Hunt-Hess Ⅲ级及其以上颅内动脉瘤的处理
摘要
目前颅内动脉瘤的治疗方法主要是显微外科手术和介入血管
内治疗及上述两种方法的联合应用。
就显微手术治疗而言，手术时机的问题一直是神经外科领域
争论的焦点之一。目前动脉瘤手术多选择在血管痉挛期之前或之后，分为早期手术和延期手术两种。所谓早期手术是指患者到达医院后，在血管痉挛期之前尽早施行手术治疗。它主要的优点在于最大程度上避免了动脉瘤再次破裂。已有大宗资料证实，动脉瘤 再出血高峰是在初次出血后24小时之内及一周之末，而且动脉瘤 再出血死亡率高达75％左右，III级以上动脉瘤患者再出血死亡率 高于8O％。显然延期手术会使一些病人因再出血而死亡，从而失去 了治疗机会。因此，动脉瘤破裂后主张早期或超早期急诊手术逐渐 成为神经外科同行的共识。其中，早期手术是指72小时以内，超早 期则指48小时以内。早期手术的另一大优点是能够清除蛛网膜下 腔和脑内的积血，引出血性脑脊液，以减少血红蛋白分解产物对 血管的刺激，从而减轻血管痉挛，降低颅内压。由于夹闭动脉瘤效果确实，术后可积极的行“3H”疗法、扩张脑血管、增加脑灌注、改善微循环以及引流血性脑脊液以缓解致命的动脉痉挛。同
时早期手术可减少急性脑积水的发生。但早期手术也有其缺点，
首先急性期手术在麻醉诱导期间及开颅过程中，易造成动脉瘤再
次破裂出血。另外急性期脑组织肿胀较严重、顺应性较差，手术
暴露动脉瘤困难，容易损伤脑组织，进一步加重脑水肿。再者夹闭
过程中，机械牵拉载瘤动脉及其附近重要血管，将加重脑血管痉
挛。随着显微神经外科及影像学的不断发展，早期手术将逐渐成
为III级及其以上动脉瘤病人的主要治疗方法。延期手术为传统的
动脉瘤治疗方案，指患者到达医院后，先行保守治疗，待血管痉
挛期过后(一般为10—14天)，再手术夹闭动脉瘤。其优点在于技
术成熟，患者术前状态较好，手术安全性高。延期手术时脑血管
痉挛期已过，手术机械牵拉血管不易造成脑缺血。另外脑水肿明
显减轻，脑组织抗机械牵拉能力较强，手术视野暴露较好，利于
手术操作。其缺点在于有一部分患者无法安全度过脑血管痉挛期，
常由于动脉瘤的再次破裂出血或脑血管痉挛造成的脑梗塞危及生
命。由于早期手术时间窗较短，对诊断及手术水平要求较高，目
前仍未得到广泛认可及普及，因此延期手术仍为治疗III级及其以
上动脉瘤病人的重要方法之一。不过目前对Hunt—Hess分级中I、
II级的病人已达成共识，即何时治疗均可，但早期更好。对III级及其以上的病人仍有很大争议，对这样的病人其综合治疗在很多
方面尚未达成共识。本文对我科自1993年5月至2004年2月收治的III级及其以上动脉瘤116例进行回顾性分析。其中起病和／或入院Hunt＆Hess Ⅲ级病人90例，单从治疗效果而言，早期手术组和延期手术组均优于间期手术组，而早期手术组与延期手术组之间无明显差别。但未手术组中，死亡率为100％，为家属拒绝手术治疗和等待痉挛期过后准备手术过程中动脉瘤再次破裂以及脑血管痉挛导致严重脑缺血、脑梗塞而死亡。结合未手术组情况，III级动脉瘤早期手术组效果最佳，延期手术组次之，间期手术组最差。因此起病即为III级的病人主要是由出血性脑损害所引起的意识障碍所致。此类病人如起病后72小时内到达医院，应早期行手治疗，以便夹闭动脉瘤的同时清除积血，解除病因。而动脉瘤首次破裂72小时后进入血管痉挛期逐渐出现意识障碍转为III级的病人，则应待血管痉挛期过后再行手术治疗，以免手术加重血管痉挛造成不可逆的脑缺血性改变。IV级动脉瘤共16例。其中，手术组8例，未手术组8例。手术组中早期手术与延期手术死亡及病残率无明显差别。而手术组与未手术组相比，死亡率明显降低。因此，积极的手术治疗可减少IV级动脉瘤死亡率，但增加残废率。V级动脉瘤是预后最差的一组。4例确诊病例中，2例在发病24小时内行急诊手术治疗，l例GOS分级II级，1例G0s分级III级；发病15
天后手术治疗1例，GOS分级II级；保守治疗1例，GOS分级I级。对于V级的患者行手术治疗虽然可以挽救一部分患者的生命，但均为预后不良，增加了患者家属及社会的负担，无实际意义。要想提高V级动脉瘤患者的预后还有待于医学技术的进一步发展，手术方法、围手术期的治疗以及康复治疗等方面的全面提高。
围手术期的治疗以及术中的处理是动脉瘤治疗过程中的重要组成部分。术前治疗的关键是防止动脉瘤的再次破裂及脑血管痉挛对脑组织造成的损害，难点在于术中动脉瘤的暴露。动脉瘤术中破裂是神经外科医师遇到的最棘手的问题，处理是否妥当会直接影响手术效果。据统计，动脉瘤整个手术过程中破裂出血的发生率为19％～50％左右。术后需根据患者病情的不同进行脑血管痉挛、脑水肿、脑积水、呼吸系统感染以及水、电解质平衡等综合治疗。
综上所述，III级及其以上动脉瘤患者，应根据发病时间、相
关神经体征以及辅助检查，判断意识障碍的原因，再根据具体情
况，结合医院的手术水平进行综合分析，选择最佳手术时机，制
定手术方案，结合围手术期的系统治疗，方可取得令人满意的效
果。
At present the main treatment methods of the intracranial aneurysm contain the microsurgery, the endovascular coiling and the united application of them.
About the microsurgery, the timing of the operation is always one of the neurosurgical focuses. The early operation is performed before the period of the vasospasm, in order to avoid the re-rupture of the aneurysm. Approved by a large amount of data, the re-rupture of the aneurysm the most easily takes place in the period of 24h and the end of initial one week after the first rupture. And the mortality of the re-rupture of the aneurysm is about 75%, whereas grade III is even above 80%. So late operation will lead a part of patients to death becourse of the re-rupture of the aneurysm. So the more and more neurosurgical doctors protest early operation, evenuper-earlyoperation. Another virtue of the early operation is to clear away the subarachnoid space and intracerebral hemorrhage, and drain bloody CSF, so that asospasm can be reduced and the intracranial pressure decreased.
