潮，贺民等,颅内动脉瘤破裂手术时机的探讨（附237例分析）[J].中国微侵袭神经外科杂志，2007,12（5）：199-201.
[17]刘承基，主编.脑血管外科学.南京：江苏科学技术出版社，2000.1-82
[18] Bradac GB,Riva A,Bergui M,et al.Endovascular coil embo lisat ion ofcerebral aneurysm s [J].Neutoradiol,1995,8:637-644.
[19] Drake CG.Ruptured intracranial aneurysms[J].Proc Soc Med,1971,64(5):477-481.
[20] Kassell N F,Torner J C,Jane J A,et al.The international cooperative studyon the timing of aneurysm surgery.Part2:surgical results[J].J Neurosurg,1990,73(1):37-47.
[21] Vinuela F,Duckwiler G, Mawad M, et al. Gugliemi detachablecoil,embolization of acute intracranial aneurysm:perioperative anatomicaland clinical outcome in403patients.J Neurosurg,1997,86:475-482.
[22] Preda L,Gaetani P,Rodriguez Y,et al.Spital CT angiography and surgicalcorrelations in the evaluation of intracranial aneurysm [J].EurRadiology,1998,8（5）：739-745.
[23] Anderson GB,Findlay JM,Steinke DE,et al.Experience with computedtomogtaphic angiography for the detection of intracranial aneurysms in thesetting of acute subarachnoid hemorrhage[J].Neurosurgery,1997,41(3):522-527.
[24] Ahn JY,Han IB,Joo JY.Aneurysm in the penetrating artery of the distalmiddle cerebral artery presenting as intracerebral hemorrhage[J].ActaNeurochir(Wien),2005,147(12):1287-1290.
[25] Mc-Carron Mo,Nicoll JA.Cerebral amyloid angioparhy and thrombolysis-related intracerebral hemorrhage[J].Lancet Neurol,2004,3(8):484-492.
[26] Lanzino G,Wakhloo AK,Fessler RD，et al Efficacy and current limitationof intravascular stents for intracranial internal carotid,vertevral,and basilarartery aneurysms.J Neurosurg,1999,81:538-546.
[27] Moret J,Congnard C,Weill A,et al.The “remodeling technigue” in thetreatment of wide neck intracranial aneurysms:Angiographic results andclinical follow-up in56cases.Intervent Neuroradiol.1997,3:21-35.
[28] Moret J,Congnard C,Weill A,et al.Reconstruction technic in the treatmentof wide-neck intracranial aneurysms.Long-term angiographic and clinicalresults.Apropos of56cases.J Neuroradical,1997,24:30-44.
[29] Zlotnik EI,Oleshkevich V,Stolkarts JZ.Microsurgical technique in thetreatment of intracranial aneurysms.[J].Neurosurg,1997,46(5):591
[30] Velthuis BK,Rinkel GJ,Ramos LM.Subarachnoid hemorrhage:aneurysmdetection and preoperation with CT angiography[J].radiology:1998,208:430-432.
[31] Chappell ET.Moure FC,Good MC.Comparison of computedtomographicangiography with digital subtraction angiography in thediagnosis of cerebral anerrysms:a meta-analysia[J]. Neurosurgery,2003,52:64
[32] Caruso R,Colonnese C,Elefante A,et al.Use of spiral computerizedtomography angiography in patients with cerebral aneyrysm.ourexperience[J]. J Neurosurg Sci,2002,46:4.
[33] Hoff DJ, Wallace MC, Terbrugge KG,el al.Rotational angiographyassessment of cerebral aneurysms.AJNR,1994,15:1945-1948.S
[34] Taniguchi M, Takimoto H, Yoshimine T, et al. Application of a rigidendoscope to the microsurgical management of54cerebral aneurysms:results in48patients. J Neurosurg,1999,91(2):231-237.
[35]姜军。伴有侧裂血肿的颅内动脉瘤显微外科治疗及影响预后的因素分析[D].吉林：吉林大学，2009.
