Advances in Clinical Medicine
Vol.
12
No.
12
(
2022
), Article ID:
59836
,
8
pages
10.12677/ACM.2022.12121738
252例行开颅夹闭术的前交通动脉瘤患者 回顾性分析
徐东梅1,陈程1,丰育功2*
1青岛大学临床医学院,山东 青岛
2青岛大学附属医院神经外科,山东 青岛
收稿日期:2022年11月26日;录用日期:2022年12月21日;发布日期:2022年12月30日
![](http://html.hanspub.org/file/165-1574955x1_hanspub.png?20230103090404494)
摘要
目的:描述近些年前交通动脉瘤患者的基本临床特点,归纳总结各因素与预后的相关性,提高患者术后的生存质量。方法:回顾性分析青岛大学附属医院神经外科2018年1月至2021年12月连续治疗的一系列前交通动脉瘤患者的资料。经过单因素的秩和检验筛查,确定与预后的相关性危险因素,将相关性危险因素纳入二元Logistic回归,明确预后的独立危险因素。结果:在2018年至2021年期间,共有252名颅内前交通动脉瘤患者接受外科手术夹闭治疗(平均年龄57.8岁,SD = 9.8岁)。1) 患者中≤50岁的有63例,其中男性39名,女性24名(38%);患者中>50岁的有189例,其中男性24名,女性103名(54%),绝经后女性罹患动脉瘤的比率由38%升至54%,差异有统计学意义(P = 0.024),发病年龄和动脉瘤大小无显著差异(P = 0.179)。2) 252例前交通动脉瘤患者术后3个月回访,治愈者(GOS 5)为227例(90%),自理患者(GOS 4) 20例(8%),植物生存患者(GO2-3) 4例(2%),死亡1例。3) 经过秩和检验初筛,SAH的CT分型、Hunt-Hess分级、术后并发症是影响前交通动脉瘤患者手术预后的相关危险因素;年龄、性别、SAH次数、动脉瘤侧别、大小、指向、手术时机、手术入路与预后的差异无统计学意义。4) 二元Logistic回归分析,未获得有统计学意义的独立危险因素,可能与样本量小有关。结论:我们的研究结果表明:绝经后的女性罹患脑动脉瘤的风险大大增加,绝经后女性应提早筛查、预防SAH的发生。另外,SAH的CT分型、Hunt-Hess分级、术后并发症是影响前交通动脉瘤患者手术预后的相关危险因素。
关键词
前交通动脉瘤(ACOA),显微外科手术,蛛网膜下出血(SAH),性别,预后
![](http://html.hanspub.org/file/165-1574955x2_hanspub.png?20230103090404494)
A Retrospective Analysis of 252 Patients with Anterior Communicating Artery Aneurysms Underwent Microsurgical Clipping
Dongmei Xu1, Cheng Chen1, Yugong Feng2*
1College of Clinical Medicine, Qingdao University, Qingdao Shandong
2Department of Neurosurgery, Affiliated Hospital of Qingdao University, Qingdao Shandong
Received: Nov. 26th, 2022; accepted: Dec. 21st, 2022; published: Dec. 30th, 2022
![](http://html.hanspub.org/file/165-1574955x4_hanspub.png?20230103090404494)
ABSTRACT
Objective: To describe the basic clinical characteristics of patients with communicating artery aneurysms in recent years, summarize the correlation between various factors and prognosis, and improve the quality of life of patients after surgery. Methods: A data of consecutive series of patients with communicating artery aneurysms treated in the Affiliated Hospital of Qingdao University was retrospectively reviewed from January 2018 to December 2021. Univariate analysis was conducted to examine the associated risk factors that possibly affected the patients’ outcomes. Binary Logistic regression analysis was conducted to obtain the independent risk factors. Results: A total of 252 patients with intracranial anterior communicating artery aneurysms underwent microsurgical clipping (mean age 57.8 years, SD = 9.8 years) extending from 2018 to 2021. 1) There are 63 patients who were less than 50-year-old, including of 39 males and 24 females (38%); And 189 patients were older than 50 years old, including of 24 males and 103 females (54%). The incidence of aneurysms in postmenopausal women increased from 38% to 54%, and the difference was statistically significant (P = 0.024). There was no significant difference between age and aneurysm size (P = 0.179). 2) A total of 252 patients with anterior communicating artery aneurysms were followed up 3 months after operation: 227 (90%) patients achieved a better outcome (GOS 5), 20 (8%) patients achieved a good outcome (GOS 4), 4 (2%) patients achieved a poor outcome (GO2-3) and one patient died. 3) Univariate analysis was conducted to prove the associated risk factors included characteristics of SAH on Computed Tomography (CT) scans, Hunt-Hess grade and absence of postoperative complications. There was no significant difference in age, sex, SAH times, aneurysm side, size, direction, surgical timing, operation approach and prognosis. 4) Binary logistic regression analysis, in which no statistically significant independent risk factors were obtained, may be associated with small sample sizes. Conclusion: We concluded that postmenopausal women have a significantly increased risk of obtaining cerebral aneurysms, and the postmenopausal women should be screened early to prevent the occurrence of SAH. In addition, characteristics of SAH on Computed Tomography (CT) scans, Hunt-Hess grade and absence of postoperative complications are the risk factors affecting the prognosis of patients with anterior communicating artery aneurysms.
