中西结合治疗动脉瘤性蛛网膜下腔出血的临床研究
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摘要
背景
动脉瘤性蛛网膜下腔出血是指颅内动脉瘤破裂血液流入蛛网膜下腔所引起的综合征,以其高致死率和致残率而严重威胁人们健康。随着颅内动脉瘤微创手术设备及理念的进展,血管内栓塞技术和材料的进步,手术的损伤越来越小,术中并发症也逐渐有所减低,但手术并不能解决出血对于机体的打击,蛛网膜下腔出血存在诸多的并发症,特别是急性或者迟发性的脑血管痉挛可以引起严重的神经功能缺损,甚至死亡。近年来,国内一些医家采用中西医治疗aSAH,收到了一定疗效,但多为小样本研究,没有得到系统评价,疗效难以肯定,发病特点及病机难以明确,难有说服力。本院自2005年3月～2009年12月这5年之间,采取中西内外结合治疗此类病人逾300例,取得了较好的疗效。
目的
了解中医药在aSAH治疗中的作用和效应点,从中医药理论阐述其发病特点及机理,以规范及促进推广中医药的使用,使患者获益。
方法
1通过对入选病例的年龄、性别、发病时间、发病特点、入院时CT-Fisher及HUNT-HESS分级以及合并病症、动脉瘤影像特征、术式、术中术后并发症、中医诊断及治疗情况、出院时GOS评分、随访情况等进行统计,并进行频数分布描述。
2对入选病人进行系统分层研究和分组对比,具体分层及分组方法见影响aSAH预后的因素赋值表及研究路线图。
3对以上所有预后影响因素进行多元回归统计方法分析诸因素对预后有无影响,并进一步分析诸影响因素之权重以及各因素之间关系。
结果
1一般资料统计结果
纳入病人总计288例,其中男性113例(39.2%),女性175例(60.8%)。平均年龄52.86±13.41岁。病人籍贯来自广州117例(40.8%),佛山35例(12.2%),东莞11例(3.8%),深圳9例(3.1%),珠海9例(3.1%),江门5例(1.7%),潮汕10例(3.5%),清远10例(3.5%),广东其他地区及外省81例(28.2%)。其中年龄对预后有显著影响,出院时GOS评分1～5级年龄均数分别为60.59、63.80、57.31、54.44、50.25岁,GOS5级与1、2、3级之间存在统计学差异,P<0.01.性别在阴阳类证中诊断阴类证中存在统计学差异,男性23例(8.68%),女性56例(21.13%), P<0.05。
2既往病史
患有高血压110例(38.2%),高血脂27例(9.4%),心脏病15例(5.2%),脑梗塞20例(6.9%),糖尿病11例(3.8%),贫血6例(2.1%),脑动静脉畸形4例(1.4%),烟雾病4例(1.4%),颅内外血管狭窄12例(4.2%),颈椎病10例(3.5%)。3发病情况统计结果
首发症状以单纯头痛起病181例(62.8%),意识障碍63例(21.9%),肢体偏瘫13例(4.5%),头晕8例(2.8%),眼部症状8例(2.8%),癫痫3例(1%),其他12例(4.2%)。入院时CT-Fisher分级0级6例(2.6%),1级130例(45.1%),2级74例(25.7%),3级56例(19.4%),4级22例(7.6%).入院时HUNT-HESS分级1级96例(33.3%),2级99例(34.4%),3级55例(19.1%),4级34例(11.8%)5级4例(1.4%)。HUNT-HESS分级在阴阳类证中诊断差异显著,阳类证HUNT-HESS分级均数2.31±1.05,阴类证HUNT-HESS分级均数1.79±1.02,P<0.01。CT-Fisher分级均数2.01±0.99,阴类证CT-Fisher分级均数1.63±0.98,P=0.06。
4发病时间特征
24节气：以秋分最多,20例(7%),寒露次之,19例(6.6%),立冬16例(5.6%),大雪15例(5.2%),大寒13例(4.5%),从立秋至大寒之间与立春至处暑比较,前者发病率要高于后者,差异存在统计学意义,P<0.05。十二天干统计发现,巳时发病率最高33例,占14.2%,其次为申时,29例,占12.4%,辰时26例,占11.2%,酉时24例,占10.3%,最低为寅时5,占2.1%,其次是丑时6例,占2.6%,与12经脉子午流注图对应发现发病率最高的两个时辰分别对应足太阴脾经及足太阳膀胱经。
5颅内动脉瘤特征及对诊治影响
