Zhongguo cuzhong zazhi (Sep 2018)
破裂大脑中动脉瘤多学科会诊治疗方案疗效评价：单中心261例回顾性分析 Evaluation of Multidisciplinary Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-center Retrospective Analysis
Abstract
目的 比较多学科会诊确定破裂大脑中动脉瘤患者行介入栓塞或手术夹闭动脉瘤的治疗效果。 方法 回顾性分析由神经外科及神经介入科联合会诊确定治疗方案的破裂大脑中动脉瘤患者病历 资料，分析患者围术期缺血性卒中事件、第一次治疗动脉瘤完全闭塞率。统计随访终点时患者动脉瘤 完全闭塞率、治疗相关的永久性缺血性卒中后遗症发生率、二次治疗率、再出血率及死亡率。 结果 研究共入组261例患者，介入栓塞107例，开颅手术夹闭154例。围术期缺血性卒中事件28 例（10.72%），其中24例（0.91%）存在永久的后遗症；第一次治疗动脉瘤完全闭塞介入栓塞组80 例（74.7%）、开颅夹闭组150例（97.4%）；随访终点动脉瘤完全闭塞179例（82.9%）。二次治疗9 例（0.34%）、再出血5例（0.19%），死亡5例（0.19%）。介入栓塞组治疗相关缺血性卒中事件发生率 （6.5% vs 16.8%，P =0.008）及其永久性后遗症（5.8% vs 14.0%，P =0.020）均高于开颅夹闭动脉瘤 组。开颅手术组在治疗后(97.4% vs 74.7%，P＜0.001）及随访期间(95.1% vs 65.2%，P＜0.001）的动 脉瘤完全闭塞率均高于介入栓塞组。开颅夹闭动脉瘤组无二次治疗患者，介入栓塞组有9例（8.4%） 随访过程中动脉瘤复发，继而进行二次治疗。两种治疗方式的再出血率（0.6% vs 3.7%）和死亡率 （1.3% vs 2.8%）差异无统计学意义。 结论 对于破裂大脑中动脉瘤患者，经神经外科及神经介入科联合会诊后确定治疗方案动脉瘤治 愈率较高，其中开颅手术夹闭较介入栓塞动脉瘤治疗相关的并发症较少，动脉瘤治愈率较高。 Abstract: Objective Different treatment strategies for ruptured intracranial aneurysms have been recently developed, and multidisciplinary treatment approaches have been applied in clinical practice. This study aimed to evaluate the outcome of multidisciplinary treatment for ruptured middle cerebral artery (MCA) aneurysms with surgical clipping or endovascular coil embolization. Methods A retrospective analysis of clinical data of patients with ruptured MCA aneurysms treated by clipping or coil embolization determined by consultation were conducted. The outcome measurement included that perioperative ischemic stroke and the complete occlusion rate after the first treatment; the complete occlusion rate, permanent sequelae of ischemic stroke arising from surgical procedures, retreatment, rebleeding and mortality after the whole follow-up. The average period of follow-up was 17.9 months. Results A total of 261 eligible patients were included in this study, with endovascular coil embolization for 107 cases and surgical clipping for 154 cases. Periprocedural ischemic stroke occurred in 28 patients (10.72%), and 24 cases (0.91%) of them had permanent sequelae associated with ischemic stroke. The complete aneurysm occlusion after the first treatment occurred in 80 patients (74.7%) with endovascular coil embolization, and in 150 cases (97.4%) with surgical clipping. After the completion of follow-up, the complete occlusion occurred in 179 cases (82.9%). 9 cases (0.34%) needed retreatment, 5 cases (0.19%) occurred rebleeding, and 5 cases (0.19%) died. The procedure related ischemic stroke incidence (6.5% vs 16.8%, P =0.008) and permanent sequelae of this kind of stroke (5.8% vs 14.0%, P =0.020) were higher in coil embolization group than that in clipping group. The complete occlusion rate of aneurysms immediately after surgery (97.4% vs 74.7%, P <0.001) and after the follow-up (95.1% vs 65.2%, P <0.001) were higher in surgical clipping group than that in coil embolization group. No patient needed retreatment in clipping group, while 9 ones needed retreatment in coil embolization group. There were no significant difference in rebleeding (0.6% vs 3.7%) and mortality (1.3% vs 2.8%) between the two groups. Conclusion The multidisciplinary treatment approaches for ruptured MCA aneurysms can achieve a better outcome. Surgical clipping for ruptured MCA aneurysms showed a lower rate of complications and a higher occlusion rate than endovascular coil embolization.
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