[36]张义松。305例动脉瘤显微手术和血管内治疗[D]。吉林：吉林大学，2005
[37] Sun, G., et al., Comparison of standard-and low-tube voltage320-detector row volume CT angiography in detection of intracranialaneurysms with digital subtraction angiography as gold standard[J]. AcadRadiol,2012.19(3): p.281-8.
[38] Lu, L., et al., Digital subtraction CT angiography for detection ofintracranial aneurysms: comparison with three-dimensional digitalsubtraction angiography[J]. Radiology,2012.262(2): p.605-12.
[39] Hochberg, A.R., et al., Accuracy of on-call resident interpretation of CTangiography for intracranial aneurysm in subarachnoid hemorrhage[J].AJR Am J Roentgenol,2011.197(6): p.1436-41.
[40]游梦星。三维CT血管造影与平板DSA对颅内动脉瘤诊断价值的对比分析[J].介入放射学杂志，2011,20（9）：676-680.
[41]范文海。动脉瘤破裂导致外侧裂血肿的诊断与治疗[J].中国医药指南，2010,8（32）：117-118.
[42]朱永强。272例颅内破裂动脉瘤回顾性分析[D].江苏：苏州大学。
[43] Thines, L., P. Bourgeois and J.P. Lejeune, Surgery for UnrupturedIntracranial Aneurysms in the ISAT and ISUIA Era[J]. Can J Neurol Sci,2012.39(2):174-9.
[44] Kim, Y.C., et al., Aspergillus-associated cerebral aneurysm successfullytreated by endovascular and surgical intervention with voriconazole inlupus nephritis patient[J]. J Korean Med Sci,2012.27(3):317-20.
[45] Yamakawa, K., et al., Incidence and neurological outcomes of aneurysmrupture during interventional neuroradiology procedures in a hybridoperating suite[J]. J Anesth,2012.
[46] Preiss, M., et al., Verbal memory capacity after treatment for rupturedintracranial aneurysm-the outcomes of three psychological tests: within amonth,1year after and5-7years after treatment[J]. Acta Neurochir(Wien),2012.154(3):417-22.
[47]. Li, Z.Q., et al.,[Microsurgery treatment with aneurysm on the top ofbasilar artery[J]. Zhonghua Yi Xue Za Zhi,2011.91(39):2747-8.
[48] Tang, X.P., et al., Effects of early hyperbaric oxygen therapy on clinicaloutcome in postoperative patients with intracranial aneurysm[J]. UnderseaHyperb Med,2011.38(6):493-501.
[49] Khaldi, A., et al., Delayed complication from a percutaneous vascularclosure device following a neuro-interventional procedure[J]. IntervNeuroradiol,2011.17(4):495-500.
[2] Prat R, Galeano I. Early surgical treatment of middle cerebral arteryaneurysms associated with intracerebral haematoma. Clin NeurolNeurosurg,2007,109(5):431-5.
[3] Gene H Barnett. High-Grade Gliomas Diagnosis and Treatment. NewJersey: Humana Press,2007,66-67.
[4] Abbed KM, Ogilvy CS. Intracerebral hematoma from aneurysm rupture.Neurosurg Focus,2003,15(4):165-8.
[5] Heiskanen O, Poranen A, Kuurne T. Acute surgery for intracerebralhaematomas caused by rupture of an intracranial arterial aneurysm. ActaNeurochir (Wien),1988,(90)81-83.
[6] Nowak G, Schwachenwald D, Schwachenwald R. Intracerebral hematomascaused by aneurysm rupture. Experience with67cases. Neurosurg Rev,1998,21(1):5-9.
[7] Velat, G.J., et al., Surgical Management of Giant Posterior CommunicatingArtery Aneurysms. Neurosurgery[J],2012.
[8] Uysal E, Yanbulo lu B, Ertürk M. Spiral CT angiography in diagnosis ofcerebral aneurysms of cases with acute subarachnoid hemorrhage. DiagnInterv Radiol,2005,11(2):77-82.
