基层医院大脑中动脉瘤的临床鉴别及救治体会（附116例报道）

doi:10.11817/j.issn.1673-9248.2020.06.004

目的

探讨大脑中动脉瘤的发病类型及诊治方法，以期提高基层医院大脑中动脉瘤的临床识别准确率，减少误诊误治，提高治愈率。

方法

回顾2007年1月至2019年1月兴安盟人民医院收治的116例大脑中动脉瘤患者临床资料，87例动脉瘤因破裂形成颅内出血而入院，29例无症状偶然发现。在出血病例中，蛛网膜下腔出血41例，24例脑内血肿、硬膜下血肿，7例出血破入脑室铸型；仅为脑内血肿15例。动脉瘤位于M1段123例、M2段1例、M3段1例。

结果

对大脑中动脉走行区附近出血或疑似动脉瘤的占位病变患者均进行血管成像检查或术中探查，116例患者共发现125个大脑中动脉瘤，有76例手术治疗用一个或多个动脉瘤夹夹闭，5例有血栓性动脉瘤同时摘除血栓并切除部分瘤体。术后恢复MRS评分0分35例，1分11例，2分12例，3~4分8例，5分3例。7例救治无效死亡。

结论

大脑中动脉瘤是一种较为常见的颅内动脉瘤，未破裂的大脑中动脉瘤普通临床体格检查不易察觉，需与脑膜瘤相鉴别；破裂型不仅表现为蛛网膜下腔出血，也可表现为侧裂池血肿，或脑内血肿、硬膜下血肿、脑室铸型等，临床应与高血压脑出血相鉴别，以免漏诊误诊。

关键词: 动脉瘤, 大脑中动脉, 破裂型, 未破裂型, 颅内出血, 临床识别

Objective

To discuss different onset patterns of middle cerebral aneurysm so as to enhance its clinical diagnostic accuracy in hospitals at primary level, and reduce misdiagnosis and mistreatment.

Methods

The clinical data of 116 cases of patients with middle cerebral artery aneurysm (MCAA) hospitalized and treated in Xing’an League People’s Hospital from January 2007 to January 2019 was reviewed, in which 87 patients were hospitalized for aneurysm rupture-caused intracranial hemorrhage, the other 29 discovered by accident asymptomatically. Among cases with hemorrhage, 41 were with subarachnoid hemorrhage, 24 accompanied by intracerebral or subdural hematoma, 7 with cerebroventricular hemorrhage, and 15 intracerebral hematoma only. The aneurysms were located in 123 cases of M1 segment ,1 case of M2 segment and 1 case of M3 segment.

Results

A total of 125 MCAA were found in 116 patients, of which 76 received surgical treatment clamped by one or more aneurysm clips; 5 with thrombosis aneurysm were removed of the thrombus and part of the tumor body. After surgery, modified Rankin score was 0 of 35 cases, 1 in 11 cases, 2 in 12 cases, 3~4 in 8 cases, 5 in three cases. Seven patients died despite all rescue measures.

Conclusion

MCAA is a common intracranial aneurysm. Unruptured MCAA can be easily neglected in general clinical examination. We need to distinguish it from meningioma. The ruptured type takes the form of not only subarachnoid hemorrhage, but also hematoma in lateral fissure pool, intracerebral hematoma, subdural hematoma, total intraventricular hemorrhage, etc, which should be differentiated carefully with hypertensive intracerebral hemorrhage in clinical practice to avoid misdiagnosis and missed diagnosis.

Key words: Aneurysm, middle cerebral arbery, Ruptured, Unruptured, Intracranial hemorrhage, Clinical diagnosis

表1 125个MCAA患者影像学检查特征

影像学检查特征	个数
颅内出血	87
SAH	41
SAH合并脑内血肿或硬膜下血肿	24
SAH伴出血破入脑室铸型	7
无SAH仅表现仅为脑内血肿	15
双侧镜像动脉瘤	9
动脉瘤位置
M1段（M1早发支/分叉）	123（8/115）
M2段	1
M3段	1
动脉瘤颈指向
MCAA指向外下部	57
MCAA指外上	68
瘤内血栓形成	38

表1 125个MCAA患者影像学检查特征

影像学检查特征	个数
颅内出血	87
SAH	41
SAH合并脑内血肿或硬膜下血肿	24
SAH伴出血破入脑室铸型	7
无SAH仅表现仅为脑内血肿	15
双侧镜像动脉瘤	9
动脉瘤位置
M1段（M1早发支/分叉）	123（8/115）
M2段	1
M3段	1
动脉瘤颈指向
MCAA指向外下部	57
MCAA指外上	68
瘤内血栓形成	38

图1 大型动脉瘤破裂出血形成侧裂池为聚集的蛛网膜下腔出血（图a）及血肿（图b，蓝箭头），并形成硬膜下血肿（图c，红箭头），数字剪影血管造影示大脑中动脉分叉处动脉瘤（图d、e；黄箭头），手术夹闭并清除血肿术后示动脉瘤夹（绿箭头），去骨瓣，颅内血肿消失（图f）

图2 未破裂型动脉瘤。图a示CT见颞叶高密度影（红箭头），图b示颞叶混杂信号占位，图c示占位病变内血液留空影，图d示占位病变增强后明显强化，图e MRI显示动脉瘤，但磁共振血管造影不能完全显示动脉瘤全貌，图f示CT血管造影完全显示动脉瘤，图g示术中见动脉瘤壁厚，图h示多个动脉瘤夹不完全夹闭，图i示动脉瘤夹（绿箭头）夹闭术后去骨瓣减压

图3 大脑中动脉瘤破裂形成单纯脑内血肿病例。头颅CT见右侧颞叶血肿脑疝（图a、b，无蛛网膜下腔出血），CT血管造影示右侧大脑中动脉瘤，血肿沿侧裂走行位于脑内（图c），急诊手术夹闭动脉瘤清除血肿去骨瓣减压，术后复查CT血管造影见动脉瘤消失（图d），绿箭头示三枚动脉瘤夹（图e）

图4 脑内血肿伴广泛蛛网膜下腔出血病例。图a示左侧颞叶血肿伴蛛网膜下腔出血，图b示左侧M2起始处动脉瘤（红箭头），图c术中夹闭前动脉瘤（白箭头示临时阻断夹，黄箭头示动脉瘤，绿箭头示动脉瘤夹），图d术前荧光造影见瘤内血栓（红圈内为动脉瘤，红箭头示子瘤，蓝箭头示瘤内血栓），图e示动脉瘤夹闭后（白箭头示临时阻断夹，绿箭头示动脉瘤夹，蓝箭头示动脉瘤，紫箭头示迷你型动脉瘤夹），图f示术后CT血肿消失（绿箭头为动脉瘤夹）

图5 隐匿出血的病例影像检查图。图a CT图见无法解释的颞角扩大（黄箭头），图b示三脑室内混杂密度（蓝箭头），图c示侧裂区无明显高密度，图d示CT血管造影见左侧大脑中分叉处动脉瘤（红箭头）

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Clinical identification and treatment strategies of middle cerebral artery aneurysm in primary hospitals

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Clinical identification and treatment strategies of middle cerebral artery aneurysm in primary hospitals