前交通动脉瘤78例(27.1%),左侧颈内动脉后交通动脉瘤39例(13.5%),右侧颈内动脉后交通动脉瘤30例(10.4%),左侧大脑前动脉瘤5例(1.7%),右侧大脑前动脉瘤6例(2.1%),左侧大脑中动脉瘤21例(7.3%),右侧大脑中动脉瘤24例(8.3%),左侧大脑后动脉瘤1例(0.3%),右侧大脑后动脉瘤2例(0.7%)基底动脉瘤18例(6.3%),左侧椎动脉瘤10例(3.5%),右侧椎动脉瘤7例(2.4%),左侧颈内动脉瘤20例(6.9%),右侧颈内动脉瘤27例(9.4%).动脉瘤的分布对中医的辨证存在统计学差异,动脉瘤位于前交通动脉、双侧颈内动脉后交通动脉、双侧大脑中动脉以及基底动脉的中医辨证基本上以风火痰瘀、闭阻脉络证型为主,P<0.05。在双侧椎动脉及双侧颈内动脉差异不明显,P>0.05。颅内动脉瘤在大脑半球的哪一侧与证型的分布无统计差异,P>0.05。颅内动脉瘤的直径对预后存在显著影响,P<0.01。瘤颈宽度预对后存在影响存在统计学差异,P<0.05。出院GOS评分为1级的病人的动脉瘤直径平均为8.49mm,瘤颈宽度为4.41mm,均要大于出院GOS评分4-5级的病人,P<0.05。破裂动脉瘤以3.9～4.2mm之间为最多,达13.5%,瘤颈宽度绝大部分在5.2mm以下,以2.8～3.2mm之间为最。其中符合宽颈动脉瘤诊断的有113例,达39.2%。本组中83.3%为单发动脉瘤,13.5%为2个动脉瘤,有6例存在3个动脉瘤,有1例6个动脉瘤的患者。动脉瘤数目对预后没有明显影响,P>0.05。但对随访结果影响存在统计差异,P<0.05。
6诊治措施对疗效的差异
采用单纯弹簧圈填塞术106例(38.5%),球囊辅助弹簧圈栓塞术49例(17.8%),支架辅助弹簧圈栓塞术16例(5.8%),翼点入路开颅夹闭术66例(24%),载瘤动脉闭塞术4例(1.5%),液体栓塞剂动脉瘤栓塞术3例(1.1%),球囊结合支架辅助弹簧圈栓塞术2例,双导管辅助弹簧圈栓塞术及带膜支架动脉瘤栓塞术各1例,行全脑血管造影术未行手术者27例(9.8%),未行全脑血管造影术及手术者13例(4.5%)。获得完全栓塞203例(82.2%),近全栓塞44例(17.8%)。术中发生脑血管痉挛15例(6%),动脉瘤破裂19例(7.6%),弹簧圈移位对血流无影响18例(7.2%),弹簧圈移位造成缺血6例(1.6%),血栓形成3例(1.2%),CCF1例(0.4%)。术式的选择对预后没有明显差异性影响,P>0.05。介入栓塞和开颅夹闭术中动脉瘤破裂的发生率存在明显差异,介入栓塞的发生率明显低于开颅夹闭术,P<0.01。术式的选择对随访结果的影响存在统计学差异。采用球囊辅助和开颅夹闭术以及onyx液体胶、载瘤动脉闭塞术能获得较高的完全栓塞度,P<0.05。但是获得完全栓塞的同时,术后脑梗塞及DCVS发生率要高于近全栓塞组,差异存在统计学意义,P<0.05。介入栓塞和开颅夹闭对术后并发症中DCVS的发生存在差异,介入栓塞组术后的DCVS发生率较开颅夹闭组低,P<0.05。术中发生动脉瘤破裂对术后再出血及癫痫的发生以及术中发生CVS对术后消化道出血的发生、术中发生弹簧圈移位对术后尿路感染的发生有统计差异,均P<0.05。术中并发症对预后无显著影响,P>0.05。但术后并发症中肺部感染及继发脑梗塞对预后影响有显著差异,P<0.01。中医治疗对改善预后有统计学意义,P<0.05,中西结合治疗组在术后的消化道出血及肺部感染发生率低于纯西医组,P<0.05。
结论
1患者女性居多,性别在阴阳类证中诊断中有明显差异,阴类证中以女性为多。发病年龄平均在50岁左右,年龄对预后有显著影响,年龄愈大,预后越差。
2入院时病情影响阴阳类证辨证,aSAH发病以阳类证占大多数。阳类证CT及HUNT-HESS评分明显较阴类证高。
3风、寒、燥邪可以导致发病率的显著增加。劳累紧张是aSAH的重要诱发因素。同时与十二经脉子午流注图比较,发病最高峰分别对应足太阴脾经及足太阳膀胱经。巳时血气最旺,管壁薄弱之处可能易受冲击以致破裂出血。酉时易产生足太阳膀胱经病症,特征与aSAH症状相符,可从足太阳膀胱经论治,其与足少阴肾经相表里,从“治未病”出发,可考虑从肾治之。“滋阴益肾柔肝”法则可贯穿未破裂动脉瘤保守观察过程始终。血压波动可能增加aSAH发病率,控制血压在上下午两个时间段对于未破裂动脉瘤患者可能具有积极意义。
4颅内动脉瘤的分布部位影响阴阳辨证,前交通动脉、双侧颈内动脉后交通动脉、双侧大脑中动脉以及基底动脉基本上以风火痰瘀、闭阻脉络证型为主。颅内动脉瘤的直径及瘤颈宽度明显影响预后,直径越大,瘤颈越宽,预后越差。术式的选择、颅内动脉瘤的数目以及动脉瘤栓塞或者夹闭程度明显影响随访结果和预后,介入栓塞相对开颅夹闭动脉瘤能明显减少术中动脉瘤破裂,采用球囊辅助等手段和开颅夹闭能明显提高栓塞程度,但是增加了DCVS及继发脑梗塞的发生率。且术中并发症对能增加部分术后并发症的发生。
5采用中西结合治疗能明显改善预后,减少术后并发症的产生,特别是对于肺部感染及消化道出血。
Objective
To learn the role of TCM during treating aSAH, and key treatment point, then explain the aSAH medical theory and mechanism by TCM, to regulate and promote the use of TCM to benefit patients.
