标题：动脉瘤夹闭与血管内弹簧圈栓塞治疗动脉瘤性蛛网膜下腔出血疗效观察

      作者：曹晓磊，顾倩，邵晶    复旦大学附属华山医院东院神经外科，上海 201206

      卷次： 2023年34卷18期

      【摘要】 目的 比较显微外科动脉瘤夹闭术与血管内弹簧圈栓塞治疗动脉瘤性蛛网膜下腔出血(aSAH)的疗效及安全性。方法 选取2019年6月至2021年6月复旦大学附属华山医院东院神经外科收治的96例 aSAH患者进行回顾性研究，按治疗方式不同分为夹闭组和栓塞组各48例。比较两组患者的围手术期指标、并发症、相关生化指标[血管内皮生长因子(VEGF)、血清高迁移率族蛋白1 (HMGB1)、血清中可溶性细胞间黏附因子-1 (sICM-1)、可溶性血管细胞黏附因子-1 (sVCAM-1)]、认知功能[简易智力状态检查量表(MMSE)]以及随访 1年的预后情况。结果 栓塞组患者术中出血量、手术时间、住院时间分别为(108.44±5.31) mL、(149.74±10.94) min、(16.33±4.05) d，明显少(短)于夹闭组的(247.16±5.02) mL、(163.48±14.32) min、(18.20±4.59) d，差异均有统计学意义(P<0.05)，但两组患者的意识恢复时间比较差异无统计学意义(P>0.05)；术后1个月，两组患者的VEGF、HMGB1、sICM-1、sVCAM-1水平均低于术前，且栓塞组患者术后1个月上述指标分别为(120.54±13.06) pg/mL、(75.94±7.66) μg/L、(452.85±27.82) ng/mL、(49.18±4.97) ng/mL，明显低于夹闭组的(142.21±13.24) pg/mL、(89.46±7.18) μg/L、(582.15±34.11) ng/mL、(56.74±5.66) ng/mL，差异均有统计学意义(P<0.05)；术后3个月，栓塞组患者的MMSE评分为(29.08±2.79)分，明显高于夹闭组的(27.55±3.02)分，差异有统计学意义(P<0.05)，但两组患者术后的认知功能障碍(POCD)发生率比较差异无统计学意义(P>0.05)；术后随访 1年，栓塞组患者的GOS评分为(3.65±0.62)分，明显高于夹闭组的(3.26±0.83)分，改良Rankin评分为(2.09±0.49)分，明显低于夹闭组的(2.31±0.55)分，差异均有统计学意义(P<0.05)，但两组患者术后的再出血率和死亡率比较差异均无统计学意义(P>0.05)。栓塞组患者的并发症总发生率为8.33%，明显低于夹闭组的22.92%，差异有统计学意义(P<0.05)。结论 动脉瘤夹闭术与血管内弹簧圈栓塞治疗 aSAH患者远期预后均较佳，但血管内弹簧圈栓塞创伤更小，并发症更少，且对患者认知功能、血管内皮及炎症反应指标影响更小，临床上应结合患者情况选择合适术式。
      【关键词】 动脉瘤性蛛网膜下腔出血；显微外科手术夹闭；血管内弹簧圈栓塞；出血量；住院时间；认知功能
      【中图分类号】 R743.35 【文献标识码】 A 【文章编号】 1003—6350（2023）18—2636—05

Therapeutic effect of aneurysm clipping and endovascular coil embolization in the treatment of aneurysmalsubarachnoid hemorrhage.
CAO Xiao-lei, GU Qian, SHAO Jing. Department of Neurosurgery, East Campus, HuashanHospital Affiated to Fudan University, Shanghai 201206, CHINA
【Abstract】 Objective To compare the efficacy and safety of microsurgical aneurysm clipping and endovascu-lar coil embolization in the treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods The clinical diagno-sis and treatment data of 96 patients with aSAH admitted to Department of Neurosurgery, East Campus, Huashan Hospi-tal Affiated to Fudan University from June 2019 to June 2021 were selected for a retrospective study. They were dividedinto clipping group and embolization group according to different treatment methods, with 48 patients in each group. Theperioperative indicators, complications, related biochemical indicators [vascular endothelial growth factor (VEGF), serumhigh mobility group protein 1 (HMGB1), serum soluble intercellular adhesion molecule-1 (sICM-1), soluble vascular celladhesion molecule-1 (sVCAM-1)], cognitive function [Mini-mental State Examination (MMSE)] and prognosis after 1year of follow-up were compared between the two groups. Results The intraoperative blood loss, surgical time, andlength of hospital stay in the embolization group were (108.44±5.31) mL, (149.74±10.94) min, and (16.33±4.05) d,which were significantly less or shorter than (247.16±5.02) mL, (163.48±14.32) min, (18.20±4.59) d in the clippinggroup (P<0.05). However, there was no significant difference in the recovery time of consciousness between the twogroups (P>0.05). The levels of VEGF, HMGB1, sICM-1, and sVCAM-1 in the two groups at 1 month after surgery weresignificantly lower than those before surgery, and the levels of above indicators in the embolization group were (120.54±13.06) pg/mL, (75.94±7.66) μg/L, (452.85±27.82) ng/mL, and (49.18±4.97) ng/mL, significantly lower than (142.21±13.24) pg/mL, (89.46±7.18) μg/L, (582.15±34.11) ng/mL, and (56.74±5.66) ng/mL in the clipping group (P<0.05). At 3months after surgery, the MMSE score in the embolization group was (29.08±2.79) points, which was significantly high-er than (27.55±3.02) points in the clipping group (P<0.05). There was no statistically significant difference in the inci-dence rate of POCD between the two groups (P>0.05). At 1 year of follow-up after surgery, the GOS score in the emboli-zation group was (3.65±0.62) points, which was significantly higher than (3.26±0.83) points in the clipping group, whilethe modified Rankin score was (2.09±0.49) points, significantly lower than (2.31±0.55) points in the clipping group (P<0.05); However, there was no significant difference in postoperative rebleeding rate and mortality between the twogroups (P>0.05). The total incidence of complications in the embolization group was 8.33%, which was significantlylower than 22.92% in the clipping group (P<0.05). Conclusion Both aneurysm clipping and endovascular coil emboli-zation have good long-term prognosis in the treatment of patients with aSAH, but endovascular coil embolization hassmaller trauma, fewer complications, and less influence on cognitive function, vascular endothelial function, and inflam-matory response. Clinically, appropriate surgical methods should be selected according to the patient 's condition.
      【Key words】 Aneurysmal subarachnoid hemorrhage; Microsurgical aneurysm clipping; Endovascular coil embo-lization; Blood loss; Length of hospital stay; Cognitive function