颅内动脉瘤围手术期中西医结合治疗的临床研究
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摘要
背景
随着显微手术夹闭颅内动脉瘤和血管内栓塞技术理念的进步,颅内动脉瘤手术成功率越来越高,术中并发症也逐渐减少,但对于颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤、巨大动脉瘤的介入治疗,仍存在较大的难点,一些与手术有关的并发症如动脉瘤术中破裂、血栓性并发症不容忽视。脑血管痉挛是蛛网膜下腔出血(SAH)的一种常见并发症。SAH后脑脊液和血清某些细胞因子水平可能发生改变,细胞因子所引起的炎症反应可能与脑血管痉挛有一定关联。因此,检测脑脊液和血清细胞因子水平对预测脑血管痉挛的严重程度、转归和及早治疗均有重要意义。目前关于防治蛛网膜下腔出血后脑血管痉挛一直是目前研究的热点之一,中医药防治脑血管痉挛目前文献并不多。本院自2005年3月～2011年12月治疗颅内动脉瘤400余例,以介入栓塞和开颅夹闭,取得了较好的临床疗效。同时采用前瞻性的随机对照试验设计,对60例动脉瘤性蛛网膜下腔出血换患者随机分为实验组和对照组,试验组给予中药治疗,发现中药在降低蛛网膜下腔出血脑血管痉挛的发生有较好的效果。
目的
了解颅内动脉瘤手术治疗的安全性和疗效,尤其是颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤介入治疗术式选择及术中并发症。同时观察蛛网膜下腔出血(SAH)后脑脊液内皮素1(ET-1)、一氧化氮(NO)水平的变化,探讨脑脉解痉汤对SAH后脑血管痉挛(CVS)的防治作用。
方法
1采集入选病例的年龄、性别、首发症状、CT分级、HUNT-HESS分级、动脉瘤直径、动脉瘤瘤颈宽度、动脉瘤部位、动脉瘤数目、颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤等复杂动脉瘤选择术式、术中并发症、栓塞结果、出院时GOS评分、随访情况等进行统计,并进行频数分布描述。
2对入选病人进行系统分层研究和分组对比,对以上所有预后影响因素进行多元回归统计方法分析诸因素对预后有无影响,并进一步分析诸影响因素之权重以及各因素之间关系。
3.对颅内复杂动脉瘤的各种术式进行比较分析,了解各种术式术中并发症发生率的差异,评价单纯弹簧圈栓塞治疗、球囊辅助弹簧圈栓塞治疗、支架辅助弹簧圈栓塞治疗在治疗颅内复杂动脉瘤的安全性和疗效。
4.采用前瞻性的随机对照试验设计,60例动脉瘤性蛛网膜下腔出血患者分为实验组及对照组,实验组给予西医治疗及脑脉解痉汤口服,对照组给予西医治疗,用酶标记免疫吸附测定法(ELISA法)检测发病后3天和7天脑脊液ET-1和NO水平,多普勒检测出血后第7天脑血管痉挛的发生率。
结果
1一般资料统计结果纳入病人总计409例,其中男性161例(39.3%),女性248例(60.7%),平均年龄54.47±13.6岁。
2发病情况统计结果
首发症状以单纯头痛起病259例(63.4%),意识障碍81例(19.7%),肢体偏瘫18例(4.4%),头晕12例(3.3%),眼部症状18例(4.4%),癫痫2例(0.5%),其他18例(4.4%)。入院时CT-Fisher分级0级103例(25.18%),1级6例(1.47%),2级181例(44.25%),3级79例(19.32%),4级40例(9.78%).入院时HUNT-HESS分级0级103例(25.18%),1级25例(6.11%),2级158例(38.63%),3级71例(17.36%),4级46例(11.25%),5级6例(1.47%)。Hunt-hess分级和肺部感染对预后有显著影响,P<0.05；Hunt-hess分级对是否发生脑血管痉挛有显著影响,P<0.05。
3颅内动脉瘤部位
前交通动脉瘤98例(23.96%),左侧颈内动脉后交通动脉瘤55例(13.45%),右侧颈内动脉后交通动脉瘤46例(11.25%),左侧大脑前动脉瘤7例(1.71%),右侧大脑前动脉瘤8例(1.96%),左侧大脑中动脉瘤23例(7.33%),右侧大脑中动脉瘤32例(7.82%),左侧大脑后动脉瘤4例(0.98%),右侧大脑后动脉瘤3例(0.73%),基底动脉瘤26例(6.36%),左侧椎动脉瘤18例(4.40%),右侧椎动脉瘤12例(2.93%),左侧颈内动脉瘤32例(7.82%),右侧颈内动脉瘤38例(9.29%)
4颅内复杂动脉瘤介入治疗术式及并发症的差异
颅内微小动脉瘤46例,未破裂微小动脉瘤9例,破裂微小动脉瘤38例,采用球囊辅助栓塞16例,单纯弹簧圈栓塞16例,支架辅助栓塞11例,onyx栓塞2例,双导管技术栓塞1例,未能栓塞1例。支架辅助栓塞中solitaire支架辅助栓塞6例,enterprise支架辅助栓塞4例,neuroform支架辅助栓塞1例。5例发生手术并发症,1例因术中出血导致死亡,1例因弹簧圈逃逸至大脑中动脉上干细小分支引起失语,其余1例患者术中少量出血、1例患者弹簧圈逃逸至大脑中动脉分叉部、1例患者弹簧圈少量脱出至载瘤动脉,均完全恢复。
介入治疗颅内宽颈动脉瘤197例,以支架辅助栓塞宽颈动脉瘤48例,1例支架无法到位,使用neuroform支架9例,solitaire支架24例,enterprise支架15例,其中solitaire及enterprise支架39例中,采用支架半释放技术33例,术中并发症动脉瘤破裂3例,弹簧圈部分脱出3例,动脉血栓1例。以球囊辅助栓塞宽颈动脉瘤59例,1例球囊无法到位,术中并发症动脉瘤破裂1例,弹簧圈部分脱出6例,弹簧圈逃逸1例,动脉血栓1例。以单纯弹簧圈栓塞宽颈动脉瘤90例,1例导管无法到位,栓塞失败,改为手术夹闭,术中并发症动脉瘤破裂7例,弹簧圈部分脱出9例,动脉血栓性并发症2例。双导管技术栓塞宽颈动脉瘤1例。
25例夹层动脉瘤患者中,大脑中动脉1例,余均位于后循环。采用了四种术式治疗颅内夹层动脉瘤,其中支架辅助弹簧圈栓塞16例、单纯支架置入3例、单纯弹簧圈栓塞动脉瘤3例、单纯弹簧圈闭塞载瘤动脉3例,1例术中动脉瘤破裂死亡,1例弹簧圈部分脱出。术后并发症有再出血1例死亡。25例夹层动脉瘤中有17例完全栓塞,3例次全栓塞,5例部分栓塞,不完全栓塞组随访2例术后后复查瘤体较前扩大,未出血,再次行栓塞治疗。
介入治疗梭形动脉瘤5例,椎动脉2例,基底动脉1例,大脑中动脉1例,颈内动脉1例,其中支架辅助弹簧圈栓塞4例,球囊结合支架辅助弹簧圈栓塞1例,除1例部分弹簧圈脱出至载瘤动脉,对血流无影响,余4例无手术并发症。
我们以“Y”型支架治疗宽颈动脉瘤3例,其中基底动脉瘤2例,大脑中动脉瘤1例。2例采用双solitaire支架辅助栓塞,1例采用双enterprise支架辅助栓塞,无术中并发症,术后1例因使用阿司匹林、波立维导致小脑出血,患者死亡。
单纯弹簧圈栓塞、球囊辅助弹簧圈栓塞较支架辅助弹簧圈栓塞获得栓塞程度较高,P<0.05；开颅夹闭组较介入栓塞组脑积水的发生率较高,P<0.05。
5脑脉解痉汤对动脉瘤性蛛网膜下腔出血阳类证患者脑脊液中内皮素1和一氧化氮含量的影响
治疗组CVS发生10例(33.3%),对照组CVS发生17例(56.7%),有统计学差异(P<0.05)；对照组和实验组脑脊液ET-1水平在出血后三天无明显差异(P>0.05),对照组和实验组的ET-1水平随时间递增(P<0.05),但对照组增加更明显,差异有统计学意义(P<0.05)；对照组和实验组脑脊液NO水平在出血后三天无明显差异(P>0.05),对照组和实验组的NO水平随时间递减(P<0.05),但对照组降低更明显,差异有统计学意义(P<0.05)。
结论
1颅内动脉瘤患者女性居多,发病平均年龄在54岁左右,多以头痛为首发症状,部位以前交通动脉、后交通动脉最为常见,Hunt-hess分级对脑血管痉挛和预后有显著影响,分级越高,脑血管痉挛的发生率越高,预后越差。
2颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤介入治疗是安全有效的,术中并发症发生率较低,但有一定的致残率和致死率。
3颅内复杂动脉瘤介入治疗术式有单纯弹簧圈栓塞、球囊辅助弹簧圈栓塞、支架辅助弹簧圈栓塞、载瘤动脉闭塞、液体胶栓塞等多种,其中球囊辅助弹簧圈栓塞、支架辅助弹簧圈栓塞在术中并发症如动脉瘤破裂、血栓形成无明显差异。
4“Y”型支架治疗分叉部宽颈动脉瘤是安全的,但手术难度较大,对术者技术水平要求高。
5对动脉瘤性蛛网膜下腔出血患者应用脑脉解痉汤治疗后,SAH患者脑脊液中ET-1水平下降,而NO水平则上升,脑血管痉挛的发生率下降,提示脑脉解痉汤对SAH后CVS有较好的防治作用。
Objective
To learn the safety and efficacy of operation treatment of intracranial aneurysms, especially the selection of interventional treatment methods and intraoperative complications of intracranial very Small aneurysms, wide-necked aneurysms, dissection aneurysms, and fusiform aneurysms. To observe the changes on the levels of the cerebrospinal fluid endothelin-1(ET-1), nitric oxide (NO) after subarachnoid hemorrhage (SAH), and to explore the mechanism of NaomaiJiejing Tang prevent the vasospasm after SAH.