Methods
1 By selected cases by age, sex, time of onset, disease characteristics, admission CT and HUNTHESS grade and combined symptoms, aneurysm imaging features, surgical procedures, postoperative complications, Chinese medicine treatment, and discharge GOS score, follow-up statistics on such cases and to describe the frequency distribution.
2 systematic stratificate on the selected patients, divide into groups to learn the difference in various factors, the method of dividing groups refers to the road map.
3 For all of the above prognostic factors in multiple regression statistical analysis whether the impact of various factors on the prognosis, and further analysis of the weights of various factors and the relationship between various factors.
Results
1 General Information
A total of 288 cases of patients,113 cases were male (39.2%) and females (60.8%), mean age 52.86±13.41 years old, mainly from Guangzhou, 117 cases (40.8%), Foshan,35 cases (12.2%), Dongguan,11 cases (3.8%), Shenzhen,9 cases (3.1%), Zhuhai 9 cases (3.1%), Jiangmen 5 cases (1.7%), Chaoshan 10 cases (3.5%), Qingyuan 10 cases (3.5%), other areas in Guangdong and other provinces 81 cases (28.2%). in which the age had significant effect on prognosis, discharge GOS score 1 to 5 ages were, respectively 50.25,54.44,57.31,63.80,60.59, GOS1 level has significant difference between grade 3,4,5, P<0.05. In the diagnostic category of yin and yang, gender has significant differences for yin, male 23 cases (8.68%), female 56 cases (21.13%), P<0.05.
2 Past medical history
hypertension in 110 cases (38.2%), hyperlipidemia in 27 cases (9.4%), heart disease,15 cases (5.2%), cerebral infarction in 20 cases (6.9%), diabetes in 11 cases (3.8%), anemia 6 cases (2.1%), AVM 4 cases (1.4%), moyamoya 4 cases (1.4%), intracranial stenosis in 12 patients (4.2%), cervical spondylosis in 10 patients (3.5%).
3 State before hospital
first symptom in 181 cases alone were headache (62.8%),63 cases of disturbance of consciousness (21.9%), hemiplegia in 13 cases (4.5%), dizziness onset in 8 cases (2.8%), ocular symptoms in 8 cases (2.8%), epilepsy in 3 cases (1%), other 12 cases (4.2%). CT grade 0 in 6 cases (2.6%), grade 1 in 130 cases (45.1%),2 Grade in 74 cases (25.7%),3 grade in 56 cases (19.4%),4 grade in 22 cases (7.6%). HUNT-HESS grade 1 in 94 cases (32.6%), grade 2 in 99 (34.4%), grade 3 in 55 cases (19.1%), grade 4 in 34 cases (11.8%). HUNT-HESS had significantly difference in the diagnostic category of yin and yang, The syndrome of Yang HUNT-HESS grade were few 2.31±1.05, the syndrome of Yin HUNT-HESS grade were 1.79±1.02, P<0.01. the syndrome of Yang CT grade class card mean 2.01±0.99, the syndrome of Yin CT grade class card mean 1.63±0.98, P> 0.05.
4 Onset time characteristics
24 Solar Terms:The Autumnal Equinox up,20 patients (3%), followed by cold dew,19 patients (2.9%), Winter begins 16 cases (2.4%), heavy snow in 15 cases (2.3%), Great cold in 13 cases (2%), between the time from the Autumn begins to the Great cold, and from the Spring begins to Stopping the heat, the former incidence of aSAH was significantly higher than the latter, P<0.05. compared 12 Heavenly Stems time, then found that Si Shi (morning)had the highest incidence of 33 cases,5%, followed by SHEN Shi (afternoon),29 cases, accounting for 4.4%, chenshi(breakfast time) 26 cases,4%, Youshi(sunfall) 24 cases, accounting for 3.6%, the lowest Yin Shi(dawn) 5 cases, accounting for 0.8%, Choushi(break) 6 cases,0.9%. Match to 12 meridians Flowing map the highest incidence of aSAH was found corresponding to the Foot Tai Yin Spleen Meridian and Foot Tai Yang bladder Meridian.
5 Intracranial aneurysm characteristics
anterior communicating artery aneurysm in 78 patients (27.1%), left posterior communicating artery aneurysm 39 cases (13.5%), right posterior communicating artery aneurysm in 30 cases (10.4%), left anterior cerebral artery 5 cases (1.7%), right anterior cerebral artery aneurysms in 6 cases (2.1%), the left middle cerebral artery aneurysm in 21 cases (7.3%), right middle cerebral artery aneurysm in 24 patients (8.3%), the left brain artery aneurysm in 1 case (0.3%), Right middle cerebral artery aneurysm in 2 cases (0.7%), basilar artery in 18 cases (6.3%), left vertebral artery aneurysm in 10 patients (3.5%), right vertebral artery aneurysm in 7 cases (2.4%), left common carotid within the aneurysm in 20 cases (6.9%), right carotid artery of 27 cases (9.4%). Aneurysms distribution had a significant effect on TCM syndrome, the anterior communicating artery, bilateral posterior communicating artery, bilateral middle cerebral artery and the basilar artery is basically Syndrome of wind, fire, phlegm, closed blocking, P<0.05. In the bilateral vertebral artery and internal carotid artery was not significant. Intracranial aneurysms locate in which hemisphere had no significant difference for the syndrome. Aneurysm diameter and neck width is significant impact on the prognosis, death of patients had an average aneurysm diameter of 8.49mm, neck width of 4.41mm, compare discharge GOS score 4 or 5 level, which is significantly larger, P<0.05. mostly ruptured aneurysms'diameter between 3.9～4.2mm (13.5%), most below to 5.2mm for width of neck, mostly between 2.8 and 3.2 mm. Which meet the wide-necked aneurysms were 113 cases, up by 39.2%, this group was 83.3% for the single aneurysm,13.5% for the two aneurysms,6 patients presented with three aneurysms, there is one case of 6 aneurysms in 1 patient. The number of aneurysms had no significant effect on prognosis, but there is significant effect on the follow-up results, P<0.05.
