王波，卜祥梅，徐超，李澤福，李建民，王成偉

(1濱州醫(yī)學(xué)院附屬醫(yī)院，山東濱州 256603；2山東大學(xué)第二醫(yī)院)doi：10.3969/j.issn.1002-266X.2016.15.041

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頸內(nèi)動(dòng)脈床突上段血泡樣動(dòng)脈瘤完全夾閉后短期內(nèi)復(fù)發(fā)1例報(bào)告

王波1，卜祥梅1，徐超1，李澤福1，李建民1，王成偉2

(1濱州醫(yī)學(xué)院附屬醫(yī)院，山東濱州 256603；2山東大學(xué)第二醫(yī)院)doi：10.3969/j.issn.1002-266X.2016.15.041

患者男，38歲,因“突發(fā)劇烈頭痛2 h”入院。既往有高血壓史5 a，患者于入院前2 h吃飯時(shí)無(wú)明顯誘因突發(fā)劇烈頭痛，并伴頭暈，遂送往我院急診。入院后行頭部CT檢查，檢查過(guò)程中再發(fā)抽搐1次，發(fā)作時(shí)四肢僵直，數(shù)分鐘后緩解，口吐白沫伴小便失禁1次，CT檢查顯示蛛網(wǎng)膜下腔出血，遂收入我科。查體顯示神清語(yǔ)利，頸強(qiáng)陽(yáng)性，余未見(jiàn)異常。患者于入院后當(dāng)天急診行DSA造影，顯示右側(cè)頸內(nèi)動(dòng)脈床突上段血泡樣動(dòng)脈瘤(BBA)，大小約4 mm×5 mm，于次日全麻下行動(dòng)脈瘤夾閉術(shù)；術(shù)中夾閉順利，且吲哚菁綠熒光造影顯示動(dòng)脈瘤夾閉良好，無(wú)瘤頸殘余。動(dòng)脈瘤夾閉術(shù)后3 d，患者頭痛劇烈，意識(shí)渾濁，腰穿腦脊液仍為血性，頭部CT復(fù)查顯示右顳部腦出血，遂行右顳去骨瓣減壓術(shù)，術(shù)后患者嗜睡狀態(tài)。右顳去骨瓣減壓術(shù)后16 d，患者突發(fā)抽搐，頭部減壓窗張力較高，頭部CT顯示蛛網(wǎng)膜下腔出再出血，次日頭部DSA造影顯示右側(cè)頸內(nèi)動(dòng)脈床突上動(dòng)脈瘤復(fù)發(fā)，大小約9.5 mm×6 mm，經(jīng)微導(dǎo)管超選進(jìn)入動(dòng)脈瘤內(nèi)行動(dòng)脈瘤栓塞術(shù)，共填入microplex彈簧圈9枚；復(fù)查DSA造影見(jiàn)動(dòng)脈瘤栓塞致密。術(shù)后患者呈嗜睡狀態(tài)，CT檢查顯示腦積水明顯，第20天行VP分流術(shù)，術(shù)后患者狀態(tài)恢復(fù)可，1周后出院神清言語(yǔ)可，左側(cè)肌力恢復(fù)正常。VP分流術(shù)后4個(gè)月，復(fù)查DSA造影見(jiàn)動(dòng)脈瘤頸處復(fù)發(fā)，再行支架輔助栓塞治療，共填入彈簧圈3枚；3個(gè)月后再次復(fù)查DSA造影未見(jiàn)動(dòng)脈瘤復(fù)發(fā)，現(xiàn)患者生活完全自理。