After clipping the aneurysm, the "3H" therapy can be used
safely. Early operation also reduce the incidence of hydrocephalos. But early operation also has the shortcomings. Early operation is easy to induce re-bleeding when the induction period of anesthesia or procedure of craniotomy. In the acute stage the brain swelling is severe, and its compliance is poor. So the brain is easy to be damaged in the operation. Above all the early operation is the main therapy method of poor-grade aneurysm. The late operation is the traditional treatment method of aneurysm. Its technique is mature. The patients' condition is a little better. So the late operation is safer than the early one. But some patients die because the aneurysm re-rupture or the vessel spasms before operation. The early operation is not used widely, so the late operation is still the important therapy method on the aneurysm. Now the aneurysm with grade I、 II can be operated in any time, and the early operation is better . But the timing of the treatment of the aneurysm of grade III or poorer isn't coincided. This article retrospectively studies 116 cases of the aneurysms of grade III or more from 1993.5 to 2004.2. In 90 cases of grade III, in tems of the treatment outcome , the late operation team and the early operation one are both better than the intermediate operation one , and the late
operation team and the early operation one are not different. In the un-operation team, the mortality is 100%. Conjugated with the un-operation team, the early operation team is the best, the late operation one is better, and the intermediate operation one is the worst. So when the patients come into grade III at the beginning, the early operation is supported. When the patients come into grade III by and by in the vasospasm period, the late operation is supported. The number of grade IV is 16. The operation team is 8 cases, and the un-operation team is 8 cases. In the operation team, the early operation ones' mortality and morbidity is not different from the late operation ones. But the operation team's death rate is lower than the un-operation one. So the active operation can reduce the mortality of the patients of grade IV, but adds the morbidity. The outcome of patients of grade V is the worst. The early operation team is 2 cases, one is GOS grade II, the other is GOS grade III. The late operation team is 1 case, GOS grade II. The un-operation team is 1 case, GOS grade I. To the patients of grade V , the operation can save a part of patients' life, but their living quality is too bad.