Methods
1By selected cases by age, sex, admission CT and HUNTHESS grade and Aneurysm diameter, aneurysm neck width, aneurysm site, the number of aneurysms, the selection of interventional treatment methods and intraoperative complications of intracranial very Small aneurysms, wide-necked aneurysms, dissection aneurysms, and fusiform aneurysms, and discharge GOS score, follow-up statistics on such cases and to describe the frequency distribution.
2Systematic stratificate on the selected patients, for all of the above prognostic factors in multiple regression statistical analysis whether the impact of various factors on the prognosis, and further analysis of the weights of various factors and the relationship between various factors.
3To learn the differences in the incidence of intraoperative complications by comparative analysis of interventional treatment methods for complex intracranial aneurysms, to evaluate safety and efficacy of pure coil embolization, balloon-assisted coil embolization, stent-assisted coil embolization in the treatment of complex intracranial aneurysms.
4A prospective randomized controlled trial designed,60patients were divided into experimental group and control group, the experimental group were given Western therapy and Naomai.liejing Tang orally, the control group was given western medicine, detected cerebrospinal fluid levels of ET-1and NO on3and7days after the onset with the enzyme-labeled immunosorbent assay (ELISA), Doppler detected the incidence of cerebral vasospasm on7days after SAH.
Results
1General Information
A total of409cases of patients,161cases were male (39.3%) and248cases were females (60.7%), mean age54.47±13.6years old.
2State before hospital
first symptom in259cases alone were headache (63.4%),81cases of disturbance of consciousness (19.7%), hemiplegia in18cases (4.4%), dizziness onset in18cases (4.4%), ocular symptoms in8cases (2.8%), epilepsy in2cases (0.5%), other18cases (4.4%). CT grade0in103cases (25.18%), grade1in6cases (1.47%),2Grade in181cases (44.15%),3grade in79cases (19.32%),4grade in40cases (9.78%). HUNT-HESS grade0in103cases (25.18%), grade1in25cases (6.11%), grade2in158(38.63%), grade3in71cases (17.36%), grade4in46cases (11.25%).
3Intracranial aneurysm site
anterior communicating artery aneurysm in98patients (23.96%), left posterior communicating artery aneurysm55cases (13.45%), right posterior communicating artery aneurysm in46cases (11.25%), left anterior cerebral artery7cases (1.71%), right anterior cerebral artery aneurysms in8cases (1.96%), the left middle cerebral artery aneurysm in23cases (7.33%), right middle cerebral artery aneurysm in32patients (7.82%), the left brain artery aneurysm in4case (0.98%), Right middle cerebral artery aneurysm in3cases (0.73%), basilar artery in26cases (6.36%), left vertebral artery aneurysm in18patients (4.4%), right vertebral artery aneurysm in12cases (2.93%), left internal carotid artery aneurysm in32cases (7.82%), right internal carotid artery aneurysm of38cases (9.29%). Hunt-hess grade and lung infection had a significant effect on the prognosis, P<0.05; Hunt-hess grade had a significant effect on the occurrence of cerebral vasospasm, P<0.05.6The differences in the incidence of interventional treatment methods and intraoperative complications for complex intracranial aneurysms
4The difference of methods and complication of complex intracranial aneurysms with interventional treatment
46cases of intracranial very small aneurysms,9cases unruptured,38cases ruptured, balloon-assisted embolization in16cases, pure coil embolization in16casesand stent-assisted embolization in11cases, onyx embolization in2case and double catheter technique embolization in1case, failed embolization in1case. Among stent-assisted embolization case, solitaire stent-assisted embolization in six cases, enterprise stent-assisted embolization in four cases, neuroform stent-assisted embolization in1cases. Five cases have intraoperative complications, including1cases due to aneurysm rupture leading to death,1cases due to coil escape to small branch of the brain middle cerebral artery caused aphasia。The remaining are fully restored in which a small amount of intraoperative bleeding in1patient, one coil escape to the brain artery bifurcation in1patient, and a small amount of coil prolapse to the parent artery in1patient.
197cases of wide-necked aneurysms, stent-assisted embolization in48cases, failed embolization in1case. Among stent-assisted embolization case, neuroform stent-assisted embolization in9cases, solitaire stent-assisted embolization in24cases, enterprise stent-assisted embolization in15cases. Semi-release technology was adopted in33cases among solitaire and enterprise stent-assisted embolization.8cases have intraoperative complications, including aneurysm rupture in3cases, a small amount of coil prolapse to the parent artery in3cases, Arterial thrombosis in1case. Balloon-assisted embolization in59cases, failed embolization in1case. Intraoperative complicationsincluding aneurysm rupture in1cases, a small amount of coil prolapse to the parent artery in6cases, coil escape to the distal of artery in1case, Arterial thrombosis in1case. Pure coil embolization in90cases, failed embolization in1case, then Surgical clipping. Intraoperative complicationsincluding aneurysm rupture in7cases, a small amount of coil prolapse to the parent artery in9cases, Arterial thrombosis in2case. Double catheter technique embolization in1cases of wide-necked aneurvsm.
25cases of dissection aneurysms, middle cerebral artery in1case Posterior circulation in3cases. Stent-assisted coil embol ization in16cases, simple coil embol ization in3cases, stent placement alone in3cases, parent occlusion in3case. Intraoperative complications including aneurysm rupture in1case leading to death, a small amount of coil prolapse to the parent artery in1cases. Postoperative complications including rebleeding in1case leading to death. Complete embolization was17cases, subtotal embol ization in3cases and partial embolization in5cases.During follow-up aneurysm of two cases in incomplete embolization group enlarge, not rebleed, ang embolism again.
5cases of fusiform aneurysms, basilar artery in1case, vertebral artery in1case, middle cerebral artery in1case, internal carotid artery in1case. Stent-assisted coil embolization in3cases, ballon combined stent-assisted coil embolization in1case. In addition to part of the coil prolapse to the parent artery in1case, had no effect on blood flow, no complications in others.
"Y" stent was placed in the treatment of wide-necked aneurysms in3cases, basilar artery aneurysm in2cases, middle cerebral artery aneurysm in1case2cases with double solitaire stent-assisted embolization,1case with doublel enterprise stent-assisted embolization,, no intraoperative complications happened, postoperative complication in1cases due to the use of aspirin, clopidogrel resulted in cerebellar hemorrhage, the patient died.
Simple coil embolization, balloon-assisted coil embolization compared with stent-assisted coil embol ization obtained a higher degree of embolization, P<0.05; craniotomy clipping group had a higher incidence of hydrocephalus than embolization group, P<0.05.5The changes on the levels of the cerebrospinal fluid endothelin-1(ET-1), nitric oxide (NO) after subarachnoid hemorrhage (SAH)
The treatment group CVS occurred in10patients (33.3%), the control group CVS occurred in17cases (56.7%), significant difference exist(P<0.05); the cerebrospinal fluid levels of ET-1on3days no significant difference (P>0.05)between control group and experimental group in after SAH, the2groups of ET-1levels increased with time (P<0.05), but the control group increased more significantly, the difference was statistically significant (P<0.05.) the NO levels of the cerebrospinal fluid control has no significant difference (P>0.05)between group and experimental group on3days after the SAH,, NO levels decrease with time in2groups (P<0.05), but the control group decreased more significantly, the difference was statistically significant (P<0.05).
Conclusion
1Patients with intracranial aneurysms are mostly women, mean age54years old or so, the most commom first symptom is headache, the most common site is anterior communicating artery aneurysm and posterior communicating artery. Hunt-hess grade had a significant effect on cerebral vasospasm and prognosis. The higher Hunt-hess grade is, the higher the incidence of cerebral vasospasm, the worse prognosis
2Interventional treatment of intracranial very small aneurysms, wide-necked aneurysms, dissection aneurysms and fusiform aneurysms is safe and effective, incidence of intraoperative complications is low, but there is a certain degree of morbidity and mortality due to procedure-related complication.
3The treatment methods of complex intracranial aneurysms involved in a simple coil embolization, balloon-assisted coil embolization, stent-assisted coil embolization, parent artery occlusion, liquid glue embolization. Intraoperative complications such as aneurysm rupture, thrombosis had no significant difference between balloon-assisted coil embolization and stent-assisted coil embolization.
4Treatment of wide-necked bifurcation aneurysms with "Y"type stent is safe, but the procedure is difficult and requires high technical level.
