張昌偉，王朝華，徐 丁

·專題：老年顱內(nèi)動(dòng)脈瘤介入診治·

血管介入栓塞術(shù)與開(kāi)顱夾閉術(shù)治療老年后交通動(dòng)脈瘤并動(dòng)眼神經(jīng)麻痹的效果及預(yù)后對(duì)比研究

張昌偉，王朝華，徐 丁

目的 比較觀察血管介入栓塞術(shù)和開(kāi)顱夾閉術(shù)治療老年后交通動(dòng)脈瘤(posterior communicating artery aneurysm, PcomAA)并動(dòng)眼神經(jīng)麻痹(oculomotornerve palsy, 0MNP)的效果及預(yù)后。方法 回顧性分析2008年1月—2013年6月在我院接受治療的322例PcomAA并0MNP臨床資料，按手術(shù)方式分為栓塞組(行血管介入栓塞治療)162例和夾閉組(行開(kāi)顱夾閉術(shù)治療)160例，比較兩組手術(shù)相關(guān)指標(biāo)、0MNP恢復(fù)效果及術(shù)后并發(fā)癥情況。結(jié)果 栓塞組手術(shù)時(shí)間、術(shù)后恢復(fù)自主呼吸時(shí)間及術(shù)中出血量均顯著優(yōu)于夾閉組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.01)。夾閉組OMNP完全恢復(fù)率高于栓塞組(P<0.05)，但兩組OMNP總恢復(fù)率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。栓塞組術(shù)后腦梗死、腦血管痙攣、腦水腫及脫水發(fā)生率顯著低于夾閉組(P<0.05或P<0.01)。結(jié)論 血管介入栓塞術(shù)和開(kāi)顱夾閉術(shù)治療老年P(guān)comAA并0MNP有著各自的優(yōu)勢(shì)與缺點(diǎn)，臨床醫(yī)師需根據(jù)患者綜合情況選擇合適的手術(shù)治療方式。

顱內(nèi)動(dòng)脈瘤；動(dòng)眼神經(jīng)損傷；老年人；血管介入栓塞；開(kāi)顱夾閉術(shù)

后交通動(dòng)脈瘤(posterior communicating artery aneurysm， PcomAA)是發(fā)病率最高的一種顱內(nèi)動(dòng)脈瘤，占顱內(nèi)動(dòng)脈瘤的45.9%[1]。因PcomAA與動(dòng)眼神經(jīng)毗鄰，動(dòng)眼神經(jīng)受到瘤體壓迫或出血導(dǎo)致動(dòng)眼神經(jīng)水腫、移位，常造成動(dòng)眼神經(jīng)麻痹(oculomotornerve palsy, 0MNP)，而蛛網(wǎng)膜下腔出血(subarachnoid hemorrhage， SAH)也是其常見(jiàn)并發(fā)癥[2]。研究指出，OMNP療效與動(dòng)眼神經(jīng)損傷程度緊密相關(guān)，早期及時(shí)治療對(duì)患者預(yù)后十分重要[3]。目前，血管介入栓塞術(shù)與開(kāi)顱夾閉術(shù)是治療PcomAA并0MNP的主要手段，而術(shù)后OMNP能否恢復(fù)及恢復(fù)程度如何，關(guān)系到患者的生活質(zhì)量。目前對(duì)于兩種手段的治療效果仍有較大爭(zhēng)議,本研究選取2008年1月—2013年6月在我院治療的322例老年P(guān)comAA并0MNP患者，探討兩種手段的治療效果及患者預(yù)后，現(xiàn)報(bào)告如下。

1 資料與方法

1.1 納入及排除標(biāo)準(zhǔn) 納入標(biāo)準(zhǔn)：①經(jīng)MRI或CT檢查確診，符合PcomAA并0MNP的診斷標(biāo)準(zhǔn)[4]；②影像學(xué)檢查證實(shí)動(dòng)眼神經(jīng)損傷與同側(cè)PcomAA有相關(guān)性；③入院時(shí)為未破裂動(dòng)脈瘤或破裂出血，但Hunt-Hess分級(jí)≤Ⅲ級(jí)；④年齡>60歲；⑤術(shù)后或隨訪經(jīng)數(shù)字減影血管造影證實(shí)PcomAA基本不顯影；⑥患者可配合術(shù)后長(zhǎng)期隨訪，所有治療均取得患者知情同意。排除標(biāo)準(zhǔn)：①入院時(shí)Hunt-Hess分級(jí)>Ⅲ級(jí)的PcomAA患者；②患者有明顯的心、肺、腎功能障礙；③患者及家屬拒絕手術(shù)。