The surrounding operation and intra-operation treatment is very
important. The key point is to prevent the aneurysm to re-rupture and reduce the lesion from the vasospasm. The difficulty is to expose the aneurysm in the operation. After the operation, according to the patients' condition, the complex treatment is needed, such as vasospasm, hydrocephalus, the infection of respiratory system, water electrolyte equilibration, and so on
内治疗及上述两种方法的联合应用。
就显微手术治疗而言，手术时机的问题一直是神经外科领域
争论的焦点之一。目前动脉瘤手术多选择在血管痉挛期之前或之后，分为早期手术和延期手术两种。所谓早期手术是指患者到达医院后，在血管痉挛期之前尽早施行手术治疗。它主要的优点在于最大程度上避免了动脉瘤再次破裂。已有大宗资料证实，动脉瘤 再出血高峰是在初次出血后24小时之内及一周之末，而且动脉瘤 再出血死亡率高达75％左右，III级以上动脉瘤患者再出血死亡率 高于8O％。显然延期手术会使一些病人因再出血而死亡，从而失去 了治疗机会。因此，动脉瘤破裂后主张早期或超早期急诊手术逐渐 成为神经外科同行的共识。其中，早期手术是指72小时以内，超早 期则指48小时以内。早期手术的另一大优点是能够清除蛛网膜下 腔和脑内的积血，引出血性脑脊液，以减少血红蛋白分解产物对 血管的刺激，从而减轻血管痉挛，降低颅内压。由于夹闭动脉瘤效果确实，术后可积极的行“3H”疗法、扩张脑血管、增加脑灌注、改善微循环以及引流血性脑脊液以缓解致命的动脉痉挛。同
时早期手术可减少急性脑积水的发生。但早期手术也有其缺点，
首先急性期手术在麻醉诱导期间及开颅过程中，易造成动脉瘤再
次破裂出血。另外急性期脑组织肿胀较严重、顺应性较差，手术
暴露动脉瘤困难，容易损伤脑组织，进一步加重脑水肿。再者夹闭
过程中，机械牵拉载瘤动脉及其附近重要血管，将加重脑血管痉
挛。随着显微神经外科及影像学的不断发展，早期手术将逐渐成
为III级及其以上动脉瘤病人的主要治疗方法。延期手术为传统的
动脉瘤治疗方案，指患者到达医院后，先行保守治疗，待血管痉
挛期过后(一般为10—14天)，再手术夹闭动脉瘤。其优点在于技
术成熟，患者术前状态较好，手术安全性高。延期手术时脑血管
痉挛期已过，手术机械牵拉血管不易造成脑缺血。另外脑水肿明
显减轻，脑组织抗机械牵拉能力较强，手术视野暴露较好，利于
手术操作。其缺点在于有一部分患者无法安全度过脑血管痉挛期，
常由于动脉瘤的再次破裂出血或脑血管痉挛造成的脑梗塞危及生
命。由于早期手术时间窗较短，对诊断及手术水平要求较高，目
前仍未得到广泛认可及普及，因此延期手术仍为治疗III级及其以
上动脉瘤病人的重要方法之一。不过目前对Hunt—Hess分级中I、
II级的病人已达成共识，即何时治疗均可，但早期更好。对III级及其以上的病人仍有很大争议，对这样的病人其综合治疗在很多
方面尚未达成共识。本文对我科自1993年5月至2004年2月收治的III级及其以上动脉瘤116例进行回顾性分析。其中起病和／或入院Hunt＆Hess Ⅲ级病人90例，单从治疗效果而言，早期手术组和延期手术组均优于间期手术组，而早期手术组与延期手术组之间无明显差别。但未手术组中，死亡率为100％，为家属拒绝手术治疗和等待痉挛期过后准备手术过程中动脉瘤再次破裂以及脑血管痉挛导致严重脑缺血、脑梗塞而死亡。结合未手术组情况，III级动脉瘤早期手术组效果最佳，延期手术组次之，间期手术组最差。因此起病即为III级的病人主要是由出血性脑损害所引起的意识障碍所致。此类病人如起病后72小时内到达医院，应早期行手治疗，以便夹闭动脉瘤的同时清除积血，解除病因。而动脉瘤首次破裂72小时后进入血管痉挛期逐渐出现意识障碍转为III级的病人，则应待血管痉挛期过后再行手术治疗，以免手术加重血管痉挛造成不可逆的脑缺血性改变。IV级动脉瘤共16例。其中，手术组8例，未手术组8例。手术组中早期手术与延期手术死亡及病残率无明显差别。而手术组与未手术组相比，死亡率明显降低。因此，积极的手术治疗可减少IV级动脉瘤死亡率，但增加残废率。V级动脉瘤是预后最差的一组。4例确诊病例中，2例在发病24小时内行急诊手术治疗，l例GOS分级II级，1例G0s分级III级；发病15
天后手术治疗1例，GOS分级II级；保守治疗1例，GOS分级I级。对于V级的患者行手术治疗虽然可以挽救一部分患者的生命，但均为预后不良，增加了患者家属及社会的负担，无实际意义。要想提高V级动脉瘤患者的预后还有待于医学技术的进一步发展，手术方法、围手术期的治疗以及康复治疗等方面的全面提高。
围手术期的治疗以及术中的处理是动脉瘤治疗过程中的重要组成部分。术前治疗的关键是防止动脉瘤的再次破裂及脑血管痉挛对脑组织造成的损害，难点在于术中动脉瘤的暴露。动脉瘤术中破裂是神经外科医师遇到的最棘手的问题，处理是否妥当会直接影响手术效果。据统计，动脉瘤整个手术过程中破裂出血的发生率为19％～50％左右。术后需根据患者病情的不同进行脑血管痉挛、脑水肿、脑积水、呼吸系统感染以及水、电解质平衡等综合治疗。
综上所述，III级及其以上动脉瘤患者，应根据发病时间、相
关神经体征以及辅助检查，判断意识障碍的原因，再根据具体情
况，结合医院的手术水平进行综合分析，选择最佳手术时机，制
定手术方案，结合围手术期的系统治疗，方可取得令人满意的效
果。
At present the main treatment methods of the intracranial aneurysm contain the microsurgery, the endovascular coiling and the united application of them.