討論：BBA發(fā)生于頸內(nèi)動(dòng)脈無(wú)分支的床突上段，占頸內(nèi)動(dòng)脈瘤的0.9%～6.5%[1]，血管造影表現(xiàn)為頸內(nèi)動(dòng)脈前壁不規(guī)則、寬基底、小的半球型突起，較快的形態(tài)學(xué)改變，短期內(nèi)快速增大等特征。許多研究[2，3]表明，BBA不是囊性動(dòng)脈瘤，而是一種特殊的假性動(dòng)脈瘤或夾層動(dòng)脈瘤。BBA動(dòng)脈瘤壁非常薄，且較為脆弱。BBA的最初病因尚不清楚，可能與小的潰瘍穿透內(nèi)彈力層形成動(dòng)脈壁的薄弱點(diǎn)有關(guān)。血流動(dòng)力學(xué)因素也是不可忽視的重要因素，頸內(nèi)動(dòng)脈床突上段轉(zhuǎn)向造成的血流沖擊床突上段動(dòng)脈壁增大了產(chǎn)生動(dòng)脈瘤的可能性[4]，瘤壁僅覆蓋纖維組織和血管外膜且缺乏膠原纖維層[2]。膠原層缺失與術(shù)中動(dòng)脈瘤破裂關(guān)系密切[5～8]。本例患者雖在動(dòng)脈瘤夾閉術(shù)術(shù)中行熒光造影顯示夾閉良好，但術(shù)后短期內(nèi)迅速增大并破裂出血。考慮其再出血原因：①與BBA的組織學(xué)特征相關(guān);②術(shù)后動(dòng)脈瘤夾可能發(fā)生移位，造成夾閉不全，再出血;③行夾閉時(shí)未與血管平行夾閉;④術(shù)中熒光造影僅能觀察當(dāng)時(shí)動(dòng)脈瘤夾閉的效果，但對(duì)于術(shù)后動(dòng)脈瘤的發(fā)展無(wú)法預(yù)知。即使在術(shù)中熒光造影證實(shí)夾閉良好的床突上端動(dòng)脈瘤，術(shù)后短期內(nèi)應(yīng)復(fù)查DSA造影，以確定動(dòng)脈瘤是否復(fù)發(fā)。

由于BBA瘤體較小且薄弱，瘤頸寬，發(fā)生于床突上段，單純行彈簧圈栓塞十分困難。Matsubara等[2]應(yīng)用球囊輔助栓塞9例BBA患者，獲得較為滿意的結(jié)果。Lee等[9]應(yīng)用支架輔助栓塞6例BBA，隨訪6個(gè)月，DSA造影顯示栓塞致密的瘤體與雙支架重建的管道之間出現(xiàn)空隙，表明新的血管內(nèi)膜的生成。Gaughen等以單純支架疊加技術(shù)治療BBA，約50%患者出現(xiàn)瘤頸殘余或動(dòng)脈瘤再增大需要進(jìn)一步處理。近期隨著血流導(dǎo)向支架進(jìn)入臨床，應(yīng)用血流導(dǎo)向支架治療此種類型動(dòng)脈瘤的報(bào)道增多[9]，血流轉(zhuǎn)向裝置可以較好地解決其他各種技術(shù)無(wú)法達(dá)到的效果，比如既處理了動(dòng)脈瘤同時(shí)又保留了頸內(nèi)動(dòng)脈的血供，特別適應(yīng)于傳統(tǒng)治療方法無(wú)法處理動(dòng)脈瘤而需要閉塞頸內(nèi)動(dòng)脈的BBA患者，解決了BBA栓塞或夾閉術(shù)后易復(fù)發(fā)，再出血機(jī)率高的病理學(xué)特性[10]。開(kāi)顱手術(shù)治療方面[11～13]包括夾閉動(dòng)脈瘤瘤頸的同時(shí)夾閉一部分正常的頸動(dòng)脈壁，以肌肉、棉片、筋膜包裹動(dòng)脈瘤加強(qiáng)脆弱的動(dòng)脈瘤壁，但是開(kāi)顱手術(shù)，術(shù)中動(dòng)脈瘤破裂，頸動(dòng)脈撕裂出血風(fēng)險(xiǎn)較大[1,7,8]。劉崢等[14]行開(kāi)顱手術(shù)夾閉的6例BBA中3例術(shù)中瘤頸處薄弱的頸動(dòng)脈撕裂，即使有些患者術(shù)前行BOT實(shí)驗(yàn)證實(shí)側(cè)支循環(huán)良好，術(shù)中閉塞頸內(nèi)動(dòng)脈，術(shù)后還是出現(xiàn)持久的血管痙攣，患者大多預(yù)后不良。鑒于本例患者治療過(guò)程，我們認(rèn)為開(kāi)顱手術(shù)治療再出血風(fēng)險(xiǎn)較高，應(yīng)以介入治療為主，介入治療應(yīng)以雙支架覆蓋瘤頸部并結(jié)合彈簧圈栓塞[15,16]，治療主要目的為加固薄弱的瘤頸，目前編織支架具有較高的金屬覆蓋面積，對(duì)瘤頸處封閉有積極作用[17～19]。本例患者最終雙支架覆蓋后復(fù)查未再見(jiàn)動(dòng)脈瘤顯影。說(shuō)明瘤頸處已完全封閉。血流導(dǎo)向支架金屬覆蓋面積更高，但其尚缺乏長(zhǎng)期的大宗病例隨訪[20]。

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