前交通动脉瘤形成、破裂和复发的危险因素及破裂的血流动力学机制研究
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摘要
第一部分前交通动脉瘤生成的危险因素研究
背景与目的：
颅内动脉瘤一旦破裂,就会引起蛛网膜下腔出血,其病死率和病残率都非常高。因此对动脉瘤的病因学研究意义重大。虽然对颅内动脉瘤形成的危险因素研究较多,但是对前交通动脉瘤目前还缺乏亚组分析。前交通动脉瘤是前循环中最为复杂的一个动脉瘤亚组,前交通动脉血管解剖生理非常特殊。本研究的目的是探讨前交通动脉瘤形成的独特的危险因素,从而为临床预防提供理论基础。
资料与方法：
本研究是一项回顾性病例对照研究。病例组收集自2006年1月至2012年10月间收治的256例前交通动脉瘤病例,均经由磁共振血管造影或数字减影血管造影证实。对照组为512例没有颅内动脉瘤的患者。我们对各种可能的危险因素都进行了数据收集,分析各临床和解剖生理因素在前交通动脉瘤形成中所起的作用。为了找出前交通动脉瘤形成的危险因素,我们对各种危险因素运用了单因素分析和多因素逻辑回归分析。
结果：
病例组的平均年龄大于对照组(P值=0.016)。单因素分析揭示：高血压、前交通动脉单侧优势A1段或一侧缺如A1段,与前交通动脉瘤的发生明显相关。多因素逻辑回归分析表明：年龄(比值比1.014,95%可信区间1.001到1.027)、高血压病史(比值比1.627,95%可信区间1.090到2.135)、单侧优势A1段(比值比2.845,95%可信区间2.019-04.009)或一侧缺如A1段(比值比4.301,95%可信区间2.174到8.507)都是前交通动脉瘤形成的独立危险因素。
结论：
年龄、高血压、单侧优势A1段或一侧缺如A1段,这些都是形成前交通动脉瘤的独立危险因素。对于具有这些危险因素的人群,应该运用磁共振血管造影定期筛查,早期发现前交通动脉瘤。当然,这种筛查需要卫生经济学上的进一步评估。
第二部分年龄、瘤体大小和A1段血管构象预测前交通动脉瘤的破裂风险
背景与目的：
随着神经影像学的进步,颅内动脉瘤的发现率相应提高。预防动脉瘤破裂出血是降低病死率和病残率最有效的方式。因此,对动脉瘤破裂风险因素进行研究很有价值,有益于预测动脉瘤将来破裂风险。尽管笼统的颅内动脉瘤破裂的危险因素已有所研究,但是前交通动脉瘤这一亚组的破裂风险却鲜有研究。基于前交通动脉解剖生理的特殊性,前交通动脉瘤被认为是前循环中最为复杂的一个动脉瘤亚组。本研究旨在分析前交通动脉瘤破裂的危险因素,为临床决策提供理论依据。
资料与方法：
本研究收集了自2006年6月至2012年10月间在我院收治的前交通动脉瘤病例。全部病例经由磁共振血管造影(MRA)或数字减影血管造影(DSA)检查证实。前交通动脉瘤破裂的危险因素有可能为：患者临床特征、前交通动脉A1段解剖构象和动脉瘤瘤体相关特征。比较分析前交通破裂动脉瘤和前交通未破裂动脉瘤病例之间,这些危险因素方面存在哪些差异。运用单因素和多因素逻辑回归分析方法,找出能预测前交通动脉瘤破裂的独立危险因素。
结果：
本研究总共收集了256例前交通动脉瘤病例,其中104例患者表现为前交通破裂动脉瘤。通过单因素分析,我们发现前交通动脉瘤破裂风险与以下因素明显相关：年龄55岁以下、有吸烟史、有饮酒史、前交通动脉A1段不对称时呈现单侧优势型A1段,或者前交通动脉一侧缺如A1段、以及动脉瘤瘤径3毫米以上。通过多因素逻辑回归分析,我们发现前交通动脉瘤破裂的独立预测因素为：年龄在55岁以下(比值比5.975,95%可信区间2.739到13.032)、前交通动脉单侧优势A1段(比值比2.463,95%可信区间1.83到5.13)或前交通动脉一侧缺如A1段(比值比6.268,95%可信区间1.819到21.601)、动脉瘤瘤径在3毫米以上(比值比23.429,95%可信区间10.998到49.908)。
结论：
年龄在55岁以下、有吸烟史、有饮酒史、前交通动脉单侧优势A1段或前交通动脉一侧缺如A1段、以及动脉瘤瘤径在3毫米以上,以上这些因素是前交通动脉瘤破裂的独立预测因素。对于具备这些危险因素的患者,建议给予预防性治疗。
第三部分破裂与未破裂前交通动脉瘤血流动力学数值模拟研究
背景与目的：
由于不同部位动脉瘤以及毗邻载瘤动脉几何学结构各不相同,别处的动脉瘤血流动力学结论不能推广到前交通动脉瘤亚组。以往,运用3D-DRA技术研究前交通动脉瘤血流动力学特点以及动脉瘤破裂的血流动力学机制,仅仅以一侧大脑前动脉A1段为流入血管,不足阐明前交通动脉瘤破裂的血流动力学特点和真正机制。本研究的目的是通过利用3D-TOF-MRA新技术,在接近真实解剖生理状态下,来探讨前交通动脉瘤独特的血流特征,找出血流动力学特征与动脉瘤破裂之间可能存在的关系。
资料与方法：
从同期我院诊治的前交通动脉瘤破裂病例中选取18例患者,以性别和年龄(±2岁)匹配,与未破裂前交通动脉配对。所有入选患者均行头颅3D-TOF MRA检查。将所获得的3D-TOF MRA原始DICOM数据输入计算机,采用专用的计算机辅助设计软件(MIMICS12.0)建立动脉瘤3D模型,应用ANSYS CFX12.0软件进行计算。获取血流动力学相关参数,包括壁面切应力分布、流线及流场基本特征、速度场、动脉瘤内血流方式、射入流速度及宽度、冲击域大小,并对动脉瘤的血液动力学特征进行分析。
