血管内治疗床突旁动脉瘤的方法选择及疗效分析
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摘要
目的探讨床突旁动脉瘤的特点及评估不同的血管内治疗方案的价值。方法回顾性分析北京地坛医院神经外科及北京清华长庚医院自2014年7月—2018年1月住院行血管内治疗的98例颅内床突旁动脉瘤(共104个动脉瘤)患者的临床资料、影像资料及随访结果。结果本组98例患者(共104个颅内动脉瘤)血管内治疗失败2例(2个动脉瘤),余下96例(102个动脉瘤)血管内治疗成功后即时造影示:90个动脉瘤完全栓塞,4个动脉瘤有瘤颈残余,动脉瘤体残余3个。术中9例患者动脉瘤破裂出血,3例患者有支架内血栓,6例患者有弹簧圈脱逸现象。术后2例患者视物模糊,难治性头痛1例,难治性眼球后疼痛1例。术后临床随访所有患者的Rankin评分为0～5分,2例患者死亡。92例患者(98个动脉瘤)术后获影像学随访,11例动脉瘤复发患者(11个动脉瘤)接受再治疗。结论本研究结果显示对于破裂和未破裂的床突旁动脉瘤,新型血管内栓塞材料存在某些局限性,且安全性及有效性有待进一步证实,传统的血管内治疗方法仍是有效的治疗方案,但是由于高分流率的存在,大部分动脉瘤需要支架辅助技术,术中尽量做到致密栓塞。
Objective To explore the clinic characteristics of paraclinoid aneurysms and evaluate the value of different endovascular treatment for it. Methods The clinical data,image data and follow-up results of 98 patients( 104 paraclinoid aneurysms) underwent endovascular treatment at Department of Neurosurgery,Beijing Ditan Hospital and Department of Neurosurgery,Beijing Tsinghua ChangGung Hospital from July 2014 to Janurary 2018,were analyzed retrospectively. Results Of the 98 patients( 104 aneurysms),2( 2 aneurysms) failed,immediate angiogram after procedure of the other 96( 102 aneurysms) showed complete occlusion in 90 aneurysms,residual necks were left in 4 aneurysms,residual aneurysm were left in 3. There were 22 patients experienced periprocedual complications,6 aneurismal perforations during the procedure,3 in-stent thromboses,2 blurred vision,1 intractable headache and 1 pain behind the eye. Clinical follow-up showed all the patients' Rankin scale was 0-5,2 patients died. 11 of the 98 aneurysm experienced retreatment. The follow-up was continued. Conclusions This study indicates that the new interventional therapy material has some limation in treating ruptured and unruptured paraclinoid aneurysms,and addional evidence is needed to support their efficacy and safety. The conventional endovascular treatment is still a safe and effective therapeutic alternative. But most of the aneurysms need stent assisted coiling because of the high recurrence rate.
Objective To explore the clinic characteristics of paraclinoid aneurysms and evaluate the value of different endovascular treatment for it. Methods The clinical data,image data and follow-up results of 98 patients( 104 paraclinoid aneurysms) underwent endovascular treatment at Department of Neurosurgery,Beijing Ditan Hospital and Department of Neurosurgery,Beijing Tsinghua ChangGung Hospital from July 2014 to Janurary 2018,were analyzed retrospectively. Results Of the 98 patients( 104 aneurysms),2( 2 aneurysms) failed,immediate angiogram after procedure of the other 96( 102 aneurysms) showed complete occlusion in 90 aneurysms,residual necks were left in 4 aneurysms,residual aneurysm were left in 3. There were 22 patients experienced periprocedual complications,6 aneurismal perforations during the procedure,3 in-stent thromboses,2 blurred vision,1 intractable headache and 1 pain behind the eye. Clinical follow-up showed all the patients' Rankin scale was 0-5,2 patients died. 11 of the 98 aneurysm experienced retreatment. The follow-up was continued. Conclusions This study indicates that the new interventional therapy material has some limation in treating ruptured and unruptured paraclinoid aneurysms,and addional evidence is needed to support their efficacy and safety. The conventional endovascular treatment is still a safe and effective therapeutic alternative. But most of the aneurysms need stent assisted coiling because of the high recurrence rate.
引文
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[16]Jeon JS,Ahn JH,Huh W,et al. A retrospective analysis on the natural history of incidental small paraclinoid unruptured aneurysm[J]. J Neurol Neurosurg Psychiatry,2014,85:289.
[17]Ajay Malhotra,Xiao Wu,Howard P,et al. Management of tiny unruptured intracranial aneurysm:A comparative effectiveness analysis[J]. JAMA Neurol,2018,75:27.
[18]张鸿祺.颅内未破裂微小动脉瘤是否需要治疗?[J].中国脑血管病杂志,2013,10:1.
[19]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,2010,41:116.
[20]Doerfler A,Becker W,Wan Ice I,et al. Endovascular treatment of cerebrovascular disease[J]. Curt opin Neurol,2004,17:481.
[21]Kirkpatrick P. Aneurysm recurrence after treatment of paraclinoid/ophthalmic segment aneurysms—a treatment-modality assessment[J]. Acta Neurochir(Wien),2005,147:611.