6 Efficacy difference of treatments
simple coil packing technique in 106 patients (38.5%), balloon-assisted coil embolization in 49 cases (17.8%), stent assisted coil embolization in 16 cases (5.8%), wing point approach craniotomy clipping surgery,66 cases (24%), parent artery occlusion in 4 cases (1.5%), liquid glue aneurysm embolization in 3 cases (1.1%), balloon angioplasty combined with stent assisted coil embolization 2 cases, double catheter assisted coil embolization and stent aneurysm embolization in 1 case, with total cerebral angiography without surgical in 27 cases (19.8%). Complete embolization was 203 cases (82.2%), and partial embolization in 44 cases (17.8%). Intraoperative CVS occurred in 15 cases (6%), aneurysm rupture in 19 patients (7.6%), coil shift but the blood flow no effect in 18 cases (7.2%), ischemia caused by coil shift in 6 cases (1.6%), thrombosis in 3 patients (1.2%), CCF in 1 patient (0.4%). surgical option on the prognosis of no significant difference in effect, However, embolization, and craniotomy with aneurysm clipping operation had significant difference in the incidence of aneurysm rupture, the incidence of embolization was significantly lower than craniotomy clipping surgery, P<0.05, and the same to follow-up results. the use of balloon-assisted, craniotomy clipping surgery and onyx liquid glue, parent artery occlusion to obtain a higher degree of complete embolization, P<0.05, at the same time, the incidence of postoperative cerebral infarction and DCVS significantly higher than in partial embolization group, P<0.05. Embolization and craniotomy clipping have differences on the occurrence of postoperative complications DCVS, interventional group lower than craniotomy clipping group, P<0.05. Intraoperative aneurysm rupture impacted on postoperative bleeding and the occurrence of epilepsy and the CVS took place in operation raised the incidence of gastrointestinal bleeding, intraoperative coil displacement on the incidence of urinary tract infections have a significant effect, P<0.05. Intraoperative complications, no significant effected on prognosis, but the pulmonary infection and cerebral infarction after operation impacted on the prognosis, which had significantly different, P<0.01. Chinese medicine treatment can significantly improve the prognosis, P<0.05, T-W medicine group, the incidence of gastrointestinal bleeding and pulmonary infection in the postoperative were significantly lower than that of WM group, P<0.05.
Conclusion
1 aSAH mostly happened on women. Men and women, there were significant difference in the diagnosis of yin and yang, women were apt to yin. the average age of onset is about 50 years, age had significant effect on the prognosis, the older had the worse prognosis.
2 State before hospital affected the yin or yang syndrome, Yang syndrome had significantly higher HUNT-HESS and CT scores than the yin syndrome, and the incidence of aSAH was majority to Yang syndrome.
3 Wind, cold, dry evil can lead to increased incidence of aSAH significantly. Fatigue and stress are important predisposing factors to aSAH. At the same time, match to the 12 meridians flowing map, corresponding to the peak incidence of Foot Tai Yin Spleen Meridian and the Foot Tai Yang bladder Meridian. blood flourishes in Si Shi, the weakness wall at the vessel may be vulnerable to shocks resulting in bleeding. It is easy to produce disease of the bladder Meridian in You Shi, whose characteristics are similar to aSAH symptoms, so we can use pinprick or herbs to the bladder Meridian in order to treat aSAH. the bladder Meridian is outside, and the Kidney Meridian is inside, "preventive treatment of disease" is encouraged, so nourish Kidney Meridian can prevent disease of the bladder Meridian. " Nourish Kidney and Liver Yin" rule can be used throughout the whole process of conservative observation for unruptured aneurysm.
4 The distribution of intracranial aneurysms affected diagnostic of yin and yang syndrome, anterior communicating artery, bilateral posterior communicating artery, bilateral middle cerebral artery and basilar artery basically belong to syndrome of wind, fire, phlegm, closed blocking.Aneurysm diameter and neck width significantly affects the prognosis, the larger diameter, the wider neck, the worse prognosis. Surgical options, the number of intracranial aneurysms and the degree of embolization or clipping effect on follow-up results and prognosis. of intervention significantly reduced the rupture of aneurysms than clipping, by means of balloon-assisted and craniotomy clipping can significantly improve the degree of embolism, but increase DCVS and secondary cerebral infarction. Intraoperative complications increase the postoperative complications.
5 Use of TCM combined western medicine can improve the prognosis, reduce the production of postoperative complications, especially pneumonia and gastrointestinal bleeding.