结果：
在本研究中,4种血流模式类型均被发现。在未破裂的动脉瘤中,以Ⅰ型(25%)和Ⅱ型(45%)血流模式多见；但在破裂和未破裂前交通动脉瘤中,血流模式类型分布没有明显的统计学差异(P=0.175)。以Ⅰ型血流模式为参照,Ⅱ型、Ⅰ型和Ⅳ型血流模式,动脉瘤破裂的发生率虽然有增高的趋势,但这种趋势并未达到统计学意义；以II型血流模式为参照,Ⅲ型、Ⅳ型血流模式动脉瘤破裂的发生率同样有增高的趋势,但这种趋势仍未达到统计学意义。
18个动脉瘤双侧A1段解剖结构上对称,流线分析表现为A型瞬时流线9个(50%),另外9个动脉瘤仅接受单侧大脑前动脉A1段血流。17个一侧A1段解剖结构上优势的动脉瘤,仅接受单侧大脑前动脉A1段血流。在A型瞬时流线中,66.7%为未破裂动脉瘤,在B、C、D型瞬时流线中,破裂动脉瘤比例似乎呈上升趋势,分别占44.4%、53.8%、66.7%。但这种趋势并未达到统计学意义(P=0.5343)。
在本研究中,我们在切应力轮廓图上测得最大壁切应力范围10-1500dyne/cm2,平均196dyne/cm2.未破裂动脉瘤,最大壁切应力值范围10-230dyne/cm2(平均,124dyne/cm2),破裂动脉瘤最大壁切应力范围35-1500dyne/cm2(平均,269dyne/cm2),以P值<0.1有统计学意义,破裂和未破裂动脉瘤最大壁切应力差异有统计学意义。未破裂的、A型流线的动脉瘤壁切应力较低,平均63dyne/cm2,A型流线中破裂的动脉瘤壁平均切应力为690dyne/cm2;B型流线的动脉瘤,最大壁切应力相对较小,破裂的动脉瘤最大壁切应力80dyne/cm2,未破裂动脉瘤最大壁切应力60dyne/cm2.C型流线的动脉瘤壁切应力大,破裂和未破裂动脉瘤平均最大壁切应力分别为285和225dyne/cm2,而在D型,破裂和未破裂动脉瘤平均最大壁切应力分别为165和150dyne/cm2。
结论：
本研究中,我们发现动脉瘤破裂与A1段发育不良、缺如所造成的不对称血流相关,破裂动脉瘤通常伴随射入流方向改变(Ⅲ、Ⅳ型血流模式)或多个涡流(Ⅱ、Ⅳ型血流模式),冲击域的大小的与动脉瘤之前破裂相关。高的壁面切应力与动脉瘤之前的破裂相关。
第四部分前交通动脉瘤的血管内栓塞复发的危险因素分析
背景和目的：
可能影响到动脉瘤弹簧圈治疗后复发的危险因素较多。其中风险较高的因素有：瘤径大、瘤颈宽、瘤腔内存在血栓、弹簧圈盘曲不致密、瘤颈残留、填塞不完全、随访周期过长、动脉瘤位于后循坏、高颈-顶比等。这些结果能否推及前交通动脉瘤的这一特别亚组中,目前不得而知。本研究旨在弄清楚接受过弹簧圈栓塞治疗的前交通动脉瘤复发的危险因素,对减少内管内治疗后复发有临床价值。
方法：
在本研究中,我们回顾性地分析了59例2006年1月至2012年10月间接受过弹簧圈栓塞治疗的前交通动脉瘤患者。研究其临床特点、形态学特征、原始血管造影以及3个月以上随访血管造影结果。分析患者各种临床特点、动脉瘤的形态特征、血管造影结果,通过逻辑回归模型找出能够预测动脉瘤栓塞治疗后复发的危险因素。
结果：
年龄、性别、吸烟史、饮酒史、糖尿病史及高血压史等临床特点在病例组和对照组间没有明显差异。]Hunter-Hess分级和血管内治疗时机在病例组和对照组间没有明显差异。瘤颈宽度在4mm以上(OR=5.570,95%CI,1.377-22.535；P=0.016)、瘤颈残留(OR=4.809,95%CI,1.015-22.792;P=0.048)以及动脉瘤腔的不完全填塞(OR=14.037,95%CI,2.683-73.447;P=0.002)是预测前交通动脉瘤血管内治疗后复发的独立危险因素。
结论：
瘤颈宽度在4mm以上、瘤颈残留、以及动脉瘤腔的不完全填塞是前交通动脉瘤血管内治疗后复发的独立危险因素。结果提示：1、在开发和评估宽颈动脉瘤新疗法时,要注重瘤颈的新内皮化问题。2、对前交通动脉瘤而言,血管内治疗要尽可能地做到致密填塞。3、对于瘤颈宽度在4mm以上、瘤颈残留、以及动脉瘤腔的不完全填塞的病例,必须进行严格的血管造影随访,以便早期发现早期治疗动脉瘤复发。
SECTION1Risk Factors for the Formation of Anterior Communicating Artery aneurysms
Objectives:
Risk factors for the formation of intracranial aneurysms (IAs) have been widely investigated; however, there is lack of subgroup analysis on risk factors for the formation of anterior communicating artery (ACoA) aneurysms. The purpose of this study was to determine risk factors for the formation of ACoA aneurysms.