5After the treatment with Naomai Jiejing Tang, the cerebrospinal fluid levels of ET-1decreased in patients with SAH, while the NO level increased, the incidence of cerebral vasospasm decreased, which suggested that NaomaiJiejing Tang can prevent and treat CVS after SAH effectively
随着显微手术夹闭颅内动脉瘤和血管内栓塞技术理念的进步,颅内动脉瘤手术成功率越来越高,术中并发症也逐渐减少,但对于颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤、巨大动脉瘤的介入治疗,仍存在较大的难点,一些与手术有关的并发症如动脉瘤术中破裂、血栓性并发症不容忽视。脑血管痉挛是蛛网膜下腔出血(SAH)的一种常见并发症。SAH后脑脊液和血清某些细胞因子水平可能发生改变,细胞因子所引起的炎症反应可能与脑血管痉挛有一定关联。因此,检测脑脊液和血清细胞因子水平对预测脑血管痉挛的严重程度、转归和及早治疗均有重要意义。目前关于防治蛛网膜下腔出血后脑血管痉挛一直是目前研究的热点之一,中医药防治脑血管痉挛目前文献并不多。本院自2005年3月～2011年12月治疗颅内动脉瘤400余例,以介入栓塞和开颅夹闭,取得了较好的临床疗效。同时采用前瞻性的随机对照试验设计,对60例动脉瘤性蛛网膜下腔出血换患者随机分为实验组和对照组,试验组给予中药治疗,发现中药在降低蛛网膜下腔出血脑血管痉挛的发生有较好的效果。
目的
了解颅内动脉瘤手术治疗的安全性和疗效,尤其是颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤介入治疗术式选择及术中并发症。同时观察蛛网膜下腔出血(SAH)后脑脊液内皮素1(ET-1)、一氧化氮(NO)水平的变化,探讨脑脉解痉汤对SAH后脑血管痉挛(CVS)的防治作用。
方法
1采集入选病例的年龄、性别、首发症状、CT分级、HUNT-HESS分级、动脉瘤直径、动脉瘤瘤颈宽度、动脉瘤部位、动脉瘤数目、颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤等复杂动脉瘤选择术式、术中并发症、栓塞结果、出院时GOS评分、随访情况等进行统计,并进行频数分布描述。
2对入选病人进行系统分层研究和分组对比,对以上所有预后影响因素进行多元回归统计方法分析诸因素对预后有无影响,并进一步分析诸影响因素之权重以及各因素之间关系。
3.对颅内复杂动脉瘤的各种术式进行比较分析,了解各种术式术中并发症发生率的差异,评价单纯弹簧圈栓塞治疗、球囊辅助弹簧圈栓塞治疗、支架辅助弹簧圈栓塞治疗在治疗颅内复杂动脉瘤的安全性和疗效。
4.采用前瞻性的随机对照试验设计,60例动脉瘤性蛛网膜下腔出血患者分为实验组及对照组,实验组给予西医治疗及脑脉解痉汤口服,对照组给予西医治疗,用酶标记免疫吸附测定法(ELISA法)检测发病后3天和7天脑脊液ET-1和NO水平,多普勒检测出血后第7天脑血管痉挛的发生率。
结果
1一般资料统计结果纳入病人总计409例,其中男性161例(39.3%),女性248例(60.7%),平均年龄54.47±13.6岁。
2发病情况统计结果
首发症状以单纯头痛起病259例(63.4%),意识障碍81例(19.7%),肢体偏瘫18例(4.4%),头晕12例(3.3%),眼部症状18例(4.4%),癫痫2例(0.5%),其他18例(4.4%)。入院时CT-Fisher分级0级103例(25.18%),1级6例(1.47%),2级181例(44.25%),3级79例(19.32%),4级40例(9.78%).入院时HUNT-HESS分级0级103例(25.18%),1级25例(6.11%),2级158例(38.63%),3级71例(17.36%),4级46例(11.25%),5级6例(1.47%)。Hunt-hess分级和肺部感染对预后有显著影响,P<0.05；Hunt-hess分级对是否发生脑血管痉挛有显著影响,P<0.05。
3颅内动脉瘤部位
前交通动脉瘤98例(23.96%),左侧颈内动脉后交通动脉瘤55例(13.45%),右侧颈内动脉后交通动脉瘤46例(11.25%),左侧大脑前动脉瘤7例(1.71%),右侧大脑前动脉瘤8例(1.96%),左侧大脑中动脉瘤23例(7.33%),右侧大脑中动脉瘤32例(7.82%),左侧大脑后动脉瘤4例(0.98%),右侧大脑后动脉瘤3例(0.73%),基底动脉瘤26例(6.36%),左侧椎动脉瘤18例(4.40%),右侧椎动脉瘤12例(2.93%),左侧颈内动脉瘤32例(7.82%),右侧颈内动脉瘤38例(9.29%)
4颅内复杂动脉瘤介入治疗术式及并发症的差异
颅内微小动脉瘤46例,未破裂微小动脉瘤9例,破裂微小动脉瘤38例,采用球囊辅助栓塞16例,单纯弹簧圈栓塞16例,支架辅助栓塞11例,onyx栓塞2例,双导管技术栓塞1例,未能栓塞1例。支架辅助栓塞中solitaire支架辅助栓塞6例,enterprise支架辅助栓塞4例,neuroform支架辅助栓塞1例。5例发生手术并发症,1例因术中出血导致死亡,1例因弹簧圈逃逸至大脑中动脉上干细小分支引起失语,其余1例患者术中少量出血、1例患者弹簧圈逃逸至大脑中动脉分叉部、1例患者弹簧圈少量脱出至载瘤动脉,均完全恢复。
介入治疗颅内宽颈动脉瘤197例,以支架辅助栓塞宽颈动脉瘤48例,1例支架无法到位,使用neuroform支架9例,solitaire支架24例,enterprise支架15例,其中solitaire及enterprise支架39例中,采用支架半释放技术33例,术中并发症动脉瘤破裂3例,弹簧圈部分脱出3例,动脉血栓1例。以球囊辅助栓塞宽颈动脉瘤59例,1例球囊无法到位,术中并发症动脉瘤破裂1例,弹簧圈部分脱出6例,弹簧圈逃逸1例,动脉血栓1例。以单纯弹簧圈栓塞宽颈动脉瘤90例,1例导管无法到位,栓塞失败,改为手术夹闭,术中并发症动脉瘤破裂7例,弹簧圈部分脱出9例,动脉血栓性并发症2例。双导管技术栓塞宽颈动脉瘤1例。
25例夹层动脉瘤患者中,大脑中动脉1例,余均位于后循环。采用了四种术式治疗颅内夹层动脉瘤,其中支架辅助弹簧圈栓塞16例、单纯支架置入3例、单纯弹簧圈栓塞动脉瘤3例、单纯弹簧圈闭塞载瘤动脉3例,1例术中动脉瘤破裂死亡,1例弹簧圈部分脱出。术后并发症有再出血1例死亡。25例夹层动脉瘤中有17例完全栓塞,3例次全栓塞,5例部分栓塞,不完全栓塞组随访2例术后后复查瘤体较前扩大,未出血,再次行栓塞治疗。
介入治疗梭形动脉瘤5例,椎动脉2例,基底动脉1例,大脑中动脉1例,颈内动脉1例,其中支架辅助弹簧圈栓塞4例,球囊结合支架辅助弹簧圈栓塞1例,除1例部分弹簧圈脱出至载瘤动脉,对血流无影响,余4例无手术并发症。
我们以“Y”型支架治疗宽颈动脉瘤3例,其中基底动脉瘤2例,大脑中动脉瘤1例。2例采用双solitaire支架辅助栓塞,1例采用双enterprise支架辅助栓塞,无术中并发症,术后1例因使用阿司匹林、波立维导致小脑出血,患者死亡。
单纯弹簧圈栓塞、球囊辅助弹簧圈栓塞较支架辅助弹簧圈栓塞获得栓塞程度较高,P<0.05；开颅夹闭组较介入栓塞组脑积水的发生率较高,P<0.05。
5脑脉解痉汤对动脉瘤性蛛网膜下腔出血阳类证患者脑脊液中内皮素1和一氧化氮含量的影响
治疗组CVS发生10例(33.3%),对照组CVS发生17例(56.7%),有统计学差异(P<0.05)；对照组和实验组脑脊液ET-1水平在出血后三天无明显差异(P>0.05),对照组和实验组的ET-1水平随时间递增(P<0.05),但对照组增加更明显,差异有统计学意义(P<0.05)；对照组和实验组脑脊液NO水平在出血后三天无明显差异(P>0.05),对照组和实验组的NO水平随时间递减(P<0.05),但对照组降低更明显,差异有统计学意义(P<0.05)。
结论
1颅内动脉瘤患者女性居多,发病平均年龄在54岁左右,多以头痛为首发症状,部位以前交通动脉、后交通动脉最为常见,Hunt-hess分级对脑血管痉挛和预后有显著影响,分级越高,脑血管痉挛的发生率越高,预后越差。
2颅内微小动脉瘤、宽颈动脉瘤、夹层动脉瘤、梭形动脉瘤介入治疗是安全有效的,术中并发症发生率较低,但有一定的致残率和致死率。
3颅内复杂动脉瘤介入治疗术式有单纯弹簧圈栓塞、球囊辅助弹簧圈栓塞、支架辅助弹簧圈栓塞、载瘤动脉闭塞、液体胶栓塞等多种,其中球囊辅助弹簧圈栓塞、支架辅助弹簧圈栓塞在术中并发症如动脉瘤破裂、血栓形成无明显差异。
4“Y”型支架治疗分叉部宽颈动脉瘤是安全的,但手术难度较大,对术者技术水平要求高。
5对动脉瘤性蛛网膜下腔出血患者应用脑脉解痉汤治疗后,SAH患者脑脊液中ET-1水平下降,而NO水平则上升,脑血管痉挛的发生率下降,提示脑脉解痉汤对SAH后CVS有较好的防治作用。
Objective
To learn the safety and efficacy of operation treatment of intracranial aneurysms, especially the selection of interventional treatment methods and intraoperative complications of intracranial very Small aneurysms, wide-necked aneurysms, dissection aneurysms, and fusiform aneurysms. To observe the changes on the levels of the cerebrospinal fluid endothelin-1(ET-1), nitric oxide (NO) after subarachnoid hemorrhage (SAH), and to explore the mechanism of NaomaiJiejing Tang prevent the vasospasm after SAH.