动脉瘤性蛛网膜下腔出血是指颅内动脉瘤破裂血液流入蛛网膜下腔所引起的综合征,以其高致死率和致残率而严重威胁人们健康。随着颅内动脉瘤微创手术设备及理念的进展,血管内栓塞技术和材料的进步,手术的损伤越来越小,术中并发症也逐渐有所减低,但手术并不能解决出血对于机体的打击,蛛网膜下腔出血存在诸多的并发症,特别是急性或者迟发性的脑血管痉挛可以引起严重的神经功能缺损,甚至死亡。近年来,国内一些医家采用中西医治疗aSAH,收到了一定疗效,但多为小样本研究,没有得到系统评价,疗效难以肯定,发病特点及病机难以明确,难有说服力。本院自2005年3月～2009年12月这5年之间,采取中西内外结合治疗此类病人逾300例,取得了较好的疗效。
目的
了解中医药在aSAH治疗中的作用和效应点,从中医药理论阐述其发病特点及机理,以规范及促进推广中医药的使用,使患者获益。
方法
1通过对入选病例的年龄、性别、发病时间、发病特点、入院时CT-Fisher及HUNT-HESS分级以及合并病症、动脉瘤影像特征、术式、术中术后并发症、中医诊断及治疗情况、出院时GOS评分、随访情况等进行统计,并进行频数分布描述。
2对入选病人进行系统分层研究和分组对比,具体分层及分组方法见影响aSAH预后的因素赋值表及研究路线图。
3对以上所有预后影响因素进行多元回归统计方法分析诸因素对预后有无影响,并进一步分析诸影响因素之权重以及各因素之间关系。
结果
1一般资料统计结果
纳入病人总计288例,其中男性113例(39.2%),女性175例(60.8%)。平均年龄52.86±13.41岁。病人籍贯来自广州117例(40.8%),佛山35例(12.2%),东莞11例(3.8%),深圳9例(3.1%),珠海9例(3.1%),江门5例(1.7%),潮汕10例(3.5%),清远10例(3.5%),广东其他地区及外省81例(28.2%)。其中年龄对预后有显著影响,出院时GOS评分1～5级年龄均数分别为60.59、63.80、57.31、54.44、50.25岁,GOS5级与1、2、3级之间存在统计学差异,P<0.01.性别在阴阳类证中诊断阴类证中存在统计学差异,男性23例(8.68%),女性56例(21.13%), P<0.05。
2既往病史
患有高血压110例(38.2%),高血脂27例(9.4%),心脏病15例(5.2%),脑梗塞20例(6.9%),糖尿病11例(3.8%),贫血6例(2.1%),脑动静脉畸形4例(1.4%),烟雾病4例(1.4%),颅内外血管狭窄12例(4.2%),颈椎病10例(3.5%)。3发病情况统计结果
首发症状以单纯头痛起病181例(62.8%),意识障碍63例(21.9%),肢体偏瘫13例(4.5%),头晕8例(2.8%),眼部症状8例(2.8%),癫痫3例(1%),其他12例(4.2%)。入院时CT-Fisher分级0级6例(2.6%),1级130例(45.1%),2级74例(25.7%),3级56例(19.4%),4级22例(7.6%).入院时HUNT-HESS分级1级96例(33.3%),2级99例(34.4%),3级55例(19.1%),4级34例(11.8%)5级4例(1.4%)。HUNT-HESS分级在阴阳类证中诊断差异显著,阳类证HUNT-HESS分级均数2.31±1.05,阴类证HUNT-HESS分级均数1.79±1.02,P<0.01。CT-Fisher分级均数2.01±0.99,阴类证CT-Fisher分级均数1.63±0.98,P=0.06。
4发病时间特征
24节气：以秋分最多,20例(7%),寒露次之,19例(6.6%),立冬16例(5.6%),大雪15例(5.2%),大寒13例(4.5%),从立秋至大寒之间与立春至处暑比较,前者发病率要高于后者,差异存在统计学意义,P<0.05。十二天干统计发现,巳时发病率最高33例,占14.2%,其次为申时,29例,占12.4%,辰时26例,占11.2%,酉时24例,占10.3%,最低为寅时5,占2.1%,其次是丑时6例,占2.6%,与12经脉子午流注图对应发现发病率最高的两个时辰分别对应足太阴脾经及足太阳膀胱经。
5颅内动脉瘤特征及对诊治影响
