夹层动脉瘤 Dissecting Aneurysms
These are discussed more extensively in Chap.16.They are most frequent in the posterior circulation,where they typically affect the basilar and vertebral arteries.Aneurysms of distal branches of the cerebellar and posterior cerebral arteries can also be due to dissection.Dissecting aneurysms are less common in the anterior circulation.The distal ICA,proximal MCA,and ACA are the most usual locations.Distal branches can occasionally be involved.Another very rare site of dissecting aneurysm is the PcomA.
这些在第16章将进行更广泛的讨论。它们最常见于后循环，通常会影响椎动脉-基底动脉。小脑动脉和大脑后动脉远端动脉瘤也可能是由于夹层所致。夹层动脉瘤在前循环系统较少见。远端ICA，MCA和ACA近端是最常见的位置。远端分支偶尔也可涉及。另一个罕见的夹层动脉瘤部位是后交通动脉（PcomA）。
梭形和巨型动脉瘤 Fusiform and Giant Aneurysms
Fusiform aneurysms are a relatively uncommon form found in the anterior circulation(supraclinoid ICA and MCA),though more frequently in the posterior circulation(vertebral and basilar arteries)(Fig.11.25).Unlike saccular aneurysms,in which a neck is recognizable,infusiform aneurysms the entire vessel expands.The pathogenesis is a particular form of arteriosclerosis,in which the initial event is lipid deposition in the intima,with disruption of the internal elastic lamina and infiltration and fibrosis of the media,leading to progressive dilatation and tortuosity of the artery,which is promoted also by the frequent presence of hypertension.The increased luminal diameter leads to a slowing down of the circulation and to thrombosis on the wall,which causes further changes,characterized by fibrosis and rigidity,which promote further dilatation(Hegedus1985;Echiverri et al.1989).
前循环系统的梭形动脉瘤比较少见（床突上段ICA、MCA），虽然更常见的是位于后循环系统（椎动脉和基底动脉）（图11.25）。不像囊状动脉瘤，颈部是可辨认的。梭形动脉瘤为整个血管扩张。发病机制多为动脉粥样硬化的一种特殊形式，此过程其起始事件是脂质在内膜沉积，内弹力层破裂和中膜的浸润和纤维化，导致动脉逐渐扩大和迂曲，经常由于高血压导致过程加速。管腔直径增大导致循环的减慢和血栓在血管壁形成，导致进一步变化，以血管壁纤维化和僵硬为特征，进而进一步促进血管扩张（Hegedus 1985 ; Echiverri等. 1989）。
Fig. 11.25 Patient presenting with progressive tetraplegia due to giant fusiform aneurysm of the basilar artery compressