【作者】 李全福；

【导师】 范振增；

【作者基本信息】 河北医科大学 ， 外科学， 2012， 硕士

【摘要】 目的：1.比较开颅夹闭和介入栓塞治疗颅内破裂动脉瘤对慢性脑积水的影响；2.探讨动脉瘤性蛛网膜下腔出血后慢性脑积水的危险因素。方法：病例来源为我校附属第一、第二医院在2009年1月1日到2011年12月20日间住院的动脉瘤性蛛网膜下腔出血病人。入组标准：①头CT或腰穿明确诊断为SAH；②依据头CTA、MRA或DSA诊断为颅内动脉瘤；③动脉瘤经开颅夹闭或介入栓塞手术治疗。排除标准：①未发现颅内动脉瘤的SAH者；②伴发外伤、肿瘤、血液疾病、动静脉畸形(AVM)和烟雾病(MoyaMoya disease)等疾病者;③SAH前已经存在脑积水者；④无法提供出血72h以内及3周以后的头CT检查结果者；⑤发病3周内死亡或失访者；⑥未行手术治疗者；⑦介入栓塞术后又行开颅手术者。查阅病历，回顾性分析入组病人的基本信息：性别、年龄、高血压、糖尿病、吸烟及饮酒史；入院时病人Hunt-Hess分级、GCS评分；动脉瘤位置、数目、大小及侧别；手术时间、手术方式、治疗措施和住院时间。通过随访病人和查阅影像科资料，收集病人出血72小时内和3周以后的头CT，判定Fisher分级，应用出血3周以后CT评价慢性脑积水。脑积水的诊断标准为:①双侧侧脑室额角尖端距离>45mm;②两侧尾状核内缘距离>25mm;③第Ⅲ脑室宽度>6mm;④第Ⅳ脑室宽度>20mm。以上标准满足任何一项且除外原发性脑萎缩即可诊断脑积水，但在具体诊断时，需要考虑到患者临床表现加以确定。依据脑积水在SAH后的时间不同分为急性（0~3天）和慢性（>21天）。第一步，依据手术方法将病人分为开颅夹闭组和介入栓塞组，进行统计检验比较两组病人的基本临床特点和慢性脑积水的患病率。第二步，依据有无慢性脑积水将病人重新分组，对各项可能危险因素和慢性脑积水进行显著性检验，然后对有统计学意义的因子再进行多因素Logistic回归分析加以确定，得出慢性脑积水危险因素。结果：动脉瘤性蛛网膜下腔出血病人共有626例病人，不符合要求者240例，纳入研究386例，其中开颅组253例，介入组133例；男性126例，女性260例；年龄20~84岁，平均年龄（53.3±10.39）岁。开颅组和介入组在年龄、性别、既往病史、Hunt-Hess分级、Fisher分级、急性脑积水、再次出血、入院GCS方面未见统计学差异。两组病人中动脉瘤的位置均以前循环动脉瘤为主（98.4%和79.1%），其中最常见的是后交通动脉瘤，其次是前交通动脉瘤和大脑中动脉动脉瘤；中等大小（5~10mm）动脉瘤占据绝大多数。两组病人在动脉瘤数目、左、右侧别上均未见统计学差异。绝大多数后循环动脉瘤病人（91.6%）经血管内介入栓塞治疗。体积较大（>10mm）的动脉瘤大多经开颅手术夹闭。两组病人在早期手术率存在统计学差异（P=0.001），介入栓塞组有更多的病人早期得到手术治疗（60.2%）；出血破入脑室（IVH）的病人开颅组（34.39%）比介入组（10.45%）多（P=0.001）；手术夹闭组平均住院时间为14.92±6.31天，较介入组病人（13.56±8.62天）住院时间长，且存在统计学差异（P=0.001）；开颅夹闭组253例病人中，最后有65例（25.7%）出现慢性脑积水；而介入栓塞组133例病人中最后39人（29.3%）发展为慢性脑积水。两组病人慢性脑积水发生率上均未见统计学差别（P=0.445）。所有病人中104例出现慢性脑积水，发病率为26.9%。经单因素统计学分析，发现与慢性脑积水出现有统计学差异（P<0.05）的因素有以下9个：年龄、出血破入脑室、急性脑积水、再出血、Hunt-Hess分级、Fisher分级、EVD、入院GCS和住院时间。通过Logistic回归分析，慢性脑积水的独立危险因素有急性脑积水、再出血、Fisher分级和入院时GCS评分。结论：经开颅夹闭手术和血管内介入栓塞手术治疗的动脉瘤病人，慢性脑积水发病率未见差异。动脉瘤性蛛网膜下腔出血后慢性脑积水是多因素共同作用的结果，研究显示4个危险因素分别为：急性脑积水、再次出血、高Fisher分级和低入院GCS评分。手术方式尚不能认为是aSAH后慢性脑积水的预测因素。更多还原