前交通动脉瘤78例(27.1%),左侧颈内动脉后交通动脉瘤39例(13.5%),右侧颈内动脉后交通动脉瘤30例(10.4%),左侧大脑前动脉瘤5例(1.7%),右侧大脑前动脉瘤6例(2.1%),左侧大脑中动脉瘤21例(7.3%),右侧大脑中动脉瘤24例(8.3%),左侧大脑后动脉瘤1例(0.3%),右侧大脑后动脉瘤2例(0.7%)基底动脉瘤18例(6.3%),左侧椎动脉瘤10例(3.5%),右侧椎动脉瘤7例(2.4%),左侧颈内动脉瘤20例(6.9%),右侧颈内动脉瘤27例(9.4%).动脉瘤的分布对中医的辨证存在统计学差异,动脉瘤位于前交通动脉、双侧颈内动脉后交通动脉、双侧大脑中动脉以及基底动脉的中医辨证基本上以风火痰瘀、闭阻脉络证型为主,P<0.05。在双侧椎动脉及双侧颈内动脉差异不明显,P>0.05。颅内动脉瘤在大脑半球的哪一侧与证型的分布无统计差异,P>0.05。颅内动脉瘤的直径对预后存在显著影响,P<0.01。瘤颈宽度预对后存在影响存在统计学差异,P<0.05。出院GOS评分为1级的病人的动脉瘤直径平均为8.49mm,瘤颈宽度为4.41mm,均要大于出院GOS评分4-5级的病人,P<0.05。破裂动脉瘤以3.9～4.2mm之间为最多,达13.5%,瘤颈宽度绝大部分在5.2mm以下,以2.8～3.2mm之间为最。其中符合宽颈动脉瘤诊断的有113例,达39.2%。本组中83.3%为单发动脉瘤,13.5%为2个动脉瘤,有6例存在3个动脉瘤,有1例6个动脉瘤的患者。动脉瘤数目对预后没有明显影响,P>0.05。但对随访结果影响存在统计差异,P<0.05。
6诊治措施对疗效的差异
采用单纯弹簧圈填塞术106例(38.5%),球囊辅助弹簧圈栓塞术49例(17.8%),支架辅助弹簧圈栓塞术16例(5.8%),翼点入路开颅夹闭术66例(24%),载瘤动脉闭塞术4例(1.5%),液体栓塞剂动脉瘤栓塞术3例(1.1%),球囊结合支架辅助弹簧圈栓塞术2例,双导管辅助弹簧圈栓塞术及带膜支架动脉瘤栓塞术各1例,行全脑血管造影术未行手术者27例(9.8%),未行全脑血管造影术及手术者13例(4.5%)。获得完全栓塞203例(82.2%),近全栓塞44例(17.8%)。术中发生脑血管痉挛15例(6%),动脉瘤破裂19例(7.6%),弹簧圈移位对血流无影响18例(7.2%),弹簧圈移位造成缺血6例(1.6%),血栓形成3例(1.2%),CCF1例(0.4%)。术式的选择对预后没有明显差异性影响,P>0.05。介入栓塞和开颅夹闭术中动脉瘤破裂的发生率存在明显差异,介入栓塞的发生率明显低于开颅夹闭术,P<0.01。术式的选择对随访结果的影响存在统计学差异。采用球囊辅助和开颅夹闭术以及onyx液体胶、载瘤动脉闭塞术能获得较高的完全栓塞度,P<0.05。但是获得完全栓塞的同时,术后脑梗塞及DCVS发生率要高于近全栓塞组,差异存在统计学意义,P<0.05。介入栓塞和开颅夹闭对术后并发症中DCVS的发生存在差异,介入栓塞组术后的DCVS发生率较开颅夹闭组低,P<0.05。术中发生动脉瘤破裂对术后再出血及癫痫的发生以及术中发生CVS对术后消化道出血的发生、术中发生弹簧圈移位对术后尿路感染的发生有统计差异,均P<0.05。术中并发症对预后无显著影响,P>0.05。但术后并发症中肺部感染及继发脑梗塞对预后影响有显著差异,P<0.01。中医治疗对改善预后有统计学意义,P<0.05,中西结合治疗组在术后的消化道出血及肺部感染发生率低于纯西医组,P<0.05。
结论
1患者女性居多,性别在阴阳类证中诊断中有明显差异,阴类证中以女性为多。发病年龄平均在50岁左右,年龄对预后有显著影响,年龄愈大,预后越差。
2入院时病情影响阴阳类证辨证,aSAH发病以阳类证占大多数。阳类证CT及HUNT-HESS评分明显较阴类证高。
3风、寒、燥邪可以导致发病率的显著增加。劳累紧张是aSAH的重要诱发因素。同时与十二经脉子午流注图比较,发病最高峰分别对应足太阴脾经及足太阳膀胱经。巳时血气最旺,管壁薄弱之处可能易受冲击以致破裂出血。酉时易产生足太阳膀胱经病症,特征与aSAH症状相符,可从足太阳膀胱经论治,其与足少阴肾经相表里,从“治未病”出发,可考虑从肾治之。“滋阴益肾柔肝”法则可贯穿未破裂动脉瘤保守观察过程始终。血压波动可能增加aSAH发病率,控制血压在上下午两个时间段对于未破裂动脉瘤患者可能具有积极意义。
4颅内动脉瘤的分布部位影响阴阳辨证,前交通动脉、双侧颈内动脉后交通动脉、双侧大脑中动脉以及基底动脉基本上以风火痰瘀、闭阻脉络证型为主。颅内动脉瘤的直径及瘤颈宽度明显影响预后,直径越大,瘤颈越宽,预后越差。术式的选择、颅内动脉瘤的数目以及动脉瘤栓塞或者夹闭程度明显影响随访结果和预后,介入栓塞相对开颅夹闭动脉瘤能明显减少术中动脉瘤破裂,采用球囊辅助等手段和开颅夹闭能明显提高栓塞程度,但是增加了DCVS及继发脑梗塞的发生率。且术中并发症对能增加部分术后并发症的发生。
5采用中西结合治疗能明显改善预后,减少术后并发症的产生,特别是对于肺部感染及消化道出血。
Objective
To learn the role of TCM during treating aSAH, and key treatment point, then explain the aSAH medical theory and mechanism by TCM, to regulate and promote the use of TCM to benefit patients.
Methods
1 By selected cases by age, sex, time of onset, disease characteristics, admission CT and HUNTHESS grade and combined symptoms, aneurysm imaging features, surgical procedures, postoperative complications, Chinese medicine treatment, and discharge GOS score, follow-up statistics on such cases and to describe the frequency distribution.
2 systematic stratificate on the selected patients, divide into groups to learn the difference in various factors, the method of dividing groups refers to the road map.
3 For all of the above prognostic factors in multiple regression statistical analysis whether the impact of various factors on the prognosis, and further analysis of the weights of various factors and the relationship between various factors.
Results
1 General Information
A total of 288 cases of patients,113 cases were male (39.2%) and females (60.8%), mean age 52.86±13.41 years old, mainly from Guangzhou, 117 cases (40.8%), Foshan,35 cases (12.2%), Dongguan,11 cases (3.8%), Shenzhen,9 cases (3.1%), Zhuhai 9 cases (3.1%), Jiangmen 5 cases (1.7%), Chaoshan 10 cases (3.5%), Qingyuan 10 cases (3.5%), other areas in Guangdong and other provinces 81 cases (28.2%). in which the age had significant effect on prognosis, discharge GOS score 1 to 5 ages were, respectively 50.25,54.44,57.31,63.80,60.59, GOS1 level has significant difference between grade 3,4,5, P<0.05. In the diagnostic category of yin and yang, gender has significant differences for yin, male 23 cases (8.68%), female 56 cases (21.13%), P<0.05.
2 Past medical history
hypertension in 110 cases (38.2%), hyperlipidemia in 27 cases (9.4%), heart disease,15 cases (5.2%), cerebral infarction in 20 cases (6.9%), diabetes in 11 cases (3.8%), anemia 6 cases (2.1%), AVM 4 cases (1.4%), moyamoya 4 cases (1.4%), intracranial stenosis in 12 patients (4.2%), cervical spondylosis in 10 patients (3.5%).
3 State before hospital
first symptom in 181 cases alone were headache (62.8%),63 cases of disturbance of consciousness (21.9%), hemiplegia in 13 cases (4.5%), dizziness onset in 8 cases (2.8%), ocular symptoms in 8 cases (2.8%), epilepsy in 3 cases (1%), other 12 cases (4.2%). CT grade 0 in 6 cases (2.6%), grade 1 in 130 cases (45.1%),2 Grade in 74 cases (25.7%),3 grade in 56 cases (19.4%),4 grade in 22 cases (7.6%). HUNT-HESS grade 1 in 94 cases (32.6%), grade 2 in 99 (34.4%), grade 3 in 55 cases (19.1%), grade 4 in 34 cases (11.8%). HUNT-HESS had significantly difference in the diagnostic category of yin and yang, The syndrome of Yang HUNT-HESS grade were few 2.31±1.05, the syndrome of Yin HUNT-HESS grade were 1.79±1.02, P<0.01. the syndrome of Yang CT grade class card mean 2.01±0.99, the syndrome of Yin CT grade class card mean 1.63±0.98, P> 0.05.
4 Onset time characteristics
24 Solar Terms:The Autumnal Equinox up,20 patients (3%), followed by cold dew,19 patients (2.9%), Winter begins 16 cases (2.4%), heavy snow in 15 cases (2.3%), Great cold in 13 cases (2%), between the time from the Autumn begins to the Great cold, and from the Spring begins to Stopping the heat, the former incidence of aSAH was significantly higher than the latter, P<0.05. compared 12 Heavenly Stems time, then found that Si Shi (morning)had the highest incidence of 33 cases,5%, followed by SHEN Shi (afternoon),29 cases, accounting for 4.4%, chenshi(breakfast time) 26 cases,4%, Youshi(sunfall) 24 cases, accounting for 3.6%, the lowest Yin Shi(dawn) 5 cases, accounting for 0.8%, Choushi(break) 6 cases,0.9%. Match to 12 meridians Flowing map the highest incidence of aSAH was found corresponding to the Foot Tai Yin Spleen Meridian and Foot Tai Yang bladder Meridian.
5 Intracranial aneurysm characteristics
anterior communicating artery aneurysm in 78 patients (27.1%), left posterior communicating artery aneurysm 39 cases (13.5%), right posterior communicating artery aneurysm in 30 cases (10.4%), left anterior cerebral artery 5 cases (1.7%), right anterior cerebral artery aneurysms in 6 cases (2.1%), the left middle cerebral artery aneurysm in 21 cases (7.3%), right middle cerebral artery aneurysm in 24 patients (8.3%), the left brain artery aneurysm in 1 case (0.3%), Right middle cerebral artery aneurysm in 2 cases (0.7%), basilar artery in 18 cases (6.3%), left vertebral artery aneurysm in 10 patients (3.5%), right vertebral artery aneurysm in 7 cases (2.4%), left common carotid within the aneurysm in 20 cases (6.9%), right carotid artery of 27 cases (9.4%). Aneurysms distribution had a significant effect on TCM syndrome, the anterior communicating artery, bilateral posterior communicating artery, bilateral middle cerebral artery and the basilar artery is basically Syndrome of wind, fire, phlegm, closed blocking, P<0.05. In the bilateral vertebral artery and internal carotid artery was not significant. Intracranial aneurysms locate in which hemisphere had no significant difference for the syndrome. Aneurysm diameter and neck width is significant impact on the prognosis, death of patients had an average aneurysm diameter of 8.49mm, neck width of 4.41mm, compare discharge GOS score 4 or 5 level, which is significantly larger, P<0.05. mostly ruptured aneurysms'diameter between 3.9～4.2mm (13.5%), most below to 5.2mm for width of neck, mostly between 2.8 and 3.2 mm. Which meet the wide-necked aneurysms were 113 cases, up by 39.2%, this group was 83.3% for the single aneurysm,13.5% for the two aneurysms,6 patients presented with three aneurysms, there is one case of 6 aneurysms in 1 patient. The number of aneurysms had no significant effect on prognosis, but there is significant effect on the follow-up results, P<0.05.
6 Efficacy difference of treatments
simple coil packing technique in 106 patients (38.5%), balloon-assisted coil embolization in 49 cases (17.8%), stent assisted coil embolization in 16 cases (5.8%), wing point approach craniotomy clipping surgery,66 cases (24%), parent artery occlusion in 4 cases (1.5%), liquid glue aneurysm embolization in 3 cases (1.1%), balloon angioplasty combined with stent assisted coil embolization 2 cases, double catheter assisted coil embolization and stent aneurysm embolization in 1 case, with total cerebral angiography without surgical in 27 cases (19.8%). Complete embolization was 203 cases (82.2%), and partial embolization in 44 cases (17.8%). Intraoperative CVS occurred in 15 cases (6%), aneurysm rupture in 19 patients (7.6%), coil shift but the blood flow no effect in 18 cases (7.2%), ischemia caused by coil shift in 6 cases (1.6%), thrombosis in 3 patients (1.2%), CCF in 1 patient (0.4%). surgical option on the prognosis of no significant difference in effect, However, embolization, and craniotomy with aneurysm clipping operation had significant difference in the incidence of aneurysm rupture, the incidence of embolization was significantly lower than craniotomy clipping surgery, P<0.05, and the same to follow-up results. the use of balloon-assisted, craniotomy clipping surgery and onyx liquid glue, parent artery occlusion to obtain a higher degree of complete embolization, P<0.05, at the same time, the incidence of postoperative cerebral infarction and DCVS significantly higher than in partial embolization group, P<0.05. Embolization and craniotomy clipping have differences on the occurrence of postoperative complications DCVS, interventional group lower than craniotomy clipping group, P<0.05. Intraoperative aneurysm rupture impacted on postoperative bleeding and the occurrence of epilepsy and the CVS took place in operation raised the incidence of gastrointestinal bleeding, intraoperative coil displacement on the incidence of urinary tract infections have a significant effect, P<0.05. Intraoperative complications, no significant effected on prognosis, but the pulmonary infection and cerebral infarction after operation impacted on the prognosis, which had significantly different, P<0.01. Chinese medicine treatment can significantly improve the prognosis, P<0.05, T-W medicine group, the incidence of gastrointestinal bleeding and pulmonary infection in the postoperative were significantly lower than that of WM group, P<0.05.
Conclusion
1 aSAH mostly happened on women. Men and women, there were significant difference in the diagnosis of yin and yang, women were apt to yin. the average age of onset is about 50 years, age had significant effect on the prognosis, the older had the worse prognosis.
2 State before hospital affected the yin or yang syndrome, Yang syndrome had significantly higher HUNT-HESS and CT scores than the yin syndrome, and the incidence of aSAH was majority to Yang syndrome.
3 Wind, cold, dry evil can lead to increased incidence of aSAH significantly. Fatigue and stress are important predisposing factors to aSAH. At the same time, match to the 12 meridians flowing map, corresponding to the peak incidence of Foot Tai Yin Spleen Meridian and the Foot Tai Yang bladder Meridian. blood flourishes in Si Shi, the weakness wall at the vessel may be vulnerable to shocks resulting in bleeding. It is easy to produce disease of the bladder Meridian in You Shi, whose characteristics are similar to aSAH symptoms, so we can use pinprick or herbs to the bladder Meridian in order to treat aSAH. the bladder Meridian is outside, and the Kidney Meridian is inside, "preventive treatment of disease" is encouraged, so nourish Kidney Meridian can prevent disease of the bladder Meridian. " Nourish Kidney and Liver Yin" rule can be used throughout the whole process of conservative observation for unruptured aneurysm.
4 The distribution of intracranial aneurysms affected diagnostic of yin and yang syndrome, anterior communicating artery, bilateral posterior communicating artery, bilateral middle cerebral artery and basilar artery basically belong to syndrome of wind, fire, phlegm, closed blocking.Aneurysm diameter and neck width significantly affects the prognosis, the larger diameter, the wider neck, the worse prognosis. Surgical options, the number of intracranial aneurysms and the degree of embolization or clipping effect on follow-up results and prognosis. of intervention significantly reduced the rupture of aneurysms than clipping, by means of balloon-assisted and craniotomy clipping can significantly improve the degree of embolism, but increase DCVS and secondary cerebral infarction. Intraoperative complications increase the postoperative complications.
5 Use of TCM combined western medicine can improve the prognosis, reduce the production of postoperative complications, especially pneumonia and gastrointestinal bleeding.
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