Methods
1By selected cases by age, sex, admission CT and HUNTHESS grade and Aneurysm diameter, aneurysm neck width, aneurysm site, the number of aneurysms, the selection of interventional treatment methods and intraoperative complications of intracranial very Small aneurysms, wide-necked aneurysms, dissection aneurysms, and fusiform aneurysms, and discharge GOS score, follow-up statistics on such cases and to describe the frequency distribution.
2Systematic stratificate on the selected patients, for all of the above prognostic factors in multiple regression statistical analysis whether the impact of various factors on the prognosis, and further analysis of the weights of various factors and the relationship between various factors.
3To learn the differences in the incidence of intraoperative complications by comparative analysis of interventional treatment methods for complex intracranial aneurysms, to evaluate safety and efficacy of pure coil embolization, balloon-assisted coil embolization, stent-assisted coil embolization in the treatment of complex intracranial aneurysms.
4A prospective randomized controlled trial designed,60patients were divided into experimental group and control group, the experimental group were given Western therapy and Naomai.liejing Tang orally, the control group was given western medicine, detected cerebrospinal fluid levels of ET-1and NO on3and7days after the onset with the enzyme-labeled immunosorbent assay (ELISA), Doppler detected the incidence of cerebral vasospasm on7days after SAH.
Results
1General Information
A total of409cases of patients,161cases were male (39.3%) and248cases were females (60.7%), mean age54.47±13.6years old.
2State before hospital
first symptom in259cases alone were headache (63.4%),81cases of disturbance of consciousness (19.7%), hemiplegia in18cases (4.4%), dizziness onset in18cases (4.4%), ocular symptoms in8cases (2.8%), epilepsy in2cases (0.5%), other18cases (4.4%). CT grade0in103cases (25.18%), grade1in6cases (1.47%),2Grade in181cases (44.15%),3grade in79cases (19.32%),4grade in40cases (9.78%). HUNT-HESS grade0in103cases (25.18%), grade1in25cases (6.11%), grade2in158(38.63%), grade3in71cases (17.36%), grade4in46cases (11.25%).
3Intracranial aneurysm site
anterior communicating artery aneurysm in98patients (23.96%), left posterior communicating artery aneurysm55cases (13.45%), right posterior communicating artery aneurysm in46cases (11.25%), left anterior cerebral artery7cases (1.71%), right anterior cerebral artery aneurysms in8cases (1.96%), the left middle cerebral artery aneurysm in23cases (7.33%), right middle cerebral artery aneurysm in32patients (7.82%), the left brain artery aneurysm in4case (0.98%), Right middle cerebral artery aneurysm in3cases (0.73%), basilar artery in26cases (6.36%), left vertebral artery aneurysm in18patients (4.4%), right vertebral artery aneurysm in12cases (2.93%), left internal carotid artery aneurysm in32cases (7.82%), right internal carotid artery aneurysm of38cases (9.29%). Hunt-hess grade and lung infection had a significant effect on the prognosis, P<0.05; Hunt-hess grade had a significant effect on the occurrence of cerebral vasospasm, P<0.05.6The differences in the incidence of interventional treatment methods and intraoperative complications for complex intracranial aneurysms
4The difference of methods and complication of complex intracranial aneurysms with interventional treatment
46cases of intracranial very small aneurysms,9cases unruptured,38cases ruptured, balloon-assisted embolization in16cases, pure coil embolization in16casesand stent-assisted embolization in11cases, onyx embolization in2case and double catheter technique embolization in1case, failed embolization in1case. Among stent-assisted embolization case, solitaire stent-assisted embolization in six cases, enterprise stent-assisted embolization in four cases, neuroform stent-assisted embolization in1cases. Five cases have intraoperative complications, including1cases due to aneurysm rupture leading to death,1cases due to coil escape to small branch of the brain middle cerebral artery caused aphasia。The remaining are fully restored in which a small amount of intraoperative bleeding in1patient, one coil escape to the brain artery bifurcation in1patient, and a small amount of coil prolapse to the parent artery in1patient.
197cases of wide-necked aneurysms, stent-assisted embolization in48cases, failed embolization in1case. Among stent-assisted embolization case, neuroform stent-assisted embolization in9cases, solitaire stent-assisted embolization in24cases, enterprise stent-assisted embolization in15cases. Semi-release technology was adopted in33cases among solitaire and enterprise stent-assisted embolization.8cases have intraoperative complications, including aneurysm rupture in3cases, a small amount of coil prolapse to the parent artery in3cases, Arterial thrombosis in1case. Balloon-assisted embolization in59cases, failed embolization in1case. Intraoperative complicationsincluding aneurysm rupture in1cases, a small amount of coil prolapse to the parent artery in6cases, coil escape to the distal of artery in1case, Arterial thrombosis in1case. Pure coil embolization in90cases, failed embolization in1case, then Surgical clipping. Intraoperative complicationsincluding aneurysm rupture in7cases, a small amount of coil prolapse to the parent artery in9cases, Arterial thrombosis in2case. Double catheter technique embolization in1cases of wide-necked aneurvsm.
25cases of dissection aneurysms, middle cerebral artery in1case Posterior circulation in3cases. Stent-assisted coil embol ization in16cases, simple coil embol ization in3cases, stent placement alone in3cases, parent occlusion in3case. Intraoperative complications including aneurysm rupture in1case leading to death, a small amount of coil prolapse to the parent artery in1cases. Postoperative complications including rebleeding in1case leading to death. Complete embolization was17cases, subtotal embol ization in3cases and partial embolization in5cases.During follow-up aneurysm of two cases in incomplete embolization group enlarge, not rebleed, ang embolism again.
5cases of fusiform aneurysms, basilar artery in1case, vertebral artery in1case, middle cerebral artery in1case, internal carotid artery in1case. Stent-assisted coil embolization in3cases, ballon combined stent-assisted coil embolization in1case. In addition to part of the coil prolapse to the parent artery in1case, had no effect on blood flow, no complications in others.
"Y" stent was placed in the treatment of wide-necked aneurysms in3cases, basilar artery aneurysm in2cases, middle cerebral artery aneurysm in1case2cases with double solitaire stent-assisted embolization,1case with doublel enterprise stent-assisted embolization,, no intraoperative complications happened, postoperative complication in1cases due to the use of aspirin, clopidogrel resulted in cerebellar hemorrhage, the patient died.
Simple coil embolization, balloon-assisted coil embolization compared with stent-assisted coil embol ization obtained a higher degree of embolization, P<0.05; craniotomy clipping group had a higher incidence of hydrocephalus than embolization group, P<0.05.5The changes on the levels of the cerebrospinal fluid endothelin-1(ET-1), nitric oxide (NO) after subarachnoid hemorrhage (SAH)
The treatment group CVS occurred in10patients (33.3%), the control group CVS occurred in17cases (56.7%), significant difference exist(P<0.05); the cerebrospinal fluid levels of ET-1on3days no significant difference (P>0.05)between control group and experimental group in after SAH, the2groups of ET-1levels increased with time (P<0.05), but the control group increased more significantly, the difference was statistically significant (P<0.05.) the NO levels of the cerebrospinal fluid control has no significant difference (P>0.05)between group and experimental group on3days after the SAH,, NO levels decrease with time in2groups (P<0.05), but the control group decreased more significantly, the difference was statistically significant (P<0.05).
Conclusion
1Patients with intracranial aneurysms are mostly women, mean age54years old or so, the most commom first symptom is headache, the most common site is anterior communicating artery aneurysm and posterior communicating artery. Hunt-hess grade had a significant effect on cerebral vasospasm and prognosis. The higher Hunt-hess grade is, the higher the incidence of cerebral vasospasm, the worse prognosis
2Interventional treatment of intracranial very small aneurysms, wide-necked aneurysms, dissection aneurysms and fusiform aneurysms is safe and effective, incidence of intraoperative complications is low, but there is a certain degree of morbidity and mortality due to procedure-related complication.
3The treatment methods of complex intracranial aneurysms involved in a simple coil embolization, balloon-assisted coil embolization, stent-assisted coil embolization, parent artery occlusion, liquid glue embolization. Intraoperative complications such as aneurysm rupture, thrombosis had no significant difference between balloon-assisted coil embolization and stent-assisted coil embolization.
4Treatment of wide-necked bifurcation aneurysms with "Y"type stent is safe, but the procedure is difficult and requires high technical level.
