多发破裂颅内动脉瘤的个体化手术治疗十三例疗效分析OA

Objective To explore the surgical strategies and efficacy for multiple ruptured intracranial aneurysms and analyze clinical outcomes.Methods A retrospective consecutive cohort of patients with multiple ruptured intracranial aneurysms admitted to the Department of Neurosurgery at the Qingdao Eighth People's Hospital from January 2021 to October 2025 was included.Clinical and imaging data were collected,including gender,age,Hunt-Hess grade,and aneurysm number,location,maximum diameter(≤0.5 cm,＞0.5 cm to＜1.5 cm,≥ 1.5 cm),distribution(unilateral anterior circulation,bilateral anterior circulation,posterior circulation,posterior circulation+anterior circulation),surgical treatment method(interventional embolization,microsurgical clipping,interventional embolization+microsurgical clipping),and treatment staging(single-stage,two-stage[second-stage treatment performed as soon as possible after the condition stabilized following the first-stage treatment],partial palliative treatment[treating only ruptured aneurysms and unruptured high-risk aneurysms]).Priority was given to the first-stage treatment of the culprit ruptured aneurysm,and all unruptured aneurysms were exposed and clipped or embolized through the same surgical approach whenever possible;for those that could not be completed in the same stage(including unruptured aneurysms that could not be exposed and clipped or were difficult to embolize),they were left for second-stage treatment(including repeat craniotomy clipping or interventional embolization)as soon as possible after the condition stabilized following the first-stage surgery.After the first-stage treatment,if the patient was elderly,in poor physical condition,or refused second-stage treatment,and the untreated aneurysm had a regular shape and small volume(maximum diameter＜3 mm),palliative treatment could be adopted,including medication to lower blood pressure and prevent constipation,with regular follow-up observation.CT and CT angiography(CTA;or MR angiography[MRA])were repeated 3 months postoperatively,and CT and DSA were repeated at 6 months postoperatively to determine the occlusion status of the aneurysms.Recurrence was considered if the visualization and morphology of the aneurysm neck and body increased compared to the first postoperative imaging examination.Thereafter,follow-up were conducted every 6 to 12 months,recording CT and CTA,MRA,or DSA results and the Glasgow outcome scale(GOS)score.At the final follow-up,a GOS score of 4 to 5 indicated a good prognosis,2 to 3 indicated disability,and 1 indicated death.Results A total of 13 patients with multiple ruptured intracranial aneurysms were included,including 4 males and 9 females,aged 33-69 years,with mean age of(47±10)years;there were 5 cases of Hunt-Hess grade 1,5 cases of grade 2,2 cases of grade 3,and 1 case of grade 4.The 13 patients had a total of 28 aneurysms,among which 11 patients had 2 aneurysms and 2 patients had 3 aneurysms;there were 8 posterior communicating artery aneurysms,2 internal carotid artery bifurcation aneurysms,6 middle cerebral artery M1 segment bifurcation aneurysms,3 middle cerebral artery M1 segment aneurysms,3 anterior communicating artery aneurysms,2 anterior cerebral artery A1 segment aneurysms,and 4posterior circulation(vertebral artery basilar artery)aneurysms;7 aneurysms had a maximum diameter of ≤0.5 cm,17 had a maximum diameter of＞0.5 cm to＜1.5 cm,and 4 had a maximum diameter of ≥ 1.5 cm;aneurysms were located in the unilateral anterior circulation in 7 patients,bilateral anterior circulation in 4 patients,anterior circulation+posterior circulation in 1 patient,and posterior circulation in 1 patient.Among the 13 patients,9received single-stage treatment,2 received two-stage treatment,and 2 received partial palliative treatment.Among the two-stage treatment patients,1 underwent interventional embolization and 1 underwent microsurgical clipping,with a total of 15 surgeries performed.Among the 28 aneurysms,13 were treated with simple coil embolization,1 was treated with stent-assisted coil embolization,and 12 with microsurgical(volume of hematoma 20.00-35.00ml,with a median volume of hematoma 25.00[23.75,30.00]ml).All 13 patients completed clinical and radiological follow-up with a follow-up duration ranging from 3 to 20 months and a median follow time of 10.0(7.0,13.5)months.Radiological follow-up at 3 and 6 months postoperatively showed no aneurysm recurrence or rebleeding in the 13 patients.At the final follow-up,the GOS scores were 5 in 9cases,4 in 1 case,3 in 1 case,2 in 1 case,and 1 in 1 case.At the final follow-up,10patients had a good prognosis,2 were disabled,and 1 died.The patient who died had a preoperative Hunt-Hess grade of 4,underwent first-stage microsurgical clipping of a left posterior communicating artery aneurysm and middle cerebral artery M1 segment bifurcation aneurysm,and second-stage stent-assisted coil embolization of the right internal carotid artery bifurcation aneurysm.Three months after the first-stage treatment,the patient developed gastrointestinal bleeding and hydrocephalus,and ultimately died of multiple organ failure.Conclusions Selecting first-stage surgical treatment based on the aneurysm location and the Hunt-Hess grade of patients with multiple ruptured intracranial aneurysms is a feasible treatment option,and can achieve a good clinical prognosis.For patients with Hunt-Hess grade 1-4 who cannot have all aneurysms treated in the first stage,second-stage treatment should be performed as early as possible after the condition stabilizes following the first-stage treatment.The sample size of this study is relatively small,the conclusions need to be further validated with a larger sample size and long-term follow-up.