[9]郭新宾,赵丛海,田宇.去骨瓣减压术在Ⅳ、Ⅴ级动脉瘤破裂患者早期手术后的应用.中国神经医学杂志.2005,4(9):967-9.1
[10]潘先文,江晓春,李真保,等.颅内动脉瘤的显微手术治疗.中国神经医学杂志.2005,4(4):397-8.
[11]郄福忠,王智,肖玉强,等.显微神经外科手术和血管内介入治疗Ⅳ、Ⅴ级颅内动脉瘤对比研究.中国神经医学杂志.2003,4(2):155-7.
[12]丰育功,刘滨,侯晓群,等. CT在诊断动脉瘤性蛛网膜下腔出血中的临床应用研究（附140例研究报道）.中国神经医学杂志.2003,2(5):343-5.
[13] Macdonald RL. Lumbar drainage after subarachnoid hemorrhage: does itreduce vasospasm and delayed hydrocephalus?. Neurocrit Care,2007,7(1):1-2.
[14]王忠诚.脑外伤神经外科学.科技出版社,北京,1998,279-386.
[15] Baskaya MK,Menendez JA,Yuceer N,et al.Results of surgical treatment ofintrasylvian hematomas due to ruptured intracranial aneurysms[J].ClinicalNeurology and Neurosurgery,2001,103(1):23-28
[16]刘翼，游潮，贺民等,颅内动脉瘤破裂手术时机的探讨（附237例分析）[J].中国微侵袭神经外科杂志，2007,12（5）：199-201.
[17]刘承基，主编.脑血管外科学.南京：江苏科学技术出版社，2000.1-82
[18] Bradac GB,Riva A,Bergui M,et al.Endovascular coil embo lisat ion ofcerebral aneurysm s [J].Neutoradiol,1995,8:637-644.
[19] Drake CG.Ruptured intracranial aneurysms[J].Proc Soc Med,1971,64(5):477-481.
[20] Kassell N F,Torner J C,Jane J A,et al.The international cooperative studyon the timing of aneurysm surgery.Part2:surgical results[J].J Neurosurg,1990,73(1):37-47.
[21] Vinuela F,Duckwiler G, Mawad M, et al. Gugliemi detachablecoil,embolization of acute intracranial aneurysm:perioperative anatomicaland clinical outcome in403patients.J Neurosurg,1997,86:475-482.
[22] Preda L,Gaetani P,Rodriguez Y,et al.Spital CT angiography and surgicalcorrelations in the evaluation of intracranial aneurysm [J].EurRadiology,1998,8（5）：739-745.
[23] Anderson GB,Findlay JM,Steinke DE,et al.Experience with computedtomogtaphic angiography for the detection of intracranial aneurysms in thesetting of acute subarachnoid hemorrhage[J].Neurosurgery,1997,41(3):522-527.
[24] Ahn JY,Han IB,Joo JY.Aneurysm in the penetrating artery of the distalmiddle cerebral artery presenting as intracerebral hemorrhage[J].ActaNeurochir(Wien),2005,147(12):1287-1290.
[25] Mc-Carron Mo,Nicoll JA.Cerebral amyloid angioparhy and thrombolysis-related intracerebral hemorrhage[J].Lancet Neurol,2004,3(8):484-492.
[26] Lanzino G,Wakhloo AK,Fessler RD，et al Efficacy and current limitationof intravascular stents for intracranial internal carotid,vertevral,and basilarartery aneurysms.J Neurosurg,1999,81:538-546.
[27] Moret J,Congnard C,Weill A,et al.The “remodeling technigue” in thetreatment of wide neck intracranial aneurysms:Angiographic results andclinical follow-up in56cases.Intervent Neuroradiol.1997,3:21-35.
[28] Moret J,Congnard C,Weill A,et al.Reconstruction technic in the treatmentof wide-neck intracranial aneurysms.Long-term angiographic and clinicalresults.Apropos of56cases.J Neuroradical,1997,24:30-44.