5After the treatment with Naomai Jiejing Tang, the cerebrospinal fluid levels of ET-1decreased in patients with SAH, while the NO level increased, the incidence of cerebral vasospasm decreased, which suggested that NaomaiJiejing Tang can prevent and treat CVS after SAH effectively
引文
[1]王彬彬,卢旺盛.动脉瘤性蛛网膜下腔出血的治疗指南重点介绍[J].海军总医院学报,2010,23(3)：157-159.
[2]张国瑾,赵增荣主编.国外脑血管病研究进展[M].北京：中国医药科技出版社,2000：81-114.
[3]J.J.A.Mooij,关靖宇.动脉瘤性SAH的分级与治疗对策[J].国外医学·脑血管疾病分册.2003,11(2)：147-147.
[4]Molyneux A. Kerr R. Stratton I, et al. International Subaraehnoid AneuryanTrial (ISAT)of neuroaurgical clipping versus endovascular coiling in 2143 patients with ruptured intraeranial aneurysm:aradmized trial[J]. Lancet.2002,360(9342):1267-1274.
[5]Moret J, Congnard C, Weil A, et al. Th e "remodeling technique" in the treatment of wide neck intracranial aneurysms:angiographic results and clinical follow. up in 56 cases[J]. Intervent Neururadiol,1997,3(1):31—35.
[6]李贵福,黄胜平,李铁林等.应用新型球囊Hyperglide或Hyperform辅助弹簧圈技术栓塞治疗颅内宽颈动脉瘤(附22例分析)[J].中国微侵袭神经外科杂志,2008,12(11)：503-505.
[7]Youn SO, Lee JI, Ko JK, et al. Endovascular Treatment of Wide-Necked Intracranial Aneurysms Using Balloon-Assisted Technique with HyperForm Balloon[T]. J Korean Neurosurg Soc.2010,48(3):207-212.
[8]Mu SQ, Yang XJ, Li YX, et al. Endovascular treatment of wide-necked intracranial aneurysms using of "remodeling technique" with the HyperForm balloon[J].Chin Med J (Engl).2008,121(8):725-729.
[9]Shima H, Nomura M, Muramatsu N, et al. Embolization of a wide-necked basilar bifurcation aneurysm by double-balloon remodeling using HyperForm compliant balloon catheters[J]. J Clin Neurosci.2009,16(4):560-2.
[10]Kelly ME, Gonugunta V, Woo HH, et al. Double-balloon trapping technique for embolization of a large wide-necked superior cerebellar artery aneurysm[J]. Neurosurgery, 2008,63 (4):291-292.
[11]Fiorella D, Albuquerque FC, Masaryk TJ, et al. Balloon-in-stent technique for the constructive endovascular treatment of "ultra-wide necked" circumferential aneurysms[J]. Neurosurgery,2005,57(6):1218-27.
[12]Akiba Y, Murayama Y, Vinuela F, et al. Balloon-assisted Guglielmi detachable coiling of wide-necked aneurysm. Part:experimental evaluation[J].1 Neurosurgery 1999,45: 519-527.
[13]Levy DI, Ku A. Balloon-assisted coil placement in wide-necked aneurysms[J]. Technical note. J Neurosurg,1997,86:724-727.
[14]Lavines SD, Masri MS, Levy ML, et al. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection[J]. J Neurosurg 1997,87:817-824.
[15]Sedat J, Chau Y, Mondot L, et al. Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling:mid-term and long-term results[J]. Neuroradiology,2009,51:401-409.
[16]Shapiro M, Babb J, Becske T, et al. Safety and efficacy of adjunctive balloon remodeling during endovascular treatment of intracranial aneurysms:a literature review. AJNR Am J Neuroradiol,2008,29:1777-1781.
[17]Malek AM, Halbach VV, Phatouros CC, et al. Balloon-assist technique for endovascular coil embolization of geometrically difficult intracranial aneurysms[J]. Neurosurgery,2000,46:1397-1406.
[18]Wanke I, Forsting M. Stents for intracranial wide-necked aneurysms:more than mechanical protection[J]. Rev. Neuroradiology.2008:50(12):991-8.
[19]刘圣,施海彬,胡卫星,等Neuroform支架辅助弹簧圈填塞治疗颅内宽颈动脉瘤[J].介入放射学杂志,2009,12：883-887.
[20]Sedat J, Chau Y, Mondot L, et al. Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling:mid-term and long-term results[J] . Neuroradiology,2009,1(6):401-409.
[21]Wajnberg E, de Souza JM, Marchiori E, et al. Single-center experience with the Neuroform stent for endovascular treatment of wide-necked intracranial aneurysms [J].Surg Neurol,2009,72(6):612-619.
[22]Luo J, Lv X, Jiang C, et al. Preliminary Use of the Leo Stent in the Endovascular Treatment of Wide-necked Cerebral Aneurysms. World Neurosurg,2010,73(4):379-384.
[23]Mocco J, Snyder KV, Albuquerque FC, et al. Treatment of intracranial aneurysms with the Enterprise stent:a multicenter registry[J]. J Neurosurg,2009,110(1):35-39.
[24]Klisch J, Clajus C, Sychra V, et al.Coil embolization of anterior circulation aneurysms supported by the Solitaire ab AB Neurovascular Remodeling Device[J]. Neuroradiology.2010,52(5):349-59.
[25]Klisch J, Eger C, Sychra V, et al. Stent-assisted coil embolization of posterior circulation aneurysms using solitaire ab:preliminary experience[J]. Neurosurgery. 2009:65(2):258-266.
[26]Lubicz B, Collignon L, Raphaeli G, et al. Solitaire ab stent for endovascular treatment of intracranial aneurysms:immediate and mid-term results in 15 patients with 17 aneurysms[J]. J Neuroradiol.2010,37(2):83-88
[27]Sychra V, Klisch J, Werner M, et al. Waffle-cone technique with Solitaire abTM AB Remodeling Device:endovascular treatment of highly selected complex cerebral aneurysms[J].Neuroradiology.2010 Sep 7. [Epub ahead of print]
[28]李强 洪波 刘建民.2009世界神经外科和神经介入大会掠影[J].介入放射学杂志,2010,2：154-157.
[29]Szikora I, Berentei Z, Kulcsar Z, et al. Treatment of Intracranial Aneurysms by Functional Reconstruction of the Parent Artery:The Budapest Experience with the Pipeline Embolization Device[J]. AJNR Am J Neuroradiol,2010,31(6):1139-1147.
[30]马朝晖,李铁林.支架辅助弹簧圈栓塞治疗颅内动脉瘤并发症的文献回顾[Rev].中国脑血管病杂志,2010,7(10)：
[31]赵文元 刘建民,许奕,等.支架辅助GDC治疗颅内动脉瘤术中并发症的防治[J].介入放射学杂志,2003,12(3)：179-181.
[32]尚发军,张鸿琪,支兴龙.Neuroform支架配合弹簧圈治疗宽颈动脉瘤[J].中国微侵袭神经外科杂志(CMINSJ),2006,11 (12):566-567
[33]于春泳,梁国标,薛洪利.Neuroform支架结合弹簧圈治疗颅内宽颈动脉瘤[J].中国临床神经外科杂志,2008,13(12)：720-722.
[34]黄伟,刘建民,许亦,等.血管内治疗椎基底动脉夹层动脉瘤[J].中国微侵袭神经外科杂志,2008,13(7)：307-309.
[35]熊录,张学文,范吉平,等.近二十年来蛛网膜下腔出血中医研究现状评述.中国中医基础医学杂志,2001,7(9)：710-712
[36]黄培新.中医专科专病丛书—神经科专病中医临床诊治[M].人民卫生出版社,2005(第(?)版)
[37]郭蓉娟,韩刚,王颖辉等.72例蛛网膜下腔出血急性期患者中医症状学与病机分析[J].北京中医药大学学报(中医临床版).2005,12(4)：11-13.
[38]周绍华,等.神经系统疾病中医证治精要[M].北京：中国农业科技出版社,1997：30.
[39]从法滋.脑病的中医论治[M].北京：人民卫生出版社,1993：95.
[40]马丽,李雁.中西结合治疗蛛同膜下腔出血急性期30例临床观察[J].新中医,1999,31(5)：44-45.
[41]刘荣辉,李皓.对蛛网膜下腔出血患者术后出现脑血管痉挛的中西药治疗对比观察[J].辽宁中医杂志,2006,33(1)：49-49.
[42]李贤.脑脊液置换术联合中药治疗蛛网膜下腔出血的疗效观察[J].中西医结合研究,2010,3：142-143 158.
[43]熊家锐,王本瀚,段传志等.通窍活血汤对蛛网膜下腔出血后迟发性缺血性脑损害患者的临床疗效[J].中国脑血管病杂志.2005,2(5)：212-214 217.
[44]冯华,王宪荣,陈志等.活血化瘀类中药脑伤泰对大鼠蛛网膜下腔出血后脑微血管构筑和血脑屏障超微结构变化的影响[J].中国临床康复.2006,8(34)：7868-7871.
[45]张宏伟,鲍圣德,孙不通.中药川芎嗪对蛛网膜下腔出血后脑血管痉挛的实验研究[J].中国微侵袭神经外科杂志(CMINSJ).2008,13(3):124-127.
[46]孙保亮,张苏明,夏作理等.银杏叶提取物对蛛网膜下腔出血后氧自由基损伤的缓解效应[J].中国临床康复,2006,10(7)：28-30.