Methods:
This is a retrospective case-control study. Cases consisted of256patients with ACoA aneurysms confirmed by MRA and/or DSA. Controls consisted of512patients without IAs. Possible risk factors for the formation of ACoA aneurysms were collected and analyzed using univariate analysis and multivariate logistic regression.
Results:
The average age was significantly older in the case group than in the control group (P=0.016). Univariate analysis revealed that hypertension and a dominant or incomplete A1were significantly associated with the presence of ACoA aneurysms. Multivariate logistic regression analysis showed that age (OR1.014,95%CI1.001to1.027), history of hypertension (OR1.627,95%CI1.090to2.135), dominant (OR2.845,95%CI2.019to4.009) or incomplete A1(OR4.301,95%CI2.174to8.507) were independent risk factors for the formation of ACoA aneurysm.
Conclusions:
Age, hypertension, and a dominant or incomplete A1were independent risk factors for the formation of ACoA aneurysm, for those with these risk factors, a periodical screening with MR angiography might be beneficial to early detection of unruptured ACoA aneurysm. However, the cost-effective of such a screening should be further evaluated.
SECTION2Age, aneurysm size and Al anatomic configuration predict rupture of anterior communicating artery aneurysms
Object:
The risk factors for the rupture of intracranial aneurysms (IAs) have been widely investigated; however, there is little subgroup analysis on the risk factors for the rupture of anterior communicating artery (ACoA) aneurysms. The purpose of this study was to determine risk factors for the rupture of ACoA aneurysms.
Methods:
Patients with ACoA aneurysm confirmed by MRA and/or DSA between June2006and October2012were included in this study. Possible risk factors for the rupture of ACoA aneurysms including clinical characteristics, Al anatomic configuration and aneurysm-related characteristics were compared by univariate analysis and multivariate logistic regression between those with ruptured ACoA aneurysms and those with unruptured ACoA aneurysm.
