Zhao W Y, Krings T, Alvarez H, Ozanne A, Holmin S, Lasjaunias P
Neuroradiologie Vasculaire Diagnostique et Thérapeutique, Hôpital Bicêtre, Le Kremlin Bicêtre, France.
Acta Neurochir (Wien). 2007 Jun;149(6):585-96; discussion 596. doi: 10.1007/s00701-007-1161-x. Epub 2007 May 21.
Haemorrhagic intracranial vertebrobasilar dissection is an uncommon cause of nontraumatic subarachnoid haemorrhage (SAH) and accounts for only 1-10% of non-traumatic SAH. Treatment in the acute phase is considered to be essential because of the high risk of rebleeding and the consequent unfavourable outcome. However, the location, the potential for involvement of eloquent vessels and the histopathological characteristics of the vessel wall make treatment demanding from both a technical and anatomical point of view. We report our experience in the management of this disease. PATIENTS AND TREATMENTS: From 1989 to June 2006, we managed 21 patients with spontaneous haemorrhagic dissection located in the intracranial vertebrobasilar system, 13 patients were treated using an endovascular approach, 1 by surgical clipping, and 7 were managed conservatively.
Among the 13 patients treated endovascularly, 7 underwent proximal occlusion, 4 underwent parent artery embolization at the site of dissection, and 2 underwent endovascular trapping. Severe, treatment-related complications due to dislodgement of the thrombus during the procedure occurred in 1 patient, who then died from brainstem ischaemia. One patient died from severe pneumonia and one patient was left disabled from vasospastic ischaemia resulting from severe initial SAH. The remaining 10 patients had satisfactory outcomes: none rebled after treatment and when discharged they had Karnovsky scores of 80-100. Of the 7 conservatively treated patients, three died of rebleeding and four were discharged with Karnovsky scores of 50-100. One patient, who was treated surgically, was discharged with a Karnovsky of 90.
The high rate of rebleeding and consequent mortality among the patients treated conservatively argues for treatment in the acute phase. Treatment should be guided by each patient's angiomorphology, clinical condition and the experience of the neurosurgical/neuroradiological team. Options include endovascular or surgical trapping of the dissection and proximal occlusion and embolisation of the parent artery at the site of the dissection.
出血性颅内椎基底动脉夹层是非创伤性蛛网膜下腔出血（SAH）的罕见病因，仅占非创伤性SAH的1%-10%。由于再出血风险高及随之而来的不良后果，急性期治疗被认为至关重要。然而，病变位置、累及功能区血管的可能性以及血管壁的组织病理学特征，使得从技术和解剖学角度来看，治疗颇具挑战性。我们报告我们在该疾病治疗方面的经验。
1989年至2006年6月，我们治疗了21例颅内椎基底动脉系统自发性出血性夹层患者，13例采用血管内治疗方法，1例采用手术夹闭，7例采用保守治疗。
在13例接受血管内治疗的患者中，7例行近端闭塞，4例在夹层部位行供血动脉栓塞，2例行血管内圈套术。1例患者在手术过程中因血栓移位出现严重的与治疗相关的并发症，随后死于脑干缺血。1例患者死于重症肺炎，1例患者因严重的初始SAH导致血管痉挛性缺血而致残。其余10例患者预后良好：治疗后均未再出血，出院时卡氏评分80-100分。在7例保守治疗的患者中，3例死于再出血，4例出院时卡氏评分50-100分。1例接受手术治疗的患者出院时卡氏评分为90分。
保守治疗患者再出血率高及随之而来的死亡率高，这表明急性期应进行治疗。治疗应根据每位患者的血管形态、临床状况以及神经外科/神经放射科团队的经验来指导。治疗选择包括对夹层进行血管内或手术圈套、在夹层部位对供血动脉进行近端闭塞和栓塞。