[47]黄作义,吴军,张海鸥等.刺五加对大鼠迟发性脑血管痉挛CGRP mRNA表达变化的影响[J].中国老年学杂志,2004,24(5)：442-443.
[48]范议方,韩如泉.蛛网膜下腔出血后脑血管痉挛的原因及治疗新进展[Rev].医学综述.2008,14(21)：3255-3258.
[49]Peter J. Pema, M. D. HyperGlide Case Report:Distal Vasospasm[J]. Micro Therapeutics, Inc. U.S.A. www.lmti.com.
[50]张治元,史继新.动脉瘤性蛛网膜下腔出血后脑血管痉挛的治疗进展[J].中华神经外科杂志.2009,29(5)：477-479.
[51]刘承基.《脑血管外科学》[M]汀苏科学技术出版社,2000.
[52]各类脑血管疾病诊断要点.中华神经科杂志.1996,20(6),379.
[53]中国医师协会超声医师分会.血管超声检查指南[J].中华超声医学影像杂志.2009,18(10)：911-920.
[54]国家中医药管理局脑病急症协作组.中风病诊断与疗效评定标准[J].北京中医药大学学报,1996,19(1),55-56.
[55]卢明,杜宝新,郭建文,等.对中风病急性期以阴阳辨证代替传统九型辨证的可行性临床验证[J].广州中医药大学学报.2006,23(4)：279-281.
[56]Sonobe M;Yamazaki T;Yonekura M;et al. Small unruptured intracranial aneurysm verification study:SUAVe study, Japan[J]. Stroke.2010,41(9):1969-77.
[57]Brinjikji W;Lanzino G;Cloft HJ; et al. Endovascular treatment of very small (3 mm or smaller) intracranial aneurysms:report of a consecutive series and a meta-analysis[J]. Stroke.2010 Jan;41 (1):116-21.
[58]Yang MS;Wong HF;Yang TH; et al. Alternative option in the treatment of very small ruptured intracranial aneurysms[J]. Surg Neurol.2009,72 Suppl 2:41-6.
[59]王大明,刘加春,王利军等.相对宽颈的颅内破裂微小动脉瘤的血管内治疗[J].中华神经外科杂志.2010,26(7)：608-610.
[60]李强,许奕,张琪等.脉络膜前动脉微小动脉瘤的介入治疗[J].中华神经外科杂志.2010 26(3)：223-227.
[61]Nguyen TN, Raymond J, Guilbert F, et al. Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture[J]. J Neurosurg 2008;108 (6):1088-1092.
[62]van Rooi j WJ;Keeren GJ;Peluso JP; et al. Clinical and angiographic results of coiling of 196 very small (< or= 3 mm) intracranial aneurysms[J]. AJNR Am J Neuroradiol.2009, 30 (4):835-9.
[63]Santillan A;Greenberg E;Patsalides A;et al。Long-Term Clinical and Angiographic Results of Neuroform Stent-Assisted Coil Embolization in Wide-Necked Intracranial Aneurysms[J]. Neurosurgery.2011 Nov 16. [Epub ahead of print]
[64]Klisch J, Clajus C, Sychra V, et al.Coil embolization of anterior circulation aneurysms supported by the Solitaire ab AB Neurovascular Remodeling Device[J]. Neuroradiology.2010,52(5):349-59.
[65]Klisch J, Eger C, Sychra V, et al. Stent-assisted coil embolization of posterior circulation aneurysms using solitaire ab:preliminary experience[J]. Neurosurgery. 2009:65(2):258-266.
[66]Gao X;Liang G;Li Z; et al。Stent-assisted coil embolization of wide-necked intracranial aneurysms using a semi-deployment technique:angiographic and clinical outcomes in 31 consecutive patients[J]. Interv Neuroradiol.2010,16 (4):385-93.
[67]Youn SO;Lee JI;Ko JK;et al。Endovascular Treatment of Wide-Necked Intracranial Aneurysms Using Balloon-Assisted Technique with HyperForm Balloon[J]. J Korean Neurosurg Soc.2010,48 (3):207-12.
[68]Kim JW;Park YS。Endovascular treatment of wide-necked intracranial aneurysms techniques and outcomes in 15 patients[J]. J Korean Neurosurg Soc.2011,49 (2):97-101
[69]FIORELLA D, ALBUQUERQUE F C, DESHMUKH V R, et al. Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms [J]. Neurosurgery,2006,59(2):291-300.
[70]FIORELLA D, ALBUQUERQUE F C, WOO H, et al. Neuroform in-stent stenosis:incidence, natural history and treatment strategies [J]. Neurosurgery,2006,59(1):34-42.
[71]马廉亭.颅内动脉夹层与夹层动脉瘤的诊断与治疗[J].中国临床神经外科杂志,2008,13(10)：577-578.
[72]Santos-Franco JA, Zenteno M, Lee A. Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options [J]. Neurosurg Rev,2008,31(2):131-140.
[73]Mizutani T, Kojima H, Asamoto S, et al. Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms [J]. J Neurosurg,2001,94(5):712-717.
[74]Cui L;Peng Q;Ha W; et al. Parent artery occlusion for intracranial aneurysms[J]..Interv Neuroradiol.2009,15 (3):309-15.
[75]Lv X;Li Y;Xinjian Y;et al. Results of endovascular treatment for intracranial wide-necked saccular and dissecting aneurysms using the Enterprise stent:A single center experience[J].. Eur J Radiol.2011VN.
[76]Park SI:Kim BM;Kim DI; et al. Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms[J]. JNR Am J Neuroradiol.2009,30 (7):1351-6.
[77]Oran I;Cinar C;Yagci B; et al. Ruptured dissecting aneurysms arising from non-vertebral arteries of the posterior circulation:endovascular treatment perspective[J]. Diagn Interv Radiol.2009,15 (3):159-65.
[78]Konya A, Wright KC. A double coaxial delivery systern for deployment of a two- stage stent — stage stent — graft. An experimental feasibility study[J]. Acta Radiol.2000.41 (1):67—72.
[79]Masuo 0, Terada T, Walker G. et al。 Study of the patency of small arterial branches after stent placement with an experimental in vivo model [J]. AINR Am J Neuroradiol.2002.23 (4):706—710.
[80]Higashida RT, Smith W, Gress D, et al. Intravascular stent and endovascular coilplacementfor a rupturedfusiform an eurysm of thebasilar artery. Case report and review of the literature[J]. J Neurosurg,1997,87 (6):944—949.
[81]Canton G, Levy DI, Lasheras JC. Hemodynamic changes due to stent placement in bifurcating intracranial aneurysms[J]. Neuro—surgery,2005,103 (1):146—155.
[82]Perez-Aoona E, Fessler RD. Basilar artery to bilateral posterior cerebral artery Y stenting for endovascular reconstruction of wide—necked basilar apex aneurysms:report of three cases [J]. Neurol Res,2004,26 (3):276 -281.
[83]Chow MM, Woo HH, Masaryk TJ,. et al. A hovel endovaseular treatment of a wide-necked basilar apex aneurysm by using a Yconf iguration, double—stent technique [J]. AJNR,2004, 25 (3):509—512.
[84]熊录,张学文,范吉平近二十年来蛛网膜下腔出血中医研究现状评述[J].中国中医基础医学杂志,2001,7(9)：70-74.
[85]蔡业峰,李贵福,郭建文,等.中医药干预aSAH围手术期迟发性血管痉挛的思路探讨[J].中国中医基础医学杂志.2008,14(9)：674-676.
[86]熊露,田少霞.原发性蛛网膜下腔出血从络、水、瘀、毒辨治初探[J].中国医药学报,2004,19(8)：484-486.
[87]吴小明,顾建明,王莹威.平肝潜阳化痰熄风法治疗蛛网膜下腔出血30例[J].中医药信息,2001,18(5)：43-44.
[88]Sobey CG, Faraci FM. Subarachnoid hemorrhage:what happens to the cerebral arteries Rev? Clin Exp Pharmacol Physiol,1998,25 (11):867-876.
[89]Neuschmelting V, Marbacher S, Fathi AR, et al. Elevated level of endothelin-1 in cerebrospinal fluid and lack of nitric oxide in basilar arterial plasma associated with cerebral vasospasm after subarachnoid haemorrhage in rabbits [J]. Acta Neurochir,2009, 151(7):795-802.
[90]Thampatty BP, Sherwood PR, Gallek MJ, et al. Role of Endothelin-1 in Human Aneurysmal Subarachnoid Hemorrhage:Associations with Vasospasm and Delayed Cerebral Ischemia [J]. Neurocrit Care,2011,15 (1):19-27.
[91]Pluta RM, Afshar JK, Thompson BC, et al. Increased cerebral blood flow but no reversal or prevention of vasospasm in response to L-arginine infusion after subarachnoid hemorrhage [J]. J Neurosurg,2000,92 (1):121-126.
[92]Durmaz R, Ozkara E, Kanbak G, et al. Nitric Oxide Level and Adenosine Deaminase Activity in Cerebrospinal Fluid of Patients with Subarachnoid Hemorrhage [J]. Turk Neurosurg,2008,18(2),157-164.
[93]张跃康,刘文科,马潞.川芎嗪对蛛网膜下腔出血后血浆及脑脊液中内皮素和一氧化氮含量的影响[J].2008,39(2)：211-213.
[94]肖健齐,许晶,杨福义,等.硫酸镁对蛛网膜下腔出血后急性脑血管痉挛大鼠血中一氧化氮和内皮素-1水平的影响研究[J]. Chinese General Practise,2010,13 (100):3403-3405.
