彭汤明;江涌;黄昌仁;万伟峰;杨小波;董劲虎;陈礼刚;
PENG Tangming;JIANG Yong;HUANG Changren;WAN Weifeng;YANG Xiaobo;DONG Jinhu;CHEN Ligang;Department of Neurosurgery,the Affiliated Hospital of Southwestern Medical University;

• 1:西南医科大学附属医院神经外科

摘要(Abstract)：

目的:探究开颅夹闭联合脑室穿刺术对脑动脉瘤破裂出血患者的疗效及影响因素。方法:79例Hunt-HessⅢ级以上的脑动脉瘤破裂伴蛛网膜下腔出血患者,分为观察组(行开颅夹闭联合脑室穿刺术,n=39)和对照组(行常规开颅夹闭术,n=40);记录两组患者治疗前和术后第24 h、第7及15天时的格拉斯哥昏迷(GCS)评分,评价患者的意识状态;比较两组患者的治疗效果、术后半年的并发症发生率及死亡率;运用Logistic多因素逐步回归分析影响观察组疗效的相关因素。结果:两组患者在术前和术后第24 h时的GCS评分比较,差异无统计学意义(P>0.05);术后第7及15天时,观察组患者GCS评分高于对照组(P<0.05);手术后,观察组患者恢复良好率高于对照组,病残率低于对照组(P<0.05);观察组患者死亡率与对照组比较,差异无统计学意义(P>0.05);术后随访半年发现,两组患者并发症主要为肺部和颅内感染、脑积水、电解质紊乱,观察组患者并发症发生率显著低于对照组(χ²=4.019,P=0.045);Logistic回归分析结果显示,动脉瘤二次出血、Hunt-Hess分级及术后脑积水是影响开颅夹闭联合脑室穿刺术治疗效果的相关危险因素。结论:脑动脉瘤破裂出血采用开颅夹闭联合脑室穿刺术式治疗效果好于常规开颅夹闭术。
Objective:To explore the therapeutic effect and affecting factors of cerebral hemorrhage caused by cerebral aneurysm rupture and treated by craniotomy clipping plus cerebral puncture. Methods:Seventy-nine patients with ruptured intracranial aneurysms at Hunt-Hess grade III or above and accompanied with subarachnoid hemorrhage in our hospital were divided into observe group( group O,n = 39,received craniotomy clipping and cerebral puncture),and clinical classification group( group C,n = 40,received conventional craniotomy clipping operation). Glasgow coma scale( GCS) scores of the 2 groups before operation,and in 24 h,and 7 and 15 days after the operation were recorded,and the conscious state of patients in the 2 groups were evaluated. The curative effects,complication incidence in half year after the operation,and mortality in the 2 groups were compared. The relative factors affecting curative effects of group O were analyzed using Logistic multi-factor stepwise regression.Results:GCS scores of the 2 groups before operation and in 24 h after operation did not differ significantly( P > 0. 05); In 7 and 15 days after operation,GCS scores in group O were higher than those in group C( P < 0. 05); The postoperative favorable rate was higher and disability rate was lower in group O than in group C( P > 0. 05); The mortality rates in the 2 groups were not different obviously( P <0. 05); The main complications of the 2 groups in half year after operation were pulmonary infection and cranial infection,hydrocephalus,and electrolyte disturbance. The complication incidance was signifficantly lower in group O than in group C( χ2=4.019,P=0.045);Logistic回归分析结果显示,动脉瘤二次出血、Hunt-Hess分级及术后脑积水是影响开颅夹闭联合脑室穿刺术治疗效果的相关危险因素。结论:脑动脉瘤破裂出血采用开颅夹闭联合脑室穿刺术式治疗效果好于常规开颅夹闭术。
Objective:To explore the therapeutic effect and affecting factors of cerebral hemorrhage caused by cerebral aneurysm rupture and treated by craniotomy clipping plus cerebral puncture. Methods:Seventy-nine patients with ruptured intracranial aneurysms at Hunt-Hess grade III or above and accompanied with subarachnoid hemorrhage in our hospital were divided into observe group( group O,n = 39,received craniotomy clipping and cerebral puncture),and clinical classification group( group C,n = 40,received conventional craniotomy clipping operation). Glasgow coma scale( GCS) scores of the 2 groups before operation,and in 24 h,and 7 and 15 days after the operation were recorded,and the conscious state of patients in the 2 groups were evaluated. The curative effects,complication incidence in half year after the operation,and mortality in the 2 groups were compared. The relative factors affecting curative effects of group O were analyzed using Logistic multi-factor stepwise regression.Results:GCS scores of the 2 groups before operation and in 24 h after operation did not differ significantly( P > 0. 05); In 7 and 15 days after operation,GCS scores in group O were higher than those in group C( P < 0. 05); The postoperative favorable rate was higher and disability rate was lower in group O than in group C( P > 0. 05); The mortality rates in the 2 groups were not different obviously( P <0. 05); The main complications of the 2 groups in half year after operation were pulmonary infection and cranial infection,hydrocephalus,and electrolyte disturbance. The complication incidance was signifficantly lower in group O than in group C( χ²= 4. 019,P = 0. 045); Logistic regression analysis results showed aneurysm secondary bleeding,Hunt-Hess grade,and postoperative hydrocephalus were relative risk factors influencing the curative effects of craniotomy clipping plus cerebral puncture. Conclusions:For cerebral aneurysm rupture,craniotomy clipping plus cerebral puncture can achieve better curative effect than simple conventional craniotomy clipping technique.