1.2 納入對(duì)象及分組 選擇2008年1月—2013年6月在我院住院治療的322例老年P(guān)comAA并0MNP患者，按手術(shù)方式分為栓塞組(血管介入栓塞治療)162例和夾閉組(開(kāi)顱動(dòng)脈瘤夾閉術(shù))160例。兩組在性別、年齡、動(dòng)脈瘤直徑、是否發(fā)生SAH、0MNP程度、發(fā)病至治療時(shí)間方面比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性。兩組一般資料見(jiàn)表1。

表1 血管介入栓塞與開(kāi)顱夾閉術(shù)治療老年后交通動(dòng)脈瘤并動(dòng)眼神經(jīng)麻痹患者一般資料比較

注：SAH為蛛網(wǎng)膜下腔出血，0MNP為動(dòng)眼神經(jīng)麻痹

1.3 治療方法

1.3.1 血管介入栓塞治療：患者取平臥位，全身麻醉后以股動(dòng)脈為穿刺點(diǎn)，常規(guī)消毒后采用Seldinger技術(shù)置入6F導(dǎo)引鞘，股動(dòng)脈入路將6指導(dǎo)引導(dǎo)管送至頸內(nèi)動(dòng)脈巖段，在微導(dǎo)絲的導(dǎo)引下將微導(dǎo)管小心置入動(dòng)脈瘤腔內(nèi)，根據(jù)造影選擇合適大小的微彈簧圈填塞入動(dòng)脈瘤腔內(nèi)，填塞完畢后造影確定動(dòng)脈瘤栓塞情況及載瘤動(dòng)脈情況。若為寬頸動(dòng)脈瘤則輔助應(yīng)用血管支架及球囊栓塞。隨訪6～12個(gè)月，復(fù)查數(shù)字減影血管造影觀察動(dòng)脈瘤變化情況。

1.3.2 開(kāi)顱夾閉術(shù)治療：采用患側(cè)標(biāo)準(zhǔn)翼點(diǎn)入路行開(kāi)顱動(dòng)脈瘤夾閉術(shù)，在顯微鏡下分離側(cè)裂后打開(kāi)視神經(jīng)池及頸內(nèi)動(dòng)脈池，降腦組織壓力，緩慢釋放腦脊液，顯露載瘤動(dòng)脈及動(dòng)脈瘤瘤頸。根據(jù)患者動(dòng)脈瘤的大小、瘤頸、指向選擇合適的動(dòng)脈瘤夾進(jìn)行夾閉。手術(shù)過(guò)程中要注意保護(hù)周圍后交通動(dòng)脈、脈絡(luò)膜前動(dòng)脈，對(duì)于粘連的動(dòng)脈瘤囊與動(dòng)眼神經(jīng)無(wú)需分離，以避免傷及動(dòng)眼神經(jīng)[5]。術(shù)后3～7 d復(fù)查頭顱計(jì)算機(jī)體層攝影血管成像了解動(dòng)脈瘤夾閉情況。

1.4 觀察指標(biāo)及評(píng)判標(biāo)準(zhǔn) 觀察記錄兩組手術(shù)一般資料，包括手術(shù)時(shí)間、術(shù)中出血量、術(shù)后恢復(fù)自主呼吸時(shí)間和術(shù)后并發(fā)癥發(fā)生情況。所有患者術(shù)后1、3、6、12個(gè)月進(jìn)行門診或電話隨訪，了解0MNP的恢復(fù)情況。0MNP診斷標(biāo)準(zhǔn)[6]:①眼瞼下垂；②眼外肌麻痹；③復(fù)視；④患側(cè)眼瞳孔散大及直接、間接對(duì)光反射消失。滿足4項(xiàng)為完全型0MNP,滿足1～3項(xiàng)則為部分型0MNP。0MNP恢復(fù)標(biāo)準(zhǔn)[6]:①無(wú)上瞼下垂；②無(wú)復(fù)視；③眼球向內(nèi)、向下、向上運(yùn)動(dòng)不受限；④瞳孔對(duì)光反射部分或完全恢復(fù)。滿足4項(xiàng)為完全恢復(fù),滿足1～3項(xiàng)則為部分恢復(fù)。