[2]张国瑾,赵增荣主编.国外脑血管病研究进展[M].北京：中国医药科技出版社,2000：81-114.
[3]J.J.A.Mooij,关靖宇.动脉瘤性SAH的分级与治疗对策[J].国外医学·脑血管疾病分册.2003,11(2)：147-147.
[4]Molyneux A. Kerr R. Stratton I, et al. International Subaraehnoid AneuryanTrial (ISAT)of neuroaurgical clipping versus endovascular coiling in 2143 patients with ruptured intraeranial aneurysm:aradmized trial[J]. Lancet.2002,360(9342):1267-1274.
[5]Moret J, Congnard C, Weil A, et al. Th e "remodeling technique" in the treatment of wide neck intracranial aneurysms:angiographic results and clinical follow. up in 56 cases[J]. Intervent Neururadiol,1997,3(1):31—35.
[6]李贵福,黄胜平,李铁林等.应用新型球囊Hyperglide或Hyperform辅助弹簧圈技术栓塞治疗颅内宽颈动脉瘤(附22例分析)[J].中国微侵袭神经外科杂志,2008,12(11)：503-505.
[7]Youn SO, Lee JI, Ko JK, et al. Endovascular Treatment of Wide-Necked Intracranial Aneurysms Using Balloon-Assisted Technique with HyperForm Balloon[T]. J Korean Neurosurg Soc.2010,48(3):207-212.
[8]Mu SQ, Yang XJ, Li YX, et al. Endovascular treatment of wide-necked intracranial aneurysms using of "remodeling technique" with the HyperForm balloon[J].Chin Med J (Engl).2008,121(8):725-729.
[9]Shima H, Nomura M, Muramatsu N, et al. Embolization of a wide-necked basilar bifurcation aneurysm by double-balloon remodeling using HyperForm compliant balloon catheters[J]. J Clin Neurosci.2009,16(4):560-2.
[10]Kelly ME, Gonugunta V, Woo HH, et al. Double-balloon trapping technique for embolization of a large wide-necked superior cerebellar artery aneurysm[J]. Neurosurgery, 2008,63 (4):291-292.
[11]Fiorella D, Albuquerque FC, Masaryk TJ, et al. Balloon-in-stent technique for the constructive endovascular treatment of "ultra-wide necked" circumferential aneurysms[J]. Neurosurgery,2005,57(6):1218-27.
[12]Akiba Y, Murayama Y, Vinuela F, et al. Balloon-assisted Guglielmi detachable coiling of wide-necked aneurysm. Part:experimental evaluation[J].1 Neurosurgery 1999,45: 519-527.
[13]Levy DI, Ku A. Balloon-assisted coil placement in wide-necked aneurysms[J]. Technical note. J Neurosurg,1997,86:724-727.
[14]Lavines SD, Masri MS, Levy ML, et al. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection[J]. J Neurosurg 1997,87:817-824.
[15]Sedat J, Chau Y, Mondot L, et al. Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling:mid-term and long-term results[J]. Neuroradiology,2009,51:401-409.
[16]Shapiro M, Babb J, Becske T, et al. Safety and efficacy of adjunctive balloon remodeling during endovascular treatment of intracranial aneurysms:a literature review. AJNR Am J Neuroradiol,2008,29:1777-1781.
[17]Malek AM, Halbach VV, Phatouros CC, et al. Balloon-assist technique for endovascular coil embolization of geometrically difficult intracranial aneurysms[J]. Neurosurgery,2000,46:1397-1406.
[18]Wanke I, Forsting M. Stents for intracranial wide-necked aneurysms:more than mechanical protection[J]. Rev. Neuroradiology.2008:50(12):991-8.
[19]刘圣,施海彬,胡卫星,等Neuroform支架辅助弹簧圈填塞治疗颅内宽颈动脉瘤[J].介入放射学杂志,2009,12：883-887.
[20]Sedat J, Chau Y, Mondot L, et al. Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling:mid-term and long-term results[J] . Neuroradiology,2009,1(6):401-409.
[21]Wajnberg E, de Souza JM, Marchiori E, et al. Single-center experience with the Neuroform stent for endovascular treatment of wide-necked intracranial aneurysms [J].Surg Neurol,2009,72(6):612-619.
[22]Luo J, Lv X, Jiang C, et al. Preliminary Use of the Leo Stent in the Endovascular Treatment of Wide-necked Cerebral Aneurysms. World Neurosurg,2010,73(4):379-384.
[23]Mocco J, Snyder KV, Albuquerque FC, et al. Treatment of intracranial aneurysms with the Enterprise stent:a multicenter registry[J]. J Neurosurg,2009,110(1):35-39.
[24]Klisch J, Clajus C, Sychra V, et al.Coil embolization of anterior circulation aneurysms supported by the Solitaire ab AB Neurovascular Remodeling Device[J]. Neuroradiology.2010,52(5):349-59.
[25]Klisch J, Eger C, Sychra V, et al. Stent-assisted coil embolization of posterior circulation aneurysms using solitaire ab:preliminary experience[J]. Neurosurgery. 2009:65(2):258-266.
[26]Lubicz B, Collignon L, Raphaeli G, et al. Solitaire ab stent for endovascular treatment of intracranial aneurysms:immediate and mid-term results in 15 patients with 17 aneurysms[J]. J Neuroradiol.2010,37(2):83-88
[27]Sychra V, Klisch J, Werner M, et al. Waffle-cone technique with Solitaire abTM AB Remodeling Device:endovascular treatment of highly selected complex cerebral aneurysms[J].Neuroradiology.2010 Sep 7. [Epub ahead of print]
[28]李强 洪波 刘建民.2009世界神经外科和神经介入大会掠影[J].介入放射学杂志,2010,2：154-157.
[29]Szikora I, Berentei Z, Kulcsar Z, et al. Treatment of Intracranial Aneurysms by Functional Reconstruction of the Parent Artery:The Budapest Experience with the Pipeline Embolization Device[J]. AJNR Am J Neuroradiol,2010,31(6):1139-1147.
[30]马朝晖,李铁林.支架辅助弹簧圈栓塞治疗颅内动脉瘤并发症的文献回顾[Rev].中国脑血管病杂志,2010,7(10)：
[31]赵文元 刘建民,许奕,等.支架辅助GDC治疗颅内动脉瘤术中并发症的防治[J].介入放射学杂志,2003,12(3)：179-181.
[32]尚发军,张鸿琪,支兴龙.Neuroform支架配合弹簧圈治疗宽颈动脉瘤[J].中国微侵袭神经外科杂志(CMINSJ),2006,11 (12):566-567
[33]于春泳,梁国标,薛洪利.Neuroform支架结合弹簧圈治疗颅内宽颈动脉瘤[J].中国临床神经外科杂志,2008,13(12)：720-722.
[34]黄伟,刘建民,许亦,等.血管内治疗椎基底动脉夹层动脉瘤[J].中国微侵袭神经外科杂志,2008,13(7)：307-309.
[35]熊录,张学文,范吉平,等.近二十年来蛛网膜下腔出血中医研究现状评述.中国中医基础医学杂志,2001,7(9)：710-712
[36]黄培新.中医专科专病丛书—神经科专病中医临床诊治[M].人民卫生出版社,2005(第(?)版)
[37]郭蓉娟,韩刚,王颖辉等.72例蛛网膜下腔出血急性期患者中医症状学与病机分析[J].北京中医药大学学报(中医临床版).2005,12(4)：11-13.
[38]周绍华,等.神经系统疾病中医证治精要[M].北京：中国农业科技出版社,1997：30.
[39]从法滋.脑病的中医论治[M].北京：人民卫生出版社,1993：95.
[40]马丽,李雁.中西结合治疗蛛同膜下腔出血急性期30例临床观察[J].新中医,1999,31(5)：44-45.
[41]刘荣辉,李皓.对蛛网膜下腔出血患者术后出现脑血管痉挛的中西药治疗对比观察[J].辽宁中医杂志,2006,33(1)：49-49.
[42]李贤.脑脊液置换术联合中药治疗蛛网膜下腔出血的疗效观察[J].中西医结合研究,2010,3：142-143 158.
[43]熊家锐,王本瀚,段传志等.通窍活血汤对蛛网膜下腔出血后迟发性缺血性脑损害患者的临床疗效[J].中国脑血管病杂志.2005,2(5)：212-214 217.
[44]冯华,王宪荣,陈志等.活血化瘀类中药脑伤泰对大鼠蛛网膜下腔出血后脑微血管构筑和血脑屏障超微结构变化的影响[J].中国临床康复.2006,8(34)：7868-7871.
[45]张宏伟,鲍圣德,孙不通.中药川芎嗪对蛛网膜下腔出血后脑血管痉挛的实验研究[J].中国微侵袭神经外科杂志(CMINSJ).2008,13(3):124-127.
[46]孙保亮,张苏明,夏作理等.银杏叶提取物对蛛网膜下腔出血后氧自由基损伤的缓解效应[J].中国临床康复,2006,10(7)：28-30.
[47]黄作义,吴军,张海鸥等.刺五加对大鼠迟发性脑血管痉挛CGRP mRNA表达变化的影响[J].中国老年学杂志,2004,24(5)：442-443.
