医学论文-急诊手术治疗颅内动脉瘤破裂出血并脑疝.docVIP

医学论文-急诊手术治疗颅内动脉瘤破裂出血并脑疝 【摘要】? 目的：探讨颅内动脉瘤破裂出血并脑疝15例急诊手术的可行性。方法：先处理颅内血肿，后行动脉瘤显露、探查及夹闭术；对术中再次破裂出血者及时控制出血并夹闭瘤体。结果：动脉瘤夹夹闭动脉瘤14例，未发现动脉瘤1例；术后脑疝恢复11例，死亡4例。术中动脉瘤再次破裂7例。结论：动脉瘤破裂出血并脑疝病情危重，需要急诊手术；只要术前准备充分，即使在探查中动脉瘤再次出血，也能很好控制夹闭动脉瘤；但如果术中遗留未夹闭的动脉瘤将是导致术后潜在出血危险的原因，甚至危及生命。 【关键词】? 颅内动脉瘤；脑疝；手术 ??? ［Abstract］Objective: To analyze the emergent operation in 15 patients with ruptured intracranial aneurysms accompanied by cerebral hernia. Methods: The intracerebral hematoma was firstly removed, then intracranial aneurysm clipping was adopted. The reruptured aneurysms in the operation were clipped immediately. Results：The intracranial aneurysm clipping was completed in 14 cases, the intracranial aneurysm was not found in one case. Eleven cases were survived and 4 cases deid after operation. The aneurysmal body was clipped successfully in 7 cases with reruptured aneurysms. Conclusion: For the patients with ruptured intracranial aneurysm accompanied by cerebral hernia, the aneurysm clipping is necessary and effective. For those with reruptured aneurysm it is also effective. The unclipped aneurysm after operation will be dangerous and sometimes lethal. ??? ［Key Words］intracranial aneurysm, cerebral hernia, operation ??? 颅内动脉瘤破裂出血并脑疝者入院时病情都较危重，手术风险大，术中不可预见情况多，术后并发症也较多。2003_03—2008_02我科收治动脉瘤破裂出血并脑疝15例，现对其抢救治疗情况分析报道如下。 ??? 1? 资料与方法 ??? 1.1? 一般资料 ??? 本组男性9例，女性6例。年龄27～68岁，平均45岁。发病至脑疝发生时间0.5～5h，平均2h。术前Hunt_Hess分级均为4～5级。主要临床表现为突发头痛、呕吐，继之意识障碍、癫、高热等。入院后均行CT检查，示脑池出血并脑内血肿13例，脑池、脑室出血并硬膜下血肿2例，入院后发现单侧瞳孔散大11例，双侧瞳孔散大4例。 ??? 1.2? 方法 ??? 本组CT检查后迅速送手术室行急诊开颅手术。手术采用扩大翼点入路，伴有颅内血肿者先迅速清除血肿，然后从血肿底部寻找动脉瘤；硬膜下血肿(2例先冲洗吸净硬膜下血肿，然后抬起额叶颞叶，从颅底部探查寻找动脉瘤并夹闭。术中动脉瘤再次破裂出血7例，在有充分准备情况下，7例都能及时顺利控制出血，准确夹闭瘤体。本组去除骨瓣减压14例，骨瓣复位后继发脑水肿而再次手术取出骨瓣减压1例。 ??? 2? 结果 ??? 本组术中采用动脉瘤夹夹闭动脉瘤14例，未发现动脉瘤1例。术后脑疝恢复11例，其中8例基本恢复正常生活及工作能力，3例植物生存。术后因并发症死亡3例，未发现动脉瘤仅单纯清除颅内血肿减压而术后再次出血致脑干功能衰竭死亡1例。术中动脉瘤再次破裂7例，都能及时控制并夹闭动脉瘤。术后出现交通性脑积水4例，经行V_P分流后治愈。 ??? 3? 讨论 ??? 3.1? 早期正确诊断 ??? 颅内动脉瘤破裂大出血致脑疝者，如不及时手术都会因脑疝而死亡。此类病人入院时除了行头颅CT检查外，都因病情危重而不能行其它进一步检查，所以入院时诊断只能根据年龄、病史及比较典型CT改变来