Results:
A total of256patients with AcomA aneurysm were included,104patients had ruptured ACoA aneurysms. Univariate analysis revealed that age<55years, cigarette smoking, alcohol consumption, a dominant or incomplete Al, and aneurysm size≥3mm were significantly associated with ACoA aneurysms rupture. Multivariate logistic regression analysis showed that only age<55years (OR5.975,95%CI2.739to13.032), a dominant (OR2.463,95%CI1.83to5.13) or incomplete Al (OR6.268,95%CI1.819to21.601) and aneurysm size≥3mm (OR23.429,95%CI10.998to49.908) were independent predictive factors for the rupture of ACoA aneurysms.
Conclusion:
Age<55years, a dominant or incomplete Al and aneurysm size>3mm were independent predictive factors for the rupture of ACoA aneurysms. For patients with these risk factors, prophylactic treatment should be recommended.
SECTION3Hemodynamic Mechanism of Rupture of Anterior Communicating Artery aneurysms
Background and Purpose:
The anterior communicating artery (AcomA) is a predilect location of aneurysms which typically carry higher rupture risks than other locations in the anterior circulation. The purpose of this study was to characterize the different flow types present in AcomA aneurysms and to investigate possible associations with rupture.
Materials and Methods:
Patient-specific computational models of36AcomA aneurysms were constructed from3D-TOF-MRA images. Visualizations of flow velocity, instantaneous streamlines, and wall shear stress (WSS) were performed. These were analyzed for flow patterns, size of the impaction zone, and peak WSS and then correlations were made with prior history of rupture.
Results:
4types of flow patterns had been detected, type1(25%) and type2(45%) were the most common. In the18aneurysms with bilateral Al Segments,9showed type A streamlines (50%), the others received blood flow from one side. In the type A streamline,66.7%of them were unruptured aneurysms. And the ratio of ruptured aneurysms were44.4%,53.85and66.7%in typeB, type C, and type D respectively. Maximum intra-aneurysmal WSS (MWSS) in type C streamline were higher than that in type A, type B and typeD. Maximum intra-aneurysmal WSS (MWSS) for the unruptured aneurysms ranged from10to230dyne/cm2(mean,124dyne/cm2) compared with ruptured aneurysms, which ranged from35to1500dyne/cm2(mean, 269dyne/cm2). This difference in MWSS was statistically significant at90%confidence levels.
Conclusions:
Aneurysms with higher flow rates entering the aneurysm, small impaction zones, and elevated MWSS are associated with a clinical history of previous rupture.
SECTION4Endovascular Embolization of Anterior Communicating Artery Aneurysm:Frequency and Risk Factors of Recurrence
Background and purpose:
Possible risk factors for recurrent of a coiled aneurysm over time have been investigated widely, large aneurysm size, wide aneurysm neck, presence of intraluminal thrombus, low packing density, neck remnant, initial incomplete occlusion, duration of follow-up, ruptured aneurysms, location in the posterior circulation and a large neck-dome ratio are associated with a higher risk of recurrence after coiling. However, whether these results can be deduced to a special subgroup of intracranial aneurysm remains unclear. The purpose of this study was to determine risk factors of recurrence after endovascular embolization of ACoA aneurysm.
Methods:
In this study, we retrospectively analyze clinical, morphological characteristics and initial angiographic results of59patients who underwent coil embolization for ACoA aneurysm and had at least a3-month follow-up angiography between January2006and October2012. Clinical characteristics of patients, characteristics of aneurysm morphology, and immediate angiographic results were were entered into a logistic regression model for the risk factors predictive of aneurysm recurrence.
Results:
There was no significant difference between the groups in terms of age, gender, history of cigarette smoking, history of alcohol consumption, history of diabetic Mellitus, history of hypertension. There was no significant difference in Hunter-Hess classification and timing of EVT at the time of initial treatment between the groups. Neck size>4(0R=5.570,95%CI,1.377-22.535; P=0.016), neck remnant (OR=4.809,95%CI,1.015-22.792; P=0.048) or incomplete occlusion (OR=14.037,95%CI,2.683-73.447; P=0.002) were identified as independent risk factors for ACoA aneurysm recurrence.
Conclusion:
Wide neck (neck size>4), neck remnant or incomplete aneurismal embolization at the time of initial endovascular treatment were independent factors predictive for the recurrence of ACoA aneurysm. The present results suggest:1) developing and evaluating new strategies of treatment and technique, especially for wide-neck aneurysms, with a focus on reinforcement and neoendothelialization at the level of the neck as objectives;2) for ACoA aneurysms, packing aneurysm with coil as densely as possible should be performed; and3) for ACoA aneurysms with a wide neck (neck size>4), or neck remnant or incomplete aneurismal embolization at the time of initial endovascular treatment, the strict follow-up angiography should be performed to detect the potential aneurysm recanalization.