[48]范议方,韩如泉.蛛网膜下腔出血后脑血管痉挛的原因及治疗新进展[Rev].医学综述.2008,14(21)：3255-3258.
[49]Peter J. Pema, M. D. HyperGlide Case Report:Distal Vasospasm[J]. Micro Therapeutics, Inc. U.S.A. www.lmti.com.
[50]张治元,史继新.动脉瘤性蛛网膜下腔出血后脑血管痉挛的治疗进展[J].中华神经外科杂志.2009,29(5)：477-479.
[51]刘承基.《脑血管外科学》[M]汀苏科学技术出版社,2000.
[52]各类脑血管疾病诊断要点.中华神经科杂志.1996,20(6),379.
[53]中国医师协会超声医师分会.血管超声检查指南[J].中华超声医学影像杂志.2009,18(10)：911-920.
[54]国家中医药管理局脑病急症协作组.中风病诊断与疗效评定标准[J].北京中医药大学学报,1996,19(1),55-56.
[55]卢明,杜宝新,郭建文,等.对中风病急性期以阴阳辨证代替传统九型辨证的可行性临床验证[J].广州中医药大学学报.2006,23(4)：279-281.
[56]Sonobe M;Yamazaki T;Yonekura M;et al. Small unruptured intracranial aneurysm verification study:SUAVe study, Japan[J]. Stroke.2010,41(9):1969-77.
[57]Brinjikji W;Lanzino G;Cloft HJ; et al. Endovascular treatment of very small (3 mm or smaller) intracranial aneurysms:report of a consecutive series and a meta-analysis[J]. Stroke.2010 Jan;41 (1):116-21.
[58]Yang MS;Wong HF;Yang TH; et al. Alternative option in the treatment of very small ruptured intracranial aneurysms[J]. Surg Neurol.2009,72 Suppl 2:41-6.
[59]王大明,刘加春,王利军等.相对宽颈的颅内破裂微小动脉瘤的血管内治疗[J].中华神经外科杂志.2010,26(7)：608-610.
[60]李强,许奕,张琪等.脉络膜前动脉微小动脉瘤的介入治疗[J].中华神经外科杂志.2010 26(3)：223-227.
[61]Nguyen TN, Raymond J, Guilbert F, et al. Association of endovascular therapy of very small ruptured aneurysms with higher rates of procedure-related rupture[J]. J Neurosurg 2008;108 (6):1088-1092.
[62]van Rooi j WJ;Keeren GJ;Peluso JP; et al. Clinical and angiographic results of coiling of 196 very small (< or= 3 mm) intracranial aneurysms[J]. AJNR Am J Neuroradiol.2009, 30 (4):835-9.
[63]Santillan A;Greenberg E;Patsalides A;et al。Long-Term Clinical and Angiographic Results of Neuroform Stent-Assisted Coil Embolization in Wide-Necked Intracranial Aneurysms[J]. Neurosurgery.2011 Nov 16. [Epub ahead of print]
[64]Klisch J, Clajus C, Sychra V, et al.Coil embolization of anterior circulation aneurysms supported by the Solitaire ab AB Neurovascular Remodeling Device[J]. Neuroradiology.2010,52(5):349-59.
[65]Klisch J, Eger C, Sychra V, et al. Stent-assisted coil embolization of posterior circulation aneurysms using solitaire ab:preliminary experience[J]. Neurosurgery. 2009:65(2):258-266.
[66]Gao X;Liang G;Li Z; et al。Stent-assisted coil embolization of wide-necked intracranial aneurysms using a semi-deployment technique:angiographic and clinical outcomes in 31 consecutive patients[J]. Interv Neuroradiol.2010,16 (4):385-93.
[67]Youn SO;Lee JI;Ko JK;et al。Endovascular Treatment of Wide-Necked Intracranial Aneurysms Using Balloon-Assisted Technique with HyperForm Balloon[J]. J Korean Neurosurg Soc.2010,48 (3):207-12.
[68]Kim JW;Park YS。Endovascular treatment of wide-necked intracranial aneurysms techniques and outcomes in 15 patients[J]. J Korean Neurosurg Soc.2011,49 (2):97-101
[69]FIORELLA D, ALBUQUERQUE F C, DESHMUKH V R, et al. Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms [J]. Neurosurgery,2006,59(2):291-300.
[70]FIORELLA D, ALBUQUERQUE F C, WOO H, et al. Neuroform in-stent stenosis:incidence, natural history and treatment strategies [J]. Neurosurgery,2006,59(1):34-42.
[71]马廉亭.颅内动脉夹层与夹层动脉瘤的诊断与治疗[J].中国临床神经外科杂志,2008,13(10)：577-578.
[72]Santos-Franco JA, Zenteno M, Lee A. Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options [J]. Neurosurg Rev,2008,31(2):131-140.
[73]Mizutani T, Kojima H, Asamoto S, et al. Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms [J]. J Neurosurg,2001,94(5):712-717.
[74]Cui L;Peng Q;Ha W; et al. Parent artery occlusion for intracranial aneurysms[J]..Interv Neuroradiol.2009,15 (3):309-15.
[75]Lv X;Li Y;Xinjian Y;et al. Results of endovascular treatment for intracranial wide-necked saccular and dissecting aneurysms using the Enterprise stent:A single center experience[J].. Eur J Radiol.2011VN.
[76]Park SI:Kim BM;Kim DI; et al. Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms[J]. JNR Am J Neuroradiol.2009,30 (7):1351-6.
[77]Oran I;Cinar C;Yagci B; et al. Ruptured dissecting aneurysms arising from non-vertebral arteries of the posterior circulation:endovascular treatment perspective[J]. Diagn Interv Radiol.2009,15 (3):159-65.
[78]Konya A, Wright KC. A double coaxial delivery systern for deployment of a two- stage stent — stage stent — graft. An experimental feasibility study[J]. Acta Radiol.2000.41 (1):67—72.
[79]Masuo 0, Terada T, Walker G. et al。 Study of the patency of small arterial branches after stent placement with an experimental in vivo model [J]. AINR Am J Neuroradiol.2002.23 (4):706—710.
[80]Higashida RT, Smith W, Gress D, et al. Intravascular stent and endovascular coilplacementfor a rupturedfusiform an eurysm of thebasilar artery. Case report and review of the literature[J]. J Neurosurg,1997,87 (6):944—949.
[81]Canton G, Levy DI, Lasheras JC. Hemodynamic changes due to stent placement in bifurcating intracranial aneurysms[J]. Neuro—surgery,2005,103 (1):146—155.
[82]Perez-Aoona E, Fessler RD. Basilar artery to bilateral posterior cerebral artery Y stenting for endovascular reconstruction of wide—necked basilar apex aneurysms:report of three cases [J]. Neurol Res,2004,26 (3):276 -281.
[83]Chow MM, Woo HH, Masaryk TJ,. et al. A hovel endovaseular treatment of a wide-necked basilar apex aneurysm by using a Yconf iguration, double—stent technique [J]. AJNR,2004, 25 (3):509—512.
[84]熊录,张学文,范吉平近二十年来蛛网膜下腔出血中医研究现状评述[J].中国中医基础医学杂志,2001,7(9)：70-74.
[85]蔡业峰,李贵福,郭建文,等.中医药干预aSAH围手术期迟发性血管痉挛的思路探讨[J].中国中医基础医学杂志.2008,14(9)：674-676.
[86]熊露,田少霞.原发性蛛网膜下腔出血从络、水、瘀、毒辨治初探[J].中国医药学报,2004,19(8)：484-486.
[87]吴小明,顾建明,王莹威.平肝潜阳化痰熄风法治疗蛛网膜下腔出血30例[J].中医药信息,2001,18(5)：43-44.
[88]Sobey CG, Faraci FM. Subarachnoid hemorrhage:what happens to the cerebral arteries Rev? Clin Exp Pharmacol Physiol,1998,25 (11):867-876.
[89]Neuschmelting V, Marbacher S, Fathi AR, et al. Elevated level of endothelin-1 in cerebrospinal fluid and lack of nitric oxide in basilar arterial plasma associated with cerebral vasospasm after subarachnoid haemorrhage in rabbits [J]. Acta Neurochir,2009, 151(7):795-802.
[90]Thampatty BP, Sherwood PR, Gallek MJ, et al. Role of Endothelin-1 in Human Aneurysmal Subarachnoid Hemorrhage:Associations with Vasospasm and Delayed Cerebral Ischemia [J]. Neurocrit Care,2011,15 (1):19-27.
[91]Pluta RM, Afshar JK, Thompson BC, et al. Increased cerebral blood flow but no reversal or prevention of vasospasm in response to L-arginine infusion after subarachnoid hemorrhage [J]. J Neurosurg,2000,92 (1):121-126.
[92]Durmaz R, Ozkara E, Kanbak G, et al. Nitric Oxide Level and Adenosine Deaminase Activity in Cerebrospinal Fluid of Patients with Subarachnoid Hemorrhage [J]. Turk Neurosurg,2008,18(2),157-164.
[93]张跃康,刘文科,马潞.川芎嗪对蛛网膜下腔出血后血浆及脑脊液中内皮素和一氧化氮含量的影响[J].2008,39(2)：211-213.
[94]肖健齐,许晶,杨福义,等.硫酸镁对蛛网膜下腔出血后急性脑血管痉挛大鼠血中一氧化氮和内皮素-1水平的影响研究[J]. Chinese General Practise,2010,13 (100):3403-3405.