《未破裂动脉瘤的治疗》课件.ppt

1、,颅 内 未破裂动脉瘤治疗决策,第四军医大学唐都医院神经外科 高国栋,问 题,治 疗,观 察,VS ？,治疗,观察,颅内动脉瘤危害：破裂出血再出血致残、致死率高,未破裂动脉瘤：造影时（多发）、CTA、MRA,简 单 的 思 考,左边：治疗的风险,右边：观察的风险,复 杂 的 考 虑,治疗的并发症率和死亡率不确定,未破裂动脉瘤年破裂率不确定,患者生存的年限不确定,就某个具体病人而言：,世界性的难解之题,治好还是不治好 ？,Unruptured intracranial aneurysms-risk of rupture and risks of surgical intervention. N

2、Engl J Med. 1998;339:17251733.,不 治 的 依 据,Unruptured intracranial aneurysms : natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362:103110.,回顾性分析：小于10mm 没有SAH患者年出血率为 0.05%有过SAH患者年出血率为 0.5%,ISUIA （自然史）,前瞻性分析：前循环动脉瘤小于7mm没有SAH患者年出血率为0%712mm的动脉瘤年出血率为0.5%后循环

3、动脉瘤 小于7mm年出血率为0.5%712mm年出血率为2.9%,ISUIA （手术风险）,前瞻性部分：手术治疗具有较高的并发症率和死亡率 (8-18%),手术治疗的风险远远大于未破裂动脉瘤 自然破裂发生的概率,ISUIA 存在的问题（一）,随访病例剔除了具有破裂前兆的病例,随访病例包含了海绵窦段的动脉瘤,按照该破裂率计算，美国人发病人数应该远低于实际发病人数,ISUIA 存在的问题（二）,开颅手术的并发症率和死亡率高于 目前多数的临床报告数据血管内治疗的样本量小、误差大 介入技术发展已经今非昔比,不能依据ISUIA的结果做出 未破裂动脉瘤不需要 治疗的结论,我 的 观 点,积 极 治 疗,具

4、有科学依据,国外文献回顾,Juvela 报告年破裂率 1.3%（181个未破裂动脉瘤随访20年）,Tsukahara 报告年破裂率3.42% 的（181个动脉瘤随访15年),Treatment of unruptured cerebral aneurysms; a multi-center study at Japanese national hospitals. Acta Neurochir Suppl. 2005;94:7785.,Morita 总结13篇文献包括 922患者，报告年破裂率2.7%.,Risk of rupture associated with intact cerebr

5、al aneurysms in the Japanese population : a systematic review of the literature from Japan. J Neurosurg. 2005;102:601606.,显微外科技术的进步,更好的显微器械：显微镜、动脉瘤夹等,神经外科医生观念改变和技术培训的完善性,更加安全的手术,并发症率 2.3%和死亡率0%(81患者94个动脉瘤/6年）,Treatment related morbidity of unruptured intracranial aneurysms: results of a prospective

6、single centre series with an interdisciplinary approach over a 6 year period (1999-2005). J Neurol Neurosurg Psychiatry. 2007;78:864-71,总并发症率和死亡率8%(62患者62个前循环巨大动脉瘤）,Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study. J Neurosurg. 2008;109:

7、1012-8.,并发症率1.7和死亡率0.27%(376患者450个动脉瘤）,Microsurgical treatment of unruptured intracranial aneurysms. A consecutive surgical experience consisting of 450 aneurysms treated in the endovascular era. Surg Neurol. 2007;67:457-64.,并发症率3.4和死亡率0.8%(116患者148个动脉瘤）,Outcome of surgical clipping of unruptured an

8、eurysms as it compares with a 10-year nonclipping survival period.Neurosurgery,2007;60:,显微神经外科技术治疗颅内未破裂动脉瘤虽然受到患者年龄、动脉瘤大小、部位以及载瘤动脉是否具有动脉硬化等因素影响，但仍然是非常安全的治疗方式，尤其是选择性应用于一部分患者，安全性很高。相对而言：无脑压高、无粘连、易显露,手术夹闭安全、可靠,介入治疗技术的发展,新型的栓塞材料：更柔软的弹簧圈、液态Onyx、生物圈、膨胀圈,柔顺性和操作性更好的微导管,有效的辅助材料：各式辅助球囊和辅助支架,非常安全的栓塞技术,并发症率 2.2%