[29] Zlotnik EI,Oleshkevich V,Stolkarts JZ.Microsurgical technique in thetreatment of intracranial aneurysms.[J].Neurosurg,1997,46(5):591
[30] Velthuis BK,Rinkel GJ,Ramos LM.Subarachnoid hemorrhage:aneurysmdetection and preoperation with CT angiography[J].radiology:1998,208:430-432.
[31] Chappell ET.Moure FC,Good MC.Comparison of computedtomographicangiography with digital subtraction angiography in thediagnosis of cerebral anerrysms:a meta-analysia[J]. Neurosurgery,2003,52:64
[32] Caruso R,Colonnese C,Elefante A,et al.Use of spiral computerizedtomography angiography in patients with cerebral aneyrysm.ourexperience[J]. J Neurosurg Sci,2002,46:4.
[33] Hoff DJ, Wallace MC, Terbrugge KG,el al.Rotational angiographyassessment of cerebral aneurysms.AJNR,1994,15:1945-1948.S
[34] Taniguchi M, Takimoto H, Yoshimine T, et al. Application of a rigidendoscope to the microsurgical management of54cerebral aneurysms:results in48patients. J Neurosurg,1999,91(2):231-237.
[35]姜军。伴有侧裂血肿的颅内动脉瘤显微外科治疗及影响预后的因素分析[D].吉林：吉林大学，2009.
[36]张义松。305例动脉瘤显微手术和血管内治疗[D]。吉林：吉林大学，2005
[37] Sun, G., et al., Comparison of standard-and low-tube voltage320-detector row volume CT angiography in detection of intracranialaneurysms with digital subtraction angiography as gold standard[J]. AcadRadiol,2012.19(3): p.281-8.
[38] Lu, L., et al., Digital subtraction CT angiography for detection ofintracranial aneurysms: comparison with three-dimensional digitalsubtraction angiography[J]. Radiology,2012.262(2): p.605-12.
[39] Hochberg, A.R., et al., Accuracy of on-call resident interpretation of CTangiography for intracranial aneurysm in subarachnoid hemorrhage[J].AJR Am J Roentgenol,2011.197(6): p.1436-41.
[40]游梦星。三维CT血管造影与平板DSA对颅内动脉瘤诊断价值的对比分析[J].介入放射学杂志，2011,20（9）：676-680.
[41]范文海。动脉瘤破裂导致外侧裂血肿的诊断与治疗[J].中国医药指南，2010,8（32）：117-118.
[42]朱永强。272例颅内破裂动脉瘤回顾性分析[D].江苏：苏州大学。
[43] Thines, L., P. Bourgeois and J.P. Lejeune, Surgery for UnrupturedIntracranial Aneurysms in the ISAT and ISUIA Era[J]. Can J Neurol Sci,2012.39(2):174-9.
[44] Kim, Y.C., et al., Aspergillus-associated cerebral aneurysm successfullytreated by endovascular and surgical intervention with voriconazole inlupus nephritis patient[J]. J Korean Med Sci,2012.27(3):317-20.
[45] Yamakawa, K., et al., Incidence and neurological outcomes of aneurysmrupture during interventional neuroradiology procedures in a hybridoperating suite[J]. J Anesth,2012.
[46] Preiss, M., et al., Verbal memory capacity after treatment for rupturedintracranial aneurysm-the outcomes of three psychological tests: within amonth,1year after and5-7years after treatment[J]. Acta Neurochir(Wien),2012.154(3):417-22.
[47]. Li, Z.Q., et al.,[Microsurgery treatment with aneurysm on the top ofbasilar artery[J]. Zhonghua Yi Xue Za Zhi,2011.91(39):2747-8.
[48] Tang, X.P., et al., Effects of early hyperbaric oxygen therapy on clinicaloutcome in postoperative patients with intracranial aneurysm[J]. UnderseaHyperb Med,2011.38(6):493-501.
[49] Khaldi, A., et al., Delayed complication from a percutaneous vascularclosure device following a neuro-interventional procedure[J]. IntervNeuroradiol,2011.17(4):495-500.