重度颈内动脉狭窄伴未破裂动脉瘤的治疗策略

doi:10.19723/j.issn.1671-167X.2019.05.007

摘要/Abstract

摘要：

目的:探讨重度颈内动脉狭窄(≥70%)合并颅内未破裂动脉瘤的血管内治疗的安全性和可行性。方法:收集2012年1月至2015年7月在北京大学第三医院就诊的重度颈内动脉狭窄或闭塞患者共213例,其中伴有颅内未破裂动脉瘤的患者14例(6.6%),对其临床、影像学资料、治疗措施及预后进行分析。结果:14例重度颈内动脉狭窄或闭塞的患者中,动脉瘤共15个,11个位于狭窄后,1个位于狭窄前,3个位于非同流域。14例患者中1例实施颈内动脉剥脱术,11例成功置入颈内动脉支架(残留狭窄0~30%,平均6.4%),2例颈内动脉狭窄未处理。合并的15个动脉瘤大小1.0~7.0 mm,平均(2.8±1.5)mm,3例患者在处理狭窄同时处理动脉瘤,均行支架辅助弹簧圈栓塞,其中1例先处理动脉瘤;1例患者拒绝手术治疗,10例患者动脉瘤<5.0 mm,均未处理动脉瘤。围手术期均无手术并发症;3例患者失访,其他11例患者随访15~55个月,中位数37个月,均预后良好。结论:重度颈内动脉狭窄合并未破裂动脉瘤患者,需根据动脉瘤部位、大小等情况制定个体化方案治疗,而颅内小动脉瘤(<5.0 mm)不增加重度颈内动脉狭窄患者血管内治疗狭窄的手术风险。

关键词: 动脉瘤, 颈动脉狭窄, 支架, 栓塞

Abstract:

Objective: To investigate the safety and feasibility of endovascular treatment for severe internal carotid artery stenosis (≥70%) with unruptured intracranial aneurysms. Methods: We retrospectively reviewed 213 cases with severe stenosis or occlusion of internal carotid artery, and those patients had been treated at Peking University Third Hospital, between January 2012 and July 2015. In the stu-dy, 14 (6.6%) cases were coexistence with unruptured intracranial aneurysms. The medical records, imaging data, treatment and prognosis were analyzed. Results: There were 15 aneurysms (11 after the stenosis, 1 before the stenosis, and 3 in the other drainage basin) in those 14 patients with severe stenosis or occlusion of internal carotid artery. One of the 14 patients underwent carotid endarterectomy, and the 11 patients were successfully implanted with an internal carotid stent (residual stenosis 0-30%, mean 6.4%). Two patients with internal carotid artery stenosis remained untreated. One of them had complete occlusion of the initial segment of the internal carotid artery and was not possible to be treated, and the other patient refused to treat with internal carotid stenosis. The sizes of aneurysms were 1.0-7.0 mm, with an average of (2.8±1.5) mm. Three cases were treated with stenosis and aneurysms treated at the same time, and stent assisted coil embolization was performed in all the aneurysms, including 1 case that treated aneurysm before the stenosis. One patient refused surgical treatment of unruptured aneurysm, and no treatment was given to 10 patients who had small unruptured aneurysms (<5.0 mm). No perioperative complications were observed during the perioperative period. Three cases were lost with the follow-up, and the other 11 patients were followed up for 15-55 months, with a median of 37 months, and had good prognosis. Conclusion: Our results suggest that patient coexistance with severe internal carotid stenosis and unruptured intracranial aneurysms should be treated individually according to the location and size of aneurysms. Moreover, the presence of a small intracranial aneurysm (<5.0 mm) does not seem to increase the risk of endovascular stenosis in patients with severe internal carotid stenosis.

Key words: Intracranial aneurysm, Carotid stenosis, Stents, Embolism

中图分类号:

R743

赵海燕,樊东升,韩金涛. 重度颈内动脉狭窄伴未破裂动脉瘤的治疗策略[J]. 北京大学学报（医学版）, 2019, 51(5): 829-834.

Hai-yan ZHAO,Dong-sheng FAN,Jin-tao HAN. Management of severe internal carotid stenosis with unruptured intracranial aneurysm[J]. Journal of Peking University(Health Sciences), 2019, 51(5): 829-834.

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Patient no.	Age (year)/ Gender	Clinical presentation	Location of carotid lesion, stenosis ratio	Aneurysm/mm	Carotid treatment	Residual stenosis ratio	Aneurysm treatment
1	50/F	Hemiplegia	R C1, 90%	R C5, 3 mm	R CAS	10%	Aneurysm embolism after CAS
2	61/F	Dizziness	R C1, 70%+L C1, 70%+L C4, 80%	R C6, 3 mm	R CAS+L CAS	10%	None
3	83/F	Dizziness	R C1, 90%	R C4, 3 mm	R CEA	0	None
4	67/F	Aphasia	R C1, 90%	L C7, 2 mm	R CAS	0	None
5	67/F	Dizziness	L C1, 90%	R C7, 2 mm	L CAS	0	None
6	65/M	Hemiplegia	L C1, 95%+L C3/C4, 50%-70%+R C1,100%	L C4, 4 mm	L CAS	0	None
7	77/M	Dizziness	R C1,80%	R C4, 4 mm	R CAS	0	None
8	65/M	Dizziness	R C1,90%	R C4, 1.4 mm+ R C4, 1.3 mm	None	None	None
9	60/M	Dizziness, amaurosis	R C1,90%	L C7, 3 mm	L CAS	0	None
10	75/M	Dizziness	L C1,80%+R C1,95%	L C4, 2 mm	R CAS	0	None
11	50/M	Dizziness	R C1,100%	L C4, 1 mm	None	None	None
12	71/M	Dizziness	R C4,80%	R C4, 3 mm	R CAS	20%	Aneurysm embolism before CAS
13	73/M	Hemiplegia	L C4,90%	L C4, 2 mm	L CAS	30%	None
14	66/M	Dizziness, hemiplegia	R C6,70%	R C6, 7 mm	R CAS	0	Aneurysm embolism after CAS