[22]Raymond J,Guilbert F,Weill A,et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils[J]. Stroke 2003,34:1398.
[23]Feng MT,Wen WL,Feng ZZ,et al. Endovascular embolization of intracranial aneurysm:To use stent(s)or not? systematic review and meta-analysis[J]. World Neurosurg,2016,93:271.
[24]Higashida RT, Halbach VV, Dowd CF, et al. Initial clinicalexperience with a new self-expanding nitinol stent for the treatment of intracranial cerebral aneurysms:the Cordis Enterprise stent[J]. Am J Neuroradiol,2005,26:1751.
[25]Florella D,Albuquerque FC,Mc Dougall CG. Durability of aneurysmal embliizationg with matrix detachable coils[J].Neurosurgery,2006,58:51.
[2]Chen LK,Kato Y,Karagiozov KL,et al. Usefulness of a simplified management scheme for paraclinoid aneurysms based on a modified classification[J]. Cerebrovasc Dis,2008,26:388.
[3]Jin SC,Kwon DH,Ahn JS,et al. Clinical and radiogical outcomes ofendovascular detachable coil embolization in paraclinoid aneurysm:a10-yearexperience[J]. J Korean Neurosurgdoi,2009,45:5.
[4]Kim JM,Romano A,Sanan A,et al. Microsurgical anatomic features and no-menclature of the paraclinoid region[J].Neurosurgery 2000,46:670; discussion 680.
[5]Roy D,Raymond J,Bouthillier A,et al. Endovascular treatment of ophthalmic segment aneurysms with guglielmi detachable coils[J].Am J Neuroradiol,1997,18:1207.
[6]李明华.一种新型的脑动脉瘤血管内治疗技术-脑血管覆膜支架的问世[J].介入放射学杂志,2010,19:253.
[7]Lubicz B,Jy G,Leclerc X,et al. Giant aneurysms of the internal carotid artery:endovascular treatment and long-term follow-up[J].Neuroradiology,2003,45:650.
[8]Ding D. Visual outcomes after treatment of paraclinoid aneurysms:comparison of surgical and endovascular interwentions[J]. Acta Neurochir(Wien),2015,157:773.
[9]Vincent F,Weill A,Roy D,et al. Carotid ophthalmic aneurysm rupture after parent vessel occlusion[J]. Am J Neuroradiol,2005,26:1372.
[10]Brilstra EH,Rinkel GJ,Klijn CJ,et al. Excimer laser-assisted bypass in aneurysm treatment:short-term outcomes[J]. J Neurosurg,2002,97:1029.
[11]Chalouhi N,Zanaty M,Whiting A,et al. Treatment of ruptured intracranial aneurysms with the pipeline embolization device[J].Neurosurgery,2015,76:165; discussion 172.
[12]Lylyk P,Miranda C,Ceratto R,et al. Curative endovascular Reconstruction of cerebral aneurysms with the pipeline embolization device:the Buenos Aires experience[J]. Neurosurgery,2009,64:632.
[13]Aydin K,Arat A,Sencer S,et al. Treatment of ruptured blood Blister-like aneurysms with flow Diverter SILK stent[J]. J Neurointery Surg,2015,7:202.
[14]D'urso PI,Karadeli HH,Kallmes DF,et al. Coiling for paraclinoid aneurysms:time to make way for flow diverters?[J]. Am J Neuroradiol,2012,33:1470.
[15]梁正,马骏.颅内微小动脉瘤的影像学诊断[J].临床神经外科杂志,2015,12:153.
[16]Jeon JS,Ahn JH,Huh W,et al. A retrospective analysis on the natural history of incidental small paraclinoid unruptured aneurysm[J]. J Neurol Neurosurg Psychiatry,2014,85:289.
[17]Ajay Malhotra,Xiao Wu,Howard P,et al. Management of tiny unruptured intracranial aneurysm:A comparative effectiveness analysis[J]. JAMA Neurol,2018,75:27.
[18]张鸿祺.颅内未破裂微小动脉瘤是否需要治疗?[J].中国脑血管病杂志,2013,10:1.
[19]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,2010,41:116.
[20]Doerfler A,Becker W,Wan Ice I,et al. Endovascular treatment of cerebrovascular disease[J]. Curt opin Neurol,2004,17:481.
[21]Kirkpatrick P. Aneurysm recurrence after treatment of paraclinoid/ophthalmic segment aneurysms—a treatment-modality assessment[J]. Acta Neurochir(Wien),2005,147:611.
[22]Raymond J,Guilbert F,Weill A,et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils[J]. Stroke 2003,34:1398.
[23]Feng MT,Wen WL,Feng ZZ,et al. Endovascular embolization of intracranial aneurysm:To use stent(s)or not? systematic review and meta-analysis[J]. World Neurosurg,2016,93:271.
[24]Higashida RT, Halbach VV, Dowd CF, et al. Initial clinicalexperience with a new self-expanding nitinol stent for the treatment of intracranial cerebral aneurysms:the Cordis Enterprise stent[J]. Am J Neuroradiol,2005,26:1751.
[25]Florella D,Albuquerque FC,Mc Dougall CG. Durability of aneurysmal embliizationg with matrix detachable coils[J].Neurosurgery,2006,58:51.