背景与目的：
颅内动脉瘤一旦破裂,就会引起蛛网膜下腔出血,其病死率和病残率都非常高。因此对动脉瘤的病因学研究意义重大。虽然对颅内动脉瘤形成的危险因素研究较多,但是对前交通动脉瘤目前还缺乏亚组分析。前交通动脉瘤是前循环中最为复杂的一个动脉瘤亚组,前交通动脉血管解剖生理非常特殊。本研究的目的是探讨前交通动脉瘤形成的独特的危险因素,从而为临床预防提供理论基础。
资料与方法：
本研究是一项回顾性病例对照研究。病例组收集自2006年1月至2012年10月间收治的256例前交通动脉瘤病例,均经由磁共振血管造影或数字减影血管造影证实。对照组为512例没有颅内动脉瘤的患者。我们对各种可能的危险因素都进行了数据收集,分析各临床和解剖生理因素在前交通动脉瘤形成中所起的作用。为了找出前交通动脉瘤形成的危险因素,我们对各种危险因素运用了单因素分析和多因素逻辑回归分析。
结果：
病例组的平均年龄大于对照组(P值=0.016)。单因素分析揭示：高血压、前交通动脉单侧优势A1段或一侧缺如A1段,与前交通动脉瘤的发生明显相关。多因素逻辑回归分析表明：年龄(比值比1.014,95%可信区间1.001到1.027)、高血压病史(比值比1.627,95%可信区间1.090到2.135)、单侧优势A1段(比值比2.845,95%可信区间2.019-04.009)或一侧缺如A1段(比值比4.301,95%可信区间2.174到8.507)都是前交通动脉瘤形成的独立危险因素。
结论：
年龄、高血压、单侧优势A1段或一侧缺如A1段,这些都是形成前交通动脉瘤的独立危险因素。对于具有这些危险因素的人群,应该运用磁共振血管造影定期筛查,早期发现前交通动脉瘤。当然,这种筛查需要卫生经济学上的进一步评估。
第二部分年龄、瘤体大小和A1段血管构象预测前交通动脉瘤的破裂风险
背景与目的：
随着神经影像学的进步,颅内动脉瘤的发现率相应提高。预防动脉瘤破裂出血是降低病死率和病残率最有效的方式。因此,对动脉瘤破裂风险因素进行研究很有价值,有益于预测动脉瘤将来破裂风险。尽管笼统的颅内动脉瘤破裂的危险因素已有所研究,但是前交通动脉瘤这一亚组的破裂风险却鲜有研究。基于前交通动脉解剖生理的特殊性,前交通动脉瘤被认为是前循环中最为复杂的一个动脉瘤亚组。本研究旨在分析前交通动脉瘤破裂的危险因素,为临床决策提供理论依据。
资料与方法：
本研究收集了自2006年6月至2012年10月间在我院收治的前交通动脉瘤病例。全部病例经由磁共振血管造影(MRA)或数字减影血管造影(DSA)检查证实。前交通动脉瘤破裂的危险因素有可能为：患者临床特征、前交通动脉A1段解剖构象和动脉瘤瘤体相关特征。比较分析前交通破裂动脉瘤和前交通未破裂动脉瘤病例之间,这些危险因素方面存在哪些差异。运用单因素和多因素逻辑回归分析方法,找出能预测前交通动脉瘤破裂的独立危险因素。
结果：
本研究总共收集了256例前交通动脉瘤病例,其中104例患者表现为前交通破裂动脉瘤。通过单因素分析,我们发现前交通动脉瘤破裂风险与以下因素明显相关：年龄55岁以下、有吸烟史、有饮酒史、前交通动脉A1段不对称时呈现单侧优势型A1段,或者前交通动脉一侧缺如A1段、以及动脉瘤瘤径3毫米以上。通过多因素逻辑回归分析,我们发现前交通动脉瘤破裂的独立预测因素为：年龄在55岁以下(比值比5.975,95%可信区间2.739到13.032)、前交通动脉单侧优势A1段(比值比2.463,95%可信区间1.83到5.13)或前交通动脉一侧缺如A1段(比值比6.268,95%可信区间1.819到21.601)、动脉瘤瘤径在3毫米以上(比值比23.429,95%可信区间10.998到49.908)。
结论：
年龄在55岁以下、有吸烟史、有饮酒史、前交通动脉单侧优势A1段或前交通动脉一侧缺如A1段、以及动脉瘤瘤径在3毫米以上,以上这些因素是前交通动脉瘤破裂的独立预测因素。对于具备这些危险因素的患者,建议给予预防性治疗。
第三部分破裂与未破裂前交通动脉瘤血流动力学数值模拟研究
背景与目的：
由于不同部位动脉瘤以及毗邻载瘤动脉几何学结构各不相同,别处的动脉瘤血流动力学结论不能推广到前交通动脉瘤亚组。以往,运用3D-DRA技术研究前交通动脉瘤血流动力学特点以及动脉瘤破裂的血流动力学机制,仅仅以一侧大脑前动脉A1段为流入血管,不足阐明前交通动脉瘤破裂的血流动力学特点和真正机制。本研究的目的是通过利用3D-TOF-MRA新技术,在接近真实解剖生理状态下,来探讨前交通动脉瘤独特的血流特征,找出血流动力学特征与动脉瘤破裂之间可能存在的关系。
资料与方法：
从同期我院诊治的前交通动脉瘤破裂病例中选取18例患者,以性别和年龄(±2岁)匹配,与未破裂前交通动脉配对。所有入选患者均行头颅3D-TOF MRA检查。将所获得的3D-TOF MRA原始DICOM数据输入计算机,采用专用的计算机辅助设计软件(MIMICS12.0)建立动脉瘤3D模型,应用ANSYS CFX12.0软件进行计算。获取血流动力学相关参数,包括壁面切应力分布、流线及流场基本特征、速度场、动脉瘤内血流方式、射入流速度及宽度、冲击域大小,并对动脉瘤的血液动力学特征进行分析。