Keywords:Anterior Communicating Artery Aneurysm (ACOA), Microsurgery, Subarachnoid Hemorrhage (SAH), Sex, Prognosis
Copyright © 2022 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
1. 引言
颅内前交通动脉动脉瘤(ACOA aneurysms)起源于双侧大脑前动脉A1段、双侧大脑前动脉A2段和ACOA本身5个动脉组成的复合体。其发病率呈逐年上升趋势,占颅内破裂动脉瘤的23%~40%,占未破裂动脉瘤的12%~15%,是颅内最常见的动脉瘤 [1]。前交通动脉瘤是前循环动脉瘤中最容易破裂的类型之一。
颅内前交通动脉动脉瘤破裂导致的蛛网膜下腔出血(SAH),是一种破坏性的卒中形式,给患者带来高病死率和疾病负担 [2] [3]。因此,有效的动脉瘤检测和治疗对于预防这类出血性卒中至关重要 [4]。本研究描述了252例前交通动脉瘤患者的基本临床特征,并对各因素进行统计学分析,以求发现其中的关联性,提高手术患者的预后。
2. 方法
2.1. 患者
数据包括2018年1月至2021年12月由青岛大学附属医院神经外科收治的252例颅内前交通动脉瘤患者,均接受显微外科夹闭手术。诊断性脑导管血管造影术(DSA)确诊了56 (22%)例患者存在前交通动脉瘤,计算机断层扫描血管造影术(CTA)确诊了195 (77%)的患者存在前交通动脉瘤,通过MRA确诊了1例前交通动脉瘤患者。如果患者有多个动脉瘤或未行DSA或CTA检查,则可根据CT下SAH模式、动脉瘤大小和形态和/或术中所见来确定前交通动脉瘤。我们的研究获得了全部患者的知情同意及青岛大学附属医院的医学伦理委员会的同意审批。
2.2. 数据采集
收集的患者患病特征包括16项参数,分别为发病时间、患者年龄,性别,SAH次数、入院Hunt-Hess分级、神志情况、动脉瘤侧别、CT下SAH分型、动脉瘤大小,动脉瘤发出部位、动脉瘤指向、手术入路方式、手术时机、术中破裂情况、术后并发症和预后情况。
CT下SAH分型 [5] 包括(0:未出血 1:局限于鞍上池内 2:双侧侧裂池鞍上池少量出血 3:双侧侧裂池鞍上池中量出血 4:双侧侧裂池鞍上池中量出血伴脑室内出血 5:额叶内血肿)。动脉瘤大小分为:(1: ≤5 mm 2: 5.1~10 mm 3: 10.1~25 mm 4: >25 mm) [6] [7]。根据动脉瘤指向将前交通动脉瘤分为:(1:前上型 2:前下型 3:后上型 4:后下型 5:复杂巨大型)。手术入路包括:(1:右翼点入路 2:左翼点入路 3:纵裂入路 4:右眉弓锁孔入路 5:左眉弓锁孔入路) [8]。手术时机分为:(1: <3D 2: 3D-2W 3: >2W)。术后并发症分为:(1:脑梗塞 2:脑积 3:脑水肿 4:无并发症 5:其他感染、出血等情况)。预后情况分为:1:治愈(GOS 5分:良好,成人能工作学习);2:自理(GOS 4分:中残或重残,生活能自理或需他人照顾);3:植物状态(GOS 2~3分:植物生存,长期昏迷,去皮质、去脑强直) 4:死亡(GOS 1分)。
2.3. 统计分析
根据中国女性自然绝经的总体中位年龄为50岁 [9],将年龄分为≤50岁和>50岁,患者年龄和性别作为分类变量,使用卡方检验,检验绝经前后女性罹患动脉瘤的差异是否有统计学意义。患者的12项基本参数经过单因素的秩和检验筛查,确定与预后的相关性危险因素,将相关性危险因素纳入二元Logistic回归,明确预后的独立危险因素。统计学意义设置为P < 0.05,使用SPSS软件(版本25.0;SPSS Inc., IBM, Armonk, New York)进行分析。