关键词(KeyWords)： 颅内动脉瘤;格拉斯哥昏迷量表;穿刺术;疗效;开颅夹闭术
cerebral aneurysm;Glasgow coma scale form;punctures;curative effect;craniotomy clipping

Abstract:

Keywords:

基金项目(Foundation): 四川省科技创新苗子项目(2016065);; 四川省教育厅青年基金(16ZB0910)

作者(Authors): 彭汤明;江涌;黄昌仁;万伟峰;杨小波;董劲虎;陈礼刚;
PENG Tangming;JIANG Yong;HUANG Changren;WAN Weifeng;YANG Xiaobo;DONG Jinhu;CHEN Ligang;Department of Neurosurgery,the Affiliated Hospital of Southwestern Medical University;

DOI: 10.19367/j.cnki.1000-2707.2017.03.025

参考文献(References)：

• [1]郑占强,郭都.蛛网膜下腔出血动脉瘤开颅夹闭术后并慢性脑积水的原因[J].中国实用神经疾病杂志,2016(16):79-81.
• [2]陈浩,于金录,郭云宝,等.单侧翼点入路同侧夹闭双侧大脑中动脉动脉瘤[J].中华神经外科杂志,2014(4):381-383.
• [3]Han J,Lim DJ,Kim SD,et al.Subdural hematoma without subarachnoid hemorrhage caused by the rupture of middle cerebral artery aneurysm[J].J Cerebrovasc Endovasc Neurosurg,2016(3):315-321.
• [4]Muehlschlegel S,Kursun O,Topcuoglu MA,et al.Differentiating reversible cerebral vasoconstriction syndrome with subarachnoid hemorrhage from other causes of subarachnoid hemorrhage[J].JAMA Neurol,2013(10):1254-1260.
• [5]彭岱,王汉东,李劲松,等.急诊开颅夹闭联合脑室穿刺治疗中高级别颅内破裂动脉瘤的疗效分析[J].临床神经外科杂志,2013(4):213-215.
• [6]Zhang Y,Jing L,Zhang Y,et al.Low wall shear stress is associated with the rupture of intracranial aneurysm with known rupture point:case report and literature review[J].BMC Neurol,2016(1):231.
• [7]张鑫,刘丽萍.颅内未破裂动脉瘤破裂危险因素及管理策略[J].中华医学杂志,2016(1):69-71.
• [8]Santiago-Sim T,Fang X,Hennessy ML,et al.THSD1(Thrombospondin Type 1 Domain Containing Protein 1)mutation in the pathogenesis of intracranial aneurysm and subarachnoid hemorrhage[J].Stroke,2016(12):3005-3013.
• [9]Wang JP,Wu ZY,Xu J,et al.Fully Endoscope-Controlled clipping bilateral middle cerebral artery aneurysm via unilateral supraorbital keyhole approach[J].J Craniofac Surg,2016(8):2151-2153.
• [10]呼铁民,杨立军,孟杰,等.显微手术夹闭及血管内介入栓塞术治疗高分级大脑中动脉瘤破裂的疗效及安全性研究[J].中国全科医学,2015(30):3671-3674.
• [11]郭继锋,霍楠楠,单显民.开颅夹闭治疗颅内前循环破裂动脉瘤疗效分析[J].中外医疗,2016(2):35-37.
• [12]周红,江华容,万云,等.颅内动脉瘤介入栓塞术的围手术期护理[J].贵阳医学院学报,2010(5):542-544.
• [13]张世明,吴江,刘建刚,等.动脉瘤体穿刺减压术在大型及巨大型颅内动脉瘤夹闭术中的应用[J].中华神经外科杂志,2014(11):1111-1114.

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