结果：
在本研究中,4种血流模式类型均被发现。在未破裂的动脉瘤中,以Ⅰ型(25%)和Ⅱ型(45%)血流模式多见；但在破裂和未破裂前交通动脉瘤中,血流模式类型分布没有明显的统计学差异(P=0.175)。以Ⅰ型血流模式为参照,Ⅱ型、Ⅰ型和Ⅳ型血流模式,动脉瘤破裂的发生率虽然有增高的趋势,但这种趋势并未达到统计学意义；以II型血流模式为参照,Ⅲ型、Ⅳ型血流模式动脉瘤破裂的发生率同样有增高的趋势,但这种趋势仍未达到统计学意义。
18个动脉瘤双侧A1段解剖结构上对称,流线分析表现为A型瞬时流线9个(50%),另外9个动脉瘤仅接受单侧大脑前动脉A1段血流。17个一侧A1段解剖结构上优势的动脉瘤,仅接受单侧大脑前动脉A1段血流。在A型瞬时流线中,66.7%为未破裂动脉瘤,在B、C、D型瞬时流线中,破裂动脉瘤比例似乎呈上升趋势,分别占44.4%、53.8%、66.7%。但这种趋势并未达到统计学意义(P=0.5343)。
在本研究中,我们在切应力轮廓图上测得最大壁切应力范围10-1500dyne/cm2,平均196dyne/cm2.未破裂动脉瘤,最大壁切应力值范围10-230dyne/cm2(平均,124dyne/cm2),破裂动脉瘤最大壁切应力范围35-1500dyne/cm2(平均,269dyne/cm2),以P值<0.1有统计学意义,破裂和未破裂动脉瘤最大壁切应力差异有统计学意义。未破裂的、A型流线的动脉瘤壁切应力较低,平均63dyne/cm2,A型流线中破裂的动脉瘤壁平均切应力为690dyne/cm2;B型流线的动脉瘤,最大壁切应力相对较小,破裂的动脉瘤最大壁切应力80dyne/cm2,未破裂动脉瘤最大壁切应力60dyne/cm2.C型流线的动脉瘤壁切应力大,破裂和未破裂动脉瘤平均最大壁切应力分别为285和225dyne/cm2,而在D型,破裂和未破裂动脉瘤平均最大壁切应力分别为165和150dyne/cm2。
结论：
本研究中,我们发现动脉瘤破裂与A1段发育不良、缺如所造成的不对称血流相关,破裂动脉瘤通常伴随射入流方向改变(Ⅲ、Ⅳ型血流模式)或多个涡流(Ⅱ、Ⅳ型血流模式),冲击域的大小的与动脉瘤之前破裂相关。高的壁面切应力与动脉瘤之前的破裂相关。
第四部分前交通动脉瘤的血管内栓塞复发的危险因素分析
背景和目的：
可能影响到动脉瘤弹簧圈治疗后复发的危险因素较多。其中风险较高的因素有：瘤径大、瘤颈宽、瘤腔内存在血栓、弹簧圈盘曲不致密、瘤颈残留、填塞不完全、随访周期过长、动脉瘤位于后循坏、高颈-顶比等。这些结果能否推及前交通动脉瘤的这一特别亚组中,目前不得而知。本研究旨在弄清楚接受过弹簧圈栓塞治疗的前交通动脉瘤复发的危险因素,对减少内管内治疗后复发有临床价值。
方法：
在本研究中,我们回顾性地分析了59例2006年1月至2012年10月间接受过弹簧圈栓塞治疗的前交通动脉瘤患者。研究其临床特点、形态学特征、原始血管造影以及3个月以上随访血管造影结果。分析患者各种临床特点、动脉瘤的形态特征、血管造影结果,通过逻辑回归模型找出能够预测动脉瘤栓塞治疗后复发的危险因素。
结果：
年龄、性别、吸烟史、饮酒史、糖尿病史及高血压史等临床特点在病例组和对照组间没有明显差异。]Hunter-Hess分级和血管内治疗时机在病例组和对照组间没有明显差异。瘤颈宽度在4mm以上(OR=5.570,95%CI,1.377-22.535；P=0.016)、瘤颈残留(OR=4.809,95%CI,1.015-22.792;P=0.048)以及动脉瘤腔的不完全填塞(OR=14.037,95%CI,2.683-73.447;P=0.002)是预测前交通动脉瘤血管内治疗后复发的独立危险因素。
结论：
瘤颈宽度在4mm以上、瘤颈残留、以及动脉瘤腔的不完全填塞是前交通动脉瘤血管内治疗后复发的独立危险因素。结果提示：1、在开发和评估宽颈动脉瘤新疗法时,要注重瘤颈的新内皮化问题。2、对前交通动脉瘤而言,血管内治疗要尽可能地做到致密填塞。3、对于瘤颈宽度在4mm以上、瘤颈残留、以及动脉瘤腔的不完全填塞的病例,必须进行严格的血管造影随访,以便早期发现早期治疗动脉瘤复发。
SECTION1Risk Factors for the Formation of Anterior Communicating Artery aneurysms
Objectives:
Risk factors for the formation of intracranial aneurysms (IAs) have been widely investigated; however, there is lack of subgroup analysis on risk factors for the formation of anterior communicating artery (ACoA) aneurysms. The purpose of this study was to determine risk factors for the formation of ACoA aneurysms.