3. 结果
在2018年至2021年期间,共有252名颅内前交通动脉瘤患者接受外科手术夹闭治疗,平均年龄为57.8岁(标准差为9.8岁,中位数为58岁,最大年龄80岁,最小年龄28岁),年龄分布:≤40岁10例(4%),41~50岁53例(21%),51~60岁81例(32%),61~69岁81例(32%),≥70岁27例(11%)。其中男性125人(50%),平均年龄55.7岁(标准差为9.4岁,中位数为55岁,最大年龄75岁,最小年龄34岁);女性127人,平均年龄59.9岁(标准差为9.9岁,中位数为56.5岁,最大年龄80岁,最小年龄28岁)。29例患者(12%)患有多发动脉瘤。
患者中≤50岁的有63例,其中男性39名,女性24名(38%);患者中>50岁的有189例,其中男性24名,女性103名(54%);性别与发病年龄具有明显差异(P = 0.024)见表1,女性绝经期后颅内前交通动脉瘤罹患率明显高于男性。 女性患者在50岁以前与50岁以后在罹患前交通动脉瘤的性别占比中从38%增加到54%。患病年龄与前交通动脉瘤大小无显著差异(P = 0.179)。
Table 1. Chi-square test for sex and age
表1. 性别与发病年龄的卡方检验
a0个单元格(0.0%)的期望计数小于5。最小期望计数为31.25。b仅针对2 × 2表进行计算。
252例前交通动脉瘤患者术后3个月回访,治愈者为227例(90%),自理患者20例(8%),植物生存患者4例(2%),死亡1例。患者年龄,性别,SAH次数、入院Hunt-Hess分级、动脉瘤侧别、CT下SAH分型、动脉瘤大小,动脉瘤指向、手术入路方式、手术时机、术中破裂情况、术后并发症和预后的具体分布情况总结于表2。经过秩和检验初筛,SAH的CT分型、Hunt-Hess分级、术后并发症与预后结局有显著差异(P < 0.001),是影响前交通动脉瘤患者手术预后的相关危险因素;年龄、性别、SAH次数、动脉瘤侧别、大小、指向、手术时机、手术入路与预后的差异无统计学意义。将相关性危险因素纳入二元Logistic回归分析,未获得有统计学意义的独立危险因素(见表3),可能与样本量小有关。
Table 2. Univariate analysis results (case, n = 252)
表2. 秩和检验结果(例,n = 252)
Table 3. Binary Logistic regression analysis
表3. 二元Logistic回归分析
a在步骤1输入的变量:Hunt-Hess分级,CT示SAH特点,并发症。
4. 讨论
动脉瘤的形成以及SAH的发生率和死亡率存在性别差异,女性通常与较高的动脉瘤患病率相关 [10] [11],尤其是在绝经后年龄的人群中 [12] [13],性激素可能具有保护性作用 [14]。Ellamushi [15] 等人最近进行的一项研究,发现女性和绝经后状态都是多发性颅内动脉瘤形成的独立危险因素。在SAH动物模型上进行的研究也支持了雌激素在尿液中形成雌激素的假说。在双侧卵巢切除的雌性大鼠中,动脉瘤形成率(60%)是对照组(20%)的3倍,平均动脉瘤大小也显著增加,双侧卵巢切除的雌性大鼠发生的动脉瘤平均大小(76 +/− 27 μm,平均 +/− 标准差)大于对照组(28 +/− 4.6 μm) (P < 0.05) [16]。
ACOA动脉瘤发生率高,且易破裂,引起的SAH带来高的死亡率和致残率,所以对ACOA动脉瘤的临床特征进行研究,有助于手术风险的评估和制定针对性的治疗策略,对提高手术疗效具有重要意义 [17]。