【Abstract】 Objective:1.To compare the effects of neurosurgical and endovasculartreatment on the development of chronic hydrocephalus in patients withruptured intracranial aneurysms.2. To study the factors of hydrocephalus inthe patients with aneurysmal subarachnoid hemorrhage.Materials and Methods: We retrospectively reviewed the medicalrecords of all patients admitted with aneurysmal SAH in our university tertiary1stand2ndhospital during3years between January1st2009and December20th2011. This retrospective analysis covered patients fufilling the followingcriteria:①The diagnosis of SAH was made by CT of head or lumbarpuncture.②The diagnosis of a cerebral aneurysm was made either by DSA,MRA or CTA.③The treatment neurosurgical clipping or endovascularcoiling was performed. Exclusion criteria included:①patients withsubarachnoid hemorrhage (SAH) but no aneurysm was found.②aneurysmalpatients complicating with trauma, tumor, blood diseases, arteriovenousmalformation or MoyaMoya disease.③hydrocephalus presented beforeSAH.④no CT scans both within72hours and after3weeks of SAH.⑤death within3weeks or loss conection⑥conservatively treated patients.⑦aneurysms treated both endovascularly and neurosurgically. We reviewed themedical records of all patients admitted with aneurysmal SAH and collectedessential information such as gender, age, hypertension, diabetes, smokingor alcohol consumption history, Hunt-Hess grade, GCS scores, aneurysmlocation, number and size, operating time, treatment and length of stay. Byfollowing up the discharging patients and reviewing the radiological records,collected cranial CT scans both within72hours and after3weeks of SAH.Assessed the Fisher grade and hydrocephalus diagnosis. The diagnosis criteria of hydrocephalus includes:①the width of lateral ventricle frontal horn ismore than45mm;②the width of inner margin of bilateral caudate nucleus>25mm;③the width of the third ventricle>6mm;④the width of the fourthventricle>20mm. However, primary brain atrophy should be excluded andclinical presentation of patients should be considered. Hydrocephalus includesacute (<3days)and chronic hydrocephalus(>21days). Firstly divided thepatients into clipping and coiling groups, then statistical analysis of the datawas performed to assess any differences in the incidence of chronichydrocephalus between the two groups. Secondly divided all patients intoCH(chronic hydrocephalus) and no CH groups, performed the univariateanalysis from which variables with p values less than0.05were entered instepwise logistic regressions. Finally the factors of chronic hydrocephalus inthe patients with aneurysmal subarachnoid hemorrhage were found.Results: In626aneurysmal SAH patients,240were excluded and threehundred and eighty-six patients were brought into research. Coiling wereperformed on253and clipping on133patients. Age of the386patients in thestudy ranged from20years to84years and mean age was53.3years±10.39(SD) with67.4%being women. No difference was found in age, gender, pasthistory, Hunt-Hess grade, Fisher grade, acute hydrocephalus, rebleeding,admission GCS scores between clipping and coiling groups. Anteriorcirculation aneurysms occupied the main location part in both the two groups.Posterior communicating artery aneurysm was most common, then Anteriorcommunicating artery aneurysm and middle artery aneurysm. Most of theaneurysms are middle size(5~10mm). The two groups had no difference in thenumber or side of aneurysms. Most of the posterior circulation aneurysms(91.6%) were coiled endovascularly while more large aneurysms(>10mm)were clipped neurosurgically. More patients in coiling group got earlytreatment than clipping group(P=0.001). Patients with intraventricularhemorrhage in clipping group(34.98%) were more than coiling group(10.45%,P=0.001). The length of stay between clipping group(14.92±6.31days) andcoiling group(13.56±8.62days) was statistically different(P=0.001). After clipping25.7%and after coiling29.3%of the patients developed chronichydrocephalus. There was no statistically significant differences in theincidence of chronic hydrocephalus between the treatment groups(p=0.445).Finally104patients(26.9%) performed chronic hydrocephalus. In a logisticregression model, chronic hydrocephalus was independently associated withacute hydrocephalus, rebleeding, Fisher grade and admission GCS.Conclusion: The treatment method neurosurgical clipping orendovascular coiling used for ruptured intracranial aneurysms, has nostatistically significant effect on the development of chronic hydrocephalus. Inour study chronic hydrocephalus after aSAH seems to have multiple riskfactors including acute hydrocephalus, rebleeding, Fisher grade and lowadmission GCS. However the treatment method used is not a predisposingfactor.更多还原