About the microsurgery, the timing of the operation is always one of the neurosurgical focuses. The early operation is performed before the period of the vasospasm, in order to avoid the re-rupture of the aneurysm. Approved by a large amount of data, the re-rupture of the aneurysm the most easily takes place in the period of 24h and the end of initial one week after the first rupture. And the mortality of the re-rupture of the aneurysm is about 75%, whereas grade III is even above 80%. So late operation will lead a part of patients to death becourse of the re-rupture of the aneurysm. So the more and more neurosurgical doctors protest early operation, evenuper-earlyoperation. Another virtue of the early operation is to clear away the subarachnoid space and intracerebral hemorrhage, and drain bloody CSF, so that asospasm can be reduced and the intracranial pressure decreased.
After clipping the aneurysm, the "3H" therapy can be used
safely. Early operation also reduce the incidence of hydrocephalos. But early operation also has the shortcomings. Early operation is easy to induce re-bleeding when the induction period of anesthesia or procedure of craniotomy. In the acute stage the brain swelling is severe, and its compliance is poor. So the brain is easy to be damaged in the operation. Above all the early operation is the main therapy method of poor-grade aneurysm. The late operation is the traditional treatment method of aneurysm. Its technique is mature. The patients' condition is a little better. So the late operation is safer than the early one. But some patients die because the aneurysm re-rupture or the vessel spasms before operation. The early operation is not used widely, so the late operation is still the important therapy method on the aneurysm. Now the aneurysm with grade I、 II can be operated in any time, and the early operation is better . But the timing of the treatment of the aneurysm of grade III or poorer isn't coincided. This article retrospectively studies 116 cases of the aneurysms of grade III or more from 1993.5 to 2004.2. In 90 cases of grade III, in tems of the treatment outcome , the late operation team and the early operation one are both better than the intermediate operation one , and the late
operation team and the early operation one are not different. In the un-operation team, the mortality is 100%. Conjugated with the un-operation team, the early operation team is the best, the late operation one is better, and the intermediate operation one is the worst. So when the patients come into grade III at the beginning, the early operation is supported. When the patients come into grade III by and by in the vasospasm period, the late operation is supported. The number of grade IV is 16. The operation team is 8 cases, and the un-operation team is 8 cases. In the operation team, the early operation ones' mortality and morbidity is not different from the late operation ones. But the operation team's death rate is lower than the un-operation one. So the active operation can reduce the mortality of the patients of grade IV, but adds the morbidity. The outcome of patients of grade V is the worst. The early operation team is 2 cases, one is GOS grade II, the other is GOS grade III. The late operation team is 1 case, GOS grade II. The un-operation team is 1 case, GOS grade I. To the patients of grade V , the operation can save a part of patients' life, but their living quality is too bad.