我们的研究表明:经过秩和检验初筛,患者的术前SAH下CT分型、Hunt-Hess分级、术后并发症3项因素与预后结局有显著差异(P < 0.001),是影响前交通动脉瘤患者手术预后的相关危险因素;患者的年龄、性别、术前SAH次数、动脉瘤侧别、大小、指向、手术时机、手术入路等8项因素与预后的差异无统计学意义。陈毅斌等人研究发现,术前Hunt-Hess分级、术后脑梗死、术后脑出血是影响前交通动脉瘤患者预后的危险因素 [18]。Wojciech Kaspera等人研究表明:前交通动脉瘤形成的风险由几个独立的临床、形态和血流动力学因素决定。最强的独立危险因素包括吸烟、A1节段不对称 > 40%、低血流搏动性、A1和A2节段之间的夹角 ≤ 100˚ [19]。
1) 年龄是影响前交通动脉瘤患者术后能否获得良好预后的因素,尽管在统计学分析中差异不显著。有学者发现年龄增长是不利结局和死亡率的独立预测因素 [20] [21]。2) 研究表明性别与前交通动脉瘤患者的预后并无显著关系 [22]。3) 患者获得良好的预后结局可能性随术前发生SAH次数增多而下降,但差异无统计学意义(P = 0.078)。4) 患者入院时的Hunt-Hess分级越高,代表病情越重,往往预后结果较差,分级高的患者临床症状较重时,可行脑室外引流,控制血压稳定后再行手术。5) 手术时机:Marie-Jeanne Buscot [23] 发现证据表明,当手术治疗发生在大约12.5小时时,获得了更有利的结果(出院、回家和12个月存活)。本组数据得出手术时机对预后差异无统计学意义,但仍支持早期行开颅夹闭治疗,可有效预防再次破裂出血,改善预后。6) 术后应最大限度地降低术后并发症(脑梗塞、脑水肿、脑积水等)能够大大提高ACOA动脉瘤患者的预后结局。将相关性危险因素纳入二元Logistic回归分析后,未获得有统计学意义的独立危险因素,可能与样本量小有关。
大量研究表明,显微手术夹闭是治疗前交通动脉瘤的一种安全有效的方法 [24] [25]。与血管内治疗相比,患者更高的完全闭塞率和更低的复发率和死亡率已在其他研究中得到证实 [26] [27]。我们的研究也证实了显微手术夹闭的治愈率很高,所有252例患者都接受了手术夹闭,存活率为99.6% (GOS > 1:251/252)。Ashish Sonig [28] 报告称,当治疗超过入院第0天时(55.26%的患者;n = 6120),手术夹闭是首选的治疗方法。
这一分析的局限性包括:1) 这项研究代表了中国山东省的单一机构经验,尽管当地机构在治疗颅内动脉瘤方面是权威的。2) 本研究未将血管内治疗纳入统计。
5. 结论
我们的研究结果表明:绝经后的女性罹患脑动脉瘤的风险大大增加,绝经后女性应提早筛查、预防SAH的发生。另外,我们的研究为进一步分析影响前交通动脉瘤夹闭术后的预后危险因素提供了起点,患者的术前SAH的CT分型、Hunt-Hess分级、术后并发症是影响前交通动脉瘤患者手术预后的相关危险因素。
文章引用
徐东梅,陈 程,丰育功. 252例行开颅夹闭术的前交通动脉瘤患者回顾性分析
A Retrospective Analysis of 252 Patients with Anterior Communicating Artery Aneurysms Underwent Microsurgical Clipping[J]. 临床医学进展, 2022, 12(12): 12060-12067. https://doi.org/10.12677/ACM.2022.12121738
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NOTES
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