9、和死亡率0%(92患者96个动脉瘤）,The merits of endovascular coil surgery for patients with unruptured intracranial aneurysms. J Korean Neurosurg Soc. 2008;43:270-4,并发症率 7.7%和死亡率1.7%（321个动脉瘤）,Feasibility, procedural morbidity and mortality, and long-term follow-up of endovascular treatment of 321 unruptured aneury

10、sms. AJNR Am J Neuroradiol. 2008;29:63-8,并发症率2.6%和死亡率1.3% （149患者176动脉瘤）,Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. AJNR Am J Neuroradiol. 2006 ;27:1678-80.,并发症率2.2%和死亡率1.1% （547患者572动脉瘤）,Endovascular Treatment of Unruptured Intracranial Aneury

11、sms: Comparison of Safety of Remodeling Technique and Standard Treatment with Coils. Radiology. 2009;24:,应用弹簧圈治疗未破裂动脉瘤的风险很低,小动脉瘤的不安全性,Yasuhiro报告74.3%为小动脉瘤（208/280) 26.1 % (73/280)小于 5 mm,Size of cerebral aneurysms and related factores in patients with subarachnoid hemorrhage. Surg Neurol. 2004;61:23

12、9245,Forget报告 85.6%为小动脉瘤（210/245）,A review of size and location of ruptured intracranial aneurysms. Neurosurgery. 2001;49:13221325.,Joo报告87.9%为小动脉瘤； 71.8%小于7mm（共627个动脉瘤）,What Is the Significance of a Large Number of Ruptured Aneurysms Smaller than 7 mm in Diameter? J Korean Neurosurg Soc. 2009; 45:

13、8589.,未破裂动脉瘤治疗的性价比分析,Treatment of Unruptured Intracranial Aneurysms： Decision and Cost-effectiveness Analysis Hidemasa Takao,MD，Takeshi Nojo, MD, MPH， Japan. Radiology: Volume 244: 3September 2007（Twelve clinical scenarios were defined on the basis of aneurysm size and location. Probabilistic sensit

14、ivity analyses were performed for 50- and 40-year-old patient cohorts. Treatment was considered to be cost-effective at an incremental costeffectiveness ratio less than $100 000 per quality-adjusted life-year.）.,未破裂动脉瘤治疗的性价比结果,In 50-year-old patients：No treatment was the most costeffective strategy

15、for aneurysms located in the cavernous carotid artery. Located in the anterior circulationFor aneurysms smaller than 7 mm no treatment was the most cost-effective strategy.,未破裂动脉瘤治疗的性价比结果,2. Endovascular treatment was the most cost-effective option for 724-mm aneurysms3. Whereas surgical treatment w

16、as the most cost-effective option for aneurysms 25 mm or larger,未破裂动脉瘤治疗的性价比结果,Located in the posterior circulationFor aneurysms smaller than 7 mm or 25 mm or larger no treatment was the most costeffective strategy.2. Surgical treatment was the most costeffective option for 712-mm aneurysms3. wherea

17、s endovascular treatment was the most cost-effective option for 1324-mm aneurysms,积极治疗颅内动脉瘤,不低的年破裂出血率,越来越安全的治疗方法,越来越长的寿命,并不安全小动脉瘤,积极治疗,临 床 实 践,国外：3050以上的报告病例为未破裂动脉瘤,国内：真正偶然发现动脉瘤非常少，主要为伴发其它出血动脉瘤的未破裂动脉瘤。,双侧后交通动脉瘤术前,一次手术同时夹闭两个AN,双侧后交通动脉瘤术后,颅内多发动脉瘤（两侧6个、两次手术夹4包2）,本着积极治疗的前提下，应综合患者的年龄、身体状态、动脉瘤的部位、动脉瘤的大小、动脉瘤的形态、医生和医院技术条件水平，制定科学、合理、安全和有效的治疗方案。,个体化的治疗方案,国内各地区各单位技术水平发展非常不平衡，高水平和一般水平的医生共存，未破裂动脉瘤患者具备择期治疗的客观条件。未破裂动脉瘤应该让具有较高水平、较丰富临床经验、最好同时擅长手术和介入的治疗团队进行治疗。,治疗单位的选择,4、CTA筛查发现可直接治,建 议,颅内未破裂动脉瘤：,2、能治、可治的尽量治,3、术中一旦发现及早治,1、力争彻底治疗并安全,谢 谢,唐 都 脑 科 医 院,