Methods:
This is a retrospective case-control study. Cases consisted of256patients with ACoA aneurysms confirmed by MRA and/or DSA. Controls consisted of512patients without IAs. Possible risk factors for the formation of ACoA aneurysms were collected and analyzed using univariate analysis and multivariate logistic regression.
Results:
The average age was significantly older in the case group than in the control group (P=0.016). Univariate analysis revealed that hypertension and a dominant or incomplete A1were significantly associated with the presence of ACoA aneurysms. Multivariate logistic regression analysis showed that age (OR1.014,95%CI1.001to1.027), history of hypertension (OR1.627,95%CI1.090to2.135), dominant (OR2.845,95%CI2.019to4.009) or incomplete A1(OR4.301,95%CI2.174to8.507) were independent risk factors for the formation of ACoA aneurysm.
Conclusions:
Age, hypertension, and a dominant or incomplete A1were independent risk factors for the formation of ACoA aneurysm, for those with these risk factors, a periodical screening with MR angiography might be beneficial to early detection of unruptured ACoA aneurysm. However, the cost-effective of such a screening should be further evaluated.
SECTION2Age, aneurysm size and Al anatomic configuration predict rupture of anterior communicating artery aneurysms
Object:
The risk factors for the rupture of intracranial aneurysms (IAs) have been widely investigated; however, there is little subgroup analysis on the risk factors for the rupture of anterior communicating artery (ACoA) aneurysms. The purpose of this study was to determine risk factors for the rupture of ACoA aneurysms.
Methods:
Patients with ACoA aneurysm confirmed by MRA and/or DSA between June2006and October2012were included in this study. Possible risk factors for the rupture of ACoA aneurysms including clinical characteristics, Al anatomic configuration and aneurysm-related characteristics were compared by univariate analysis and multivariate logistic regression between those with ruptured ACoA aneurysms and those with unruptured ACoA aneurysm.
