Neurosurgery:动脉瘤**栓塞还是夹闭?难道要反转?

2019-07-06 杨中华 脑血管病及重症文献导读

随机临床试验的系统性综述显示弹簧圈栓塞破裂动脉瘤的预后优于外科手术夹闭动脉瘤。因为这些试验,在一些中心逐渐把弹簧圈栓塞术取代了动脉瘤夹闭手术,一些中心或国家也把弹簧圈栓塞作为一线治疗选择。不过,这些试验也存在一些问题。首先,研究期间大部分患者未被纳入研究;其次,由于这些试验全球越来越多的医院采取弹簧圈治疗动脉瘤,这会导致许多经验不够丰富的医生(vs 临床试验的医生)进行手术;第三,弹簧圈栓塞辅助工

随机临床试验的系统性综述显示弹簧圈栓塞破裂动脉瘤的预后优于外科手术夹闭动脉瘤。因为这些试验,在一些中心逐渐把弹簧圈栓塞术取代了动脉瘤夹闭手术,一些中心或国家也把弹簧圈栓塞作为一线治疗选择。不过,这些试验也存在一些问题。首先,研究期间大部分患者未被纳入研究;其次,由于这些试验全球越来越多的医院采取弹簧圈治疗动脉瘤,这会导致许多经验不够丰富的医生(vs 临床试验的医生)进行手术;第三,弹簧圈栓塞辅助工具比如球囊或支架被越来越多的采用,这些工具会增加并发症的风险。

在这些情况下,抛开临床试验的限制,在日常临床实践中患者的预后是否不同于临床试验的预后,这是一个问题。为了评价日常临床实践中弹簧圈栓塞和外科夹闭动脉瘤的预后,2019年5月来自荷兰的Antti Lindgren等在NEUROSURGERY上发表了他们的研究结果。

在这个对照、非随机的研究中,共纳入了来自欧洲、美国和澳大利亚22家三级医院共7658例动脉瘤蛛网膜下腔出血(aSAH)患者(行政数据库[administrative dataset]),这些患者接受了血管内弹簧圈栓塞和神经外科夹闭破裂动脉瘤。因为这个行政数据库的结果与随机试验的结果相互矛盾,作者又进一步利用2个欧洲中心的大型临床数据库中1501例患者(临床数据库)进行了验乞。

在行政数据库中,动脉瘤夹闭组和弹簧圈栓塞组的14天粗病死率分别为6.4%(95% CI 5.6% - 7.2%)和8.2%(95% CI 7.4 - 9.1%)。调整年龄、性别和共病/严重程度后,弹簧圈比较夹闭手术14天病死率的 OR 为1.32(95% CI 1.1 - 1.58)。

在临床数据库中,动脉瘤夹闭组和弹簧圈栓塞组的14天粗病死率分别为5.7%(95% CI 4.2% - 7.8%)和9%(95% CI 7.3% - 11.2%)。在多参数log回归分析中,弹簧圈比较夹闭手术14天病死率的 OR 为1.7(95% 1.1 - 2.7),90天病死率的 OR 为1.28(95% CI 0.91 - 1.82),90天不良功能预后的 OR 为0.78(95% CI 0.6 - 1.01)。

最终作者认为在临床实践中,与动脉瘤外科手术夹闭相比,aSAH 后弹簧圈治疗动脉瘤与较高的14天病死率有关,90天预后没有优势。两种手术方案皆可以考虑。进一步研究需要探讨临床数据和 RCT 研究数据产生差异的原因。

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    2019-07-29 chg121
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    2019-07-08 lsndxfj
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  6. [GetPortalCommentsPageByObjectIdResponse(id=2021661, encodeId=d5552021661d7, content=<a href='/topic/show?id=31e8e9669d' target=_blank style='color:#2F92EE;'>#GER#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=7966, encryptionId=31e8e9669d, topicName=GER)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=48732500158, createdName=12498c32m68暂无昵称, createdTime=Mon Sep 23 04:24:00 CST 2019, time=2019-09-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1877739, encodeId=f83618e7739b9, content=<a href='/topic/show?id=b013169237f' target=_blank style='color:#2F92EE;'>#surgery#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=16923, encryptionId=b013169237f, topicName=surgery)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Mon Jul 29 22:24:00 CST 2019, time=2019-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1364504, encodeId=69ee136450481, content=<a href='/topic/show?id=7c5615628ad' target=_blank style='color:#2F92EE;'>#ROS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=15628, encryptionId=7c5615628ad, topicName=ROS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=acc3210, createdName=lsndxfj, createdTime=Mon Jul 08 14:24:00 CST 2019, time=2019-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=369270, encodeId=0b643692e09a, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Mon Jul 08 05:26:27 CST 2019, time=2019-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=369269, encodeId=8179369269a6, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Mon Jul 08 05:26:12 CST 2019, time=2019-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=369219, encodeId=5293369219e6, content=谢谢了,学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=30331616752, createdName=txqjm, createdTime=Sun Jul 07 06:52:25 CST 2019, time=2019-07-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=369207, encodeId=3aa936920e4d, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Sun Jul 07 03:15:04 CST 2019, time=2019-07-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=369204, encodeId=926536920467, content=值得借鉴和学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCEEr4dM45RatXXGAkFCicnNYiasFiaRicicO1YWsIeTFOhgapauqib8Z8TChNB3ttVC5RqNHptDvAxA72Q/0, createdBy=a82a1611288, createdName=yydlt, createdTime=Sat Jul 06 23:28:31 CST 2019, time=2019-07-06, status=1, ipAttribution=)]
    2019-07-07 txqjm

    谢谢了,学习

    0

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    2019-07-07 飛歌

    学习了很有用不错

    0

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    2019-07-06 yydlt

    值得借鉴和学习

    0

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73岁,女性。既往高血压和糖尿病病史。表现为突发头痛和右侧眶周瘀斑。

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男,54岁。因头痛伴恶心、呕吐1h余入院。既往史、个人史及家族史无特殊。查体:体温36.8℃,脉搏64/min,呼吸18/min,血压158/93mmHg。心、肺及腹部等检查未见明显异常。神经系统查体:意识清楚,精神萎靡,应答尚切题。视力粗测正常,眼球活动正常,左侧瞳孔3.5mm,右侧瞳孔2.5mm,光反应稍迟钝。双侧鼻唇沟对称等深,无鼓腮漏气,伸舌居中。双耳听力粗测正常,转颈受限。四肢肌力及

JAHA:二叶主动脉瓣患者胸主动脉瘤的生长

在BAV引起的TAA患者中,主动脉僵硬度和脉动动脉负荷增加提示与动脉瘤的扩张加速有关。

脑动脉瘤破裂前6例首诊误诊原因分析

女,61岁,因“头颈部疼痛半小时”来院急诊。CT:桥脑斑片状稍低密度影;X射线片:颈椎退行性变。神经内科首诊:不排除后循环缺血和颈椎病,建议查血管彩超和MRI,患者未依从,次日诊断为颈椎病入住骨科,MRI:C3~C4和C4~C5椎间盘突出。保守治疗1周,疼痛缓解出院。38d后,突发意识不清再入院,CT:第四脑室积血,累及第三脑室和双侧脑室,后颅窝高压(图1①b)。DSA:左侧小脑后下动脉远端动脉瘤