The surrounding operation and intra-operation treatment is very
important. The key point is to prevent the aneurysm to re-rupture and reduce the lesion from the vasospasm. The difficulty is to expose the aneurysm in the operation. After the operation, according to the patients' condition, the complex treatment is needed, such as vasospasm, hydrocephalus, the infection of respiratory system, water electrolyte equilibration, and so on
引文
1.王忠诚,主编.神经外科学.武汉:湖北科学技术出版社,1998.583- 625
2.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
3.van Gijn J, Rinkel GJE，著.陈兴洲,李宏建,倪长江，译. 蛛网膜下腔出血的诊断、病因和治疗. 国外医学脑血管疾病分
册,2002,1(10):3-24
4.de Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review ofthe literature.Neurosurgery，2002 Feb;50(2):336-40; discussion, 340-2
5.M.G.Yasargil，著.凌锋，主译.显微神经外科学（II）.北京：中国科学技术出版社，2002.1－33
6.朱昀，周岱，王中.脑池内灌注尼卡地平治疗ＣＶＳ的临床研究.中国血液流变学杂志,2001，11(4)：321－2
7.王君，周敬安，刘策等.罂粟碱对于防治脑动脉瘤术后脑血管痉挛的临床研究. 解放军医学杂志,2002，12（27）：1109－10
8.Kassel LNF, Helm G, Simmons N, etal. Treatment of cerebral vasospasm with intra arterial papaverine. J Neurusurg, 1992,77: 848-852
9.Dorai Z, Hynan LS, Kopitnik TA, Samson D. Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery, 1999 Nov;45(5):1120-7; discussion 1127-8
10.Qureshi AI, Suri MF, Sung GY, Straw RN, Yahia AM, Saad M, Guterman LR, Hopkins LN. Prognostic significance of hypernatremia and hyponatremia among patients with aneurysmal subarachnoid hemorrhage.Neurosurgery.2002 Apr; 50(4): 749-55; discussion 755-6
11.安晓芳，吕波，郭娜，于光屹，宋临军.脑动脉瘤术后康复评价及治疗.中国临床康复，2002，5（6）：1398－9
2.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
3.van Gijn J, Rinkel GJE，著.陈兴洲,李宏建,倪长江，译. 蛛网膜下腔出血的诊断、病因和治疗. 国外医学脑血管疾病分
册,2002,1(10):3-24
4.de Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review ofthe literature.Neurosurgery，2002 Feb;50(2):336-40; discussion, 340-2
5.M.G.Yasargil，著.凌锋，主译.显微神经外科学（II）.北京：中国科学技术出版社，2002.1－33
6.朱昀，周岱，王中.脑池内灌注尼卡地平治疗ＣＶＳ的临床研究.中国血液流变学杂志,2001，11(4)：321－2
7.王君，周敬安，刘策等.罂粟碱对于防治脑动脉瘤术后脑血管痉挛的临床研究. 解放军医学杂志,2002，12（27）：1109－10
8.Kassel LNF, Helm G, Simmons N, etal. Treatment of cerebral vasospasm with intra arterial papaverine. J Neurusurg, 1992,77: 848-852
9.Dorai Z, Hynan LS, Kopitnik TA, Samson D. Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery, 1999 Nov;45(5):1120-7; discussion 1127-8
10.Qureshi AI, Suri MF, Sung GY, Straw RN, Yahia AM, Saad M, Guterman LR, Hopkins LN. Prognostic significance of hypernatremia and hyponatremia among patients with aneurysmal subarachnoid hemorrhage.Neurosurgery.2002 Apr; 50(4): 749-55; discussion 755-6
11.安晓芳，吕波，郭娜，于光屹，宋临军.脑动脉瘤术后康复评价及治疗.中国临床康复，2002，5（6）：1398－9