Results:
A total of256patients with AcomA aneurysm were included,104patients had ruptured ACoA aneurysms. Univariate analysis revealed that age<55years, cigarette smoking, alcohol consumption, a dominant or incomplete Al, and aneurysm size≥3mm were significantly associated with ACoA aneurysms rupture. Multivariate logistic regression analysis showed that only age<55years (OR5.975,95%CI2.739to13.032), a dominant (OR2.463,95%CI1.83to5.13) or incomplete Al (OR6.268,95%CI1.819to21.601) and aneurysm size≥3mm (OR23.429,95%CI10.998to49.908) were independent predictive factors for the rupture of ACoA aneurysms.
Conclusion:
Age<55years, a dominant or incomplete Al and aneurysm size>3mm were independent predictive factors for the rupture of ACoA aneurysms. For patients with these risk factors, prophylactic treatment should be recommended.
SECTION3Hemodynamic Mechanism of Rupture of Anterior Communicating Artery aneurysms
Background and Purpose:
The anterior communicating artery (AcomA) is a predilect location of aneurysms which typically carry higher rupture risks than other locations in the anterior circulation. The purpose of this study was to characterize the different flow types present in AcomA aneurysms and to investigate possible associations with rupture.
Materials and Methods:
Patient-specific computational models of36AcomA aneurysms were constructed from3D-TOF-MRA images. Visualizations of flow velocity, instantaneous streamlines, and wall shear stress (WSS) were performed. These were analyzed for flow patterns, size of the impaction zone, and peak WSS and then correlations were made with prior history of rupture.
Results:
4types of flow patterns had been detected, type1(25%) and type2(45%) were the most common. In the18aneurysms with bilateral Al Segments,9showed type A streamlines (50%), the others received blood flow from one side. In the type A streamline,66.7%of them were unruptured aneurysms. And the ratio of ruptured aneurysms were44.4%,53.85and66.7%in typeB, type C, and type D respectively. Maximum intra-aneurysmal WSS (MWSS) in type C streamline were higher than that in type A, type B and typeD. Maximum intra-aneurysmal WSS (MWSS) for the unruptured aneurysms ranged from10to230dyne/cm2(mean,124dyne/cm2) compared with ruptured aneurysms, which ranged from35to1500dyne/cm2(mean, 269dyne/cm2). This difference in MWSS was statistically significant at90%confidence levels.
Conclusions:
Aneurysms with higher flow rates entering the aneurysm, small impaction zones, and elevated MWSS are associated with a clinical history of previous rupture.
SECTION4Endovascular Embolization of Anterior Communicating Artery Aneurysm:Frequency and Risk Factors of Recurrence
Background and purpose:
Possible risk factors for recurrent of a coiled aneurysm over time have been investigated widely, large aneurysm size, wide aneurysm neck, presence of intraluminal thrombus, low packing density, neck remnant, initial incomplete occlusion, duration of follow-up, ruptured aneurysms, location in the posterior circulation and a large neck-dome ratio are associated with a higher risk of recurrence after coiling. However, whether these results can be deduced to a special subgroup of intracranial aneurysm remains unclear. The purpose of this study was to determine risk factors of recurrence after endovascular embolization of ACoA aneurysm.
Methods:
In this study, we retrospectively analyze clinical, morphological characteristics and initial angiographic results of59patients who underwent coil embolization for ACoA aneurysm and had at least a3-month follow-up angiography between January2006and October2012. Clinical characteristics of patients, characteristics of aneurysm morphology, and immediate angiographic results were were entered into a logistic regression model for the risk factors predictive of aneurysm recurrence.
Results:
There was no significant difference between the groups in terms of age, gender, history of cigarette smoking, history of alcohol consumption, history of diabetic Mellitus, history of hypertension. There was no significant difference in Hunter-Hess classification and timing of EVT at the time of initial treatment between the groups. Neck size>4(0R=5.570,95%CI,1.377-22.535; P=0.016), neck remnant (OR=4.809,95%CI,1.015-22.792; P=0.048) or incomplete occlusion (OR=14.037,95%CI,2.683-73.447; P=0.002) were identified as independent risk factors for ACoA aneurysm recurrence.
Conclusion:
Wide neck (neck size>4), neck remnant or incomplete aneurismal embolization at the time of initial endovascular treatment were independent factors predictive for the recurrence of ACoA aneurysm. The present results suggest:1) developing and evaluating new strategies of treatment and technique, especially for wide-neck aneurysms, with a focus on reinforcement and neoendothelialization at the level of the neck as objectives;2) for ACoA aneurysms, packing aneurysm with coil as densely as possible should be performed; and3) for ACoA aneurysms with a wide neck (neck size>4), or neck remnant or incomplete aneurismal embolization at the time of initial endovascular treatment, the strict follow-up angiography should be performed to detect the potential aneurysm recanalization.
引文
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