2 結(jié)果

2.1 手術(shù)相關(guān)指標(biāo)比較 治療后，栓塞組手術(shù)時(shí)間、術(shù)后恢復(fù)自主呼吸時(shí)間以及術(shù)中出血量均顯著優(yōu)于夾閉組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.01)。見(jiàn)表2。

表2 血管介入栓塞與開(kāi)顱夾閉術(shù)治療老年后交通動(dòng)脈瘤并動(dòng)眼神經(jīng)麻痹患者手術(shù)相關(guān)指標(biāo)比較±s)

2.2 0MNP恢復(fù)效果比較 夾閉組0MNP完全恢復(fù)率高于栓塞組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；但兩組0MNP總恢復(fù)率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。見(jiàn)表3。

表3 血管介入栓塞與開(kāi)顱夾閉術(shù)治療老年后交通動(dòng)脈瘤并動(dòng)眼神經(jīng)麻痹患者動(dòng)眼神經(jīng)麻痹恢復(fù)效果比較[例(%)]

2.3 術(shù)后并發(fā)癥比較 栓塞組術(shù)后腦梗死、腦血管痙攣、腦水腫及脫水并發(fā)癥發(fā)生率顯著均低于夾閉組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05或P<0.01)。見(jiàn)表4。

表4 血管介入栓塞與開(kāi)顱夾閉術(shù)治療老年后交通動(dòng)脈瘤并動(dòng)眼神經(jīng)麻痹患者術(shù)后并發(fā)癥[例(%)]

3 討論

PcomAA與動(dòng)眼神經(jīng)位置毗鄰，顱內(nèi)動(dòng)脈瘤機(jī)械性占位效應(yīng)被認(rèn)為是導(dǎo)致OMNP的主要原因。有研究指出，于瘤體導(dǎo)致動(dòng)眼神經(jīng)傳導(dǎo)阻滯的早期予治療干預(yù)，可解除瘤體對(duì)動(dòng)眼神經(jīng)的壓迫、水腫、移位作用，能夠顯著提高OMNP的臨床療效[7]。PcomAA瘤體的長(zhǎng)時(shí)間壓迫可引起動(dòng)眼神經(jīng)細(xì)胞缺血、缺氧，導(dǎo)致其纖維化反應(yīng)；而瘤體中流出的血液可浸泡動(dòng)眼神經(jīng)，引發(fā)動(dòng)眼神經(jīng)水腫，并且血液刺激神經(jīng)細(xì)胞導(dǎo)致纖維化及瘢痕形成[8]。有研究證實(shí)，動(dòng)眼神經(jīng)發(fā)生纖維化后再進(jìn)行治療將難以取得理想效果，動(dòng)眼神經(jīng)功能將無(wú)法得到有效恢復(fù)[9]。開(kāi)顱夾閉術(shù)能夠?qū)α鲶w采取塑性、夾閉、穿刺及切除等手段，消除PcomAA對(duì)動(dòng)眼神經(jīng)的損傷作用，從而消除或改善OMNP癥狀。

隨著神經(jīng)介入技術(shù)的發(fā)展，近年來(lái)血管介入栓塞治療已成為治療顱內(nèi)動(dòng)脈瘤的重要手段。本文主要探討PcomAA并OMNP患者采用何種治療手段更為有益，結(jié)果顯示栓塞組手術(shù)時(shí)間、術(shù)后恢復(fù)自主呼吸時(shí)間均顯著短于夾閉組，術(shù)中出血量顯著少于夾閉組，且栓塞組術(shù)后并發(fā)癥發(fā)生率顯著低于夾閉組。有研究指出，與傳統(tǒng)的開(kāi)顱夾閉術(shù)比較，血管介入栓塞治療能夠使PcomAA并OMNP患者動(dòng)眼神經(jīng)功能得到一定程度的恢復(fù)，可能與消除了動(dòng)脈瘤搏動(dòng)有關(guān)[10]。動(dòng)眼神經(jīng)在受到刺激后較易出現(xiàn)OMNP相關(guān)癥狀，即便在單純治療顱內(nèi)動(dòng)脈瘤時(shí)，為完全暴露動(dòng)脈瘤而牽拉動(dòng)眼神經(jīng)，術(shù)后亦可出現(xiàn)不同程度的OMNP。國(guó)內(nèi)大量研究指出，血管介入栓塞治療PcomAA并OMNP患者效果優(yōu)于顯微外科手術(shù)，并有利于動(dòng)眼神經(jīng)功能的恢復(fù)[11]。由于血管介入栓塞治療可有效緩解瘤體搏動(dòng)對(duì)神經(jīng)的刺激，減輕瘤體對(duì)神經(jīng)的搏動(dòng)性沖擊，并在瘤體內(nèi)形成血栓，進(jìn)一步使動(dòng)脈瘤縮小，從而使動(dòng)眼神經(jīng)功能部分或完全恢復(fù)[12]。開(kāi)顱夾閉術(shù)雖對(duì)患者腦組織損傷較大，但可通過(guò)對(duì)PcomAA的夾閉，能有效阻斷瘤體搏動(dòng)力的傳播，減輕瘤體對(duì)動(dòng)眼神經(jīng)的壓迫，減少動(dòng)脈瘤搏動(dòng)次數(shù)，防控動(dòng)脈瘤再次出血，從而有效改善患者OMNP癥狀[13]。目前有研究指出，開(kāi)顱夾閉術(shù)能夠更為有效地恢復(fù)動(dòng)眼神經(jīng)的傳導(dǎo)功能，而且血管介入栓塞治療對(duì)于動(dòng)脈瘤瘤體的占位效應(yīng)的解除并不理想，而彈簧圈的置入甚至可能加重瘤體的占位效應(yīng)[14]。本次研究結(jié)果顯示，夾閉組OMNP完全恢復(fù)率優(yōu)于栓塞組，但是兩組總恢復(fù)率比較差異無(wú)統(tǒng)計(jì)學(xué)意義。分析夾閉組OMNP恢復(fù)效果優(yōu)于栓塞組的原因可能為：①開(kāi)顱夾閉術(shù)可清除局部血腫，而血管介入栓塞治療則要等待血腫自然吸收后方可進(jìn)行；②血管介入栓塞治療后瘤體有膨大的可能性，而開(kāi)顱夾閉術(shù)則會(huì)使瘤體萎縮；③開(kāi)顱夾閉手術(shù)后無(wú)血液外滲，而血管介入栓塞治療后可能有少量血液外滲[15]。

綜上所述，血管介入栓塞和開(kāi)顱夾閉術(shù)治療老年P(guān)comAA并OMNP患者有各自的優(yōu)勢(shì)與缺點(diǎn)，因此，需根據(jù)患者的綜合情況選擇合適的手術(shù)治療方式，以獲得更好的預(yù)后。

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Prognostic Analysis of Endovascular Embolization and Surgical Clipping for Posterior Communicating Artery Aneurysm Caused Oculomotor Palsy in Elder Patients

ZHANG Chang-wei, WANG Chao-hua, XU Ding

(Department of Neurosurgery, West China of Sichuan University, Chengdu 610041, China)

Objective To study the prognostic analysis of endovascular embolization and surgical clipping for posterior communicating artery aneurysm caused oculomotor palsy in elder patients. Methods 322 cases of elderly patients in our hospital from the January 2008-2013 year in June were analyzed retrospectively, whose symptoms were oculomotor paralysis caused by Posterior communicating artery aneurysm. According to the different ways of operation, these patients were divided into embolization group and occlusion group. The embolization group were 162 cases, 160 cases were clipped. Related surgical factors, recover of OP and postoperative complications were compared. Results The embolization group operation time(2.11±0.28)h, recovery time of spontaneous breath in time(0.58±0.12)h were significantly shorter than the clipping group, and the amount of bleeding(9.35±3.61)ml was less than the clipping group, the differences between the two groups were statistically significant (P<0.01). The recovery effect of clipping group was better than that of embolization group, the difference was statistically significant (P<0.05), but there was no significant differences in recovery rate between the two groups (P>0.05). The postoperative complications such as cerebral infarction, vasospasm, cerebral edema, dehydration and other complications were significantly less than that of the clipping group, and the difference was statistically significant (P<0.05 orP<0.01). Conclusion Endovascular embolization and microsurgical clipping have their advantages and disadvantages for aneurysm oculomotor paralysis in elderly patients, and clinicians should be based on the comprehensive conditions of patients suggest appropriate surgical modality for patients.

Intracranial aneurysm； Oculomotor nerve injuries； Aged; Oculomotor paraly; Interventional embolization

四川省科技支撐計(jì)劃項(xiàng)目(2016FZ0073)

610041 成都，四川大學(xué)華西醫(yī)院神經(jīng)外科

R743.9

A

1002-3429(2017)04-0065-04

10.3969/j.issn.1002-3429.2017.04.024

2016-12-11 修回時(shí)間：2017-02-11)