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电解解脱性弹簧圈血管内栓塞颅内动脉瘤治疗进展
http://www.100md.com 2003年7月8日 www.chinaneuro.com
     作者地址:广州第一军医大学珠江医院神经外科

    1 GDC血管内栓塞颅内动脉瘤的适应证[7~11]

    GDC的临床应用极大的拓展了颅内动脉瘤的栓塞范围:(1)类似开颅手术可处理的囊状动脉瘤是GDC栓塞的最佳适应证;(2)手术夹闭失败者;(3)全身情况不允许者(如Hunt-Hess分级Ⅳ-Ⅴ级)或病人拒绝开颅手术者;(4)多次蛛网膜下腔出血,瘤周粘连明显,开颅手术风险较大者;(5)后循环动脉瘤,手术不易达到者。

    2 GDC血管内栓塞颅内动脉瘤的技术要点[12~14]

    (1)栓塞前行脑血管造影,了解脑循环情况,且个别病人为多发性动脉瘤,不可遗漏。2)栓塞前根据动脉瘤的大小及瘤颈的方向选择合适的X线投照位,使动脉瘤显影充分,以免微导管到位过程中刺破动脉瘤,且能达到完全栓塞而保证载瘤动脉不被意外栓塞的目的。3)测量动脉瘤体的大小及瘤颈的宽窄,注意动脉瘤的形状及方向,再根据动脉瘤的不同部位选择相应的微导管及栓塞材料,选好微导管后,其末端要塑成合适的角度。如动脉瘤位于前交通,且病人年龄大,动脉硬化迂曲明显,则可考虑用Fas Tracker-10微导管,因其顺应性好,易到位。若动脉瘤位于后交通,且较大,可考虑用Tracker-18微导管,因其走行路程短,微导管容易到位,且能选用GDC-18较粗弹簧圈栓塞,降低栓塞造价。如动脉瘤形状不规则,呈多角形,预示曾多次发生出血,选择弹簧圈型号时宜小于动脉瘤的最小直径,且应选择柔顺性好的弹簧,如GDC-soft,这种弹簧圈不但柔顺,而且末端更柔软,对动脉瘤壁创伤小。4)术中操作轻柔,避免导管或导丝忽上忽下,用力过猛;当微导管接近动脉瘤时,微导丝不可露出微导管过多,在微导管进入动脉瘤的过程中,进微导管的同时退微导丝,微导管进入动脉瘤时微导丝退至微导管内,避免微导丝损伤动脉瘤壁。5)微导管前端应置于瘤腔内近1/3处,不可直抵动脉瘤壁,以免微弹簧圈刺破动脉瘤。6)第一个微弹簧圈的放置至关重要,如能合适放置第一个弹簧,相当于手术成功了70%,选择与动脉瘤直径相当或略小的弹簧,沿动脉瘤壁盘旋缠绕成“篮筐”状,以利于其它弹簧圈在“篮筐”内盘旋及存留,以后弹簧的大小应逐渐减小,直至致密填塞。第一个微弹簧圈可选用GDC-soft及GDC-2D型弹簧圈,因此类弹簧圈呈双螺旋形,第一个螺旋圈较小,便于在瘤内盘绕。7)若动脉瘤与载瘤动脉关系不清,多见于大脑中动脉分叉处的动脉瘤,微弹簧圈接近动脉瘤时不易进入动脉瘤腔,可用微弹簧圈导引技术,因微弹簧圈比导丝更柔软,且弯度大,易到位,对动脉瘤损伤小。8)若动脉瘤颈较宽,可采用Remodeling重建技术栓塞,即微导管到位后,再于对侧股动脉插管,将Sulstice球囊导管放置于动脉瘤颈处,球囊充盈后用微弹簧圈栓塞动脉瘤,栓塞完全后,松开球囊导管并拔除。目前即将投放市场的GDC-3D微弹簧圈有更好的空间适应性,可为宽颈动脉瘤形成一“篮筐”,替代Remodeling技术。
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    3 GDC血管内栓塞颅内动脉瘤的优点[15]1)与其它栓塞材料相比,GDC操作简便,导管易到位,但导管的塑形至关重要,应根据血管走行及动脉瘤方向,塑成合适的角度。2)因微导管柔顺性好,尤其适于栓塞走行路径较长的前交通或大脑中动脉动脉瘤。3)GD C较柔软,有些前端有soft接头,有些有2D双环结构,第一个环较小,便于瘤内盘绕,不易撑破或刺破动脉瘤。目前新推出的GDC-3D空间结构,有更好的空间适应性,为动脉瘤的栓塞准备了更完善的材料。4)在微导管接近动脉瘤时,可用GDC代替微导丝,因GDC比导丝更柔软,且末端弯度大,更易进入动脉瘤内,同时不易造成血管或动脉瘤壁的损伤5)GDC型号极多,分GDC-18和GDC-10两大类,每一类中又根据弹簧圈直径的大小和长度的不同分为若干个型号,同一型号又有末端soft接头型及2D双环型,便于根据不同动脉瘤的具体情况进行选择,易于达到瘤内致密填塞。6)当GDC到位后,通电解脱弹簧圈,避免了机械解脱时弹簧圈在动脉瘤内的旋转和变位,从而避免了对动脉瘤的损伤,同时又减少了瘤内血栓脱出栓塞正常血管的危险性。
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    4 GDC栓塞颅内动脉瘤的并发症及防治4.1 GDC栓塞术中动脉瘤破裂的处理[16] 栓塞术中动脉瘤破裂后危险性极大,常危及生命,故应保持镇静,使抢救工作有条不紊的进行。(1)明确动脉瘤破裂后,不主张自微导管或导引管内注射造影剂,因为少量造影剂进入蛛网膜下腔可对脑组织造成强烈刺激,诱发癫痫大发作,甚至呼吸停止。(2)立即中和肝素,启动凝血系统。(3)继续用GDC栓塞动脉瘤,动脉瘤闭塞后出血即可停止。(4)若微弹簧圈大部分逸出动脉瘤外,原则上不应将弹簧圈拉回瘤内,以免弹簧圈再次损伤瘤壁,造成破口增大。但若弹簧圈仅有小部分逸出,可考虑小心将其拉回,并盘绕于动脉瘤内,瘤内放置一个弹簧圈即可起到止血的作用,继续放置弹簧圈直至完全填塞。(5)术后立即行CT检查,了解出血的程度,是否需开颅手术,若出血较少,腰穿置换脑脊液常可达到满意效果。

    4.2 GDC栓塞术中脑梗塞的处理[17] GDC电解解脱过程中,易吸附红细胞、血小板,聚集成血栓,若血栓脱落后可造成脑梗塞。明确脑梗塞后,应立即动脉内用尿激酶溶栓,效果较好。但若为动脉硬化斑栓子,则溶栓效果较差。
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    4.3 术后动脉瘤复发 主要原因有:(1)弹簧填塞不致密;(2)瘤内有血栓,术后部分弹簧逐渐移至血栓内;(3)血流冲击,尤其基底动脉末端动脉瘤及大脑中动脉分叉部动脉瘤,弹簧极易因血流冲击而向瘤内移位。

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    (9):1645~1651., 百拇医药(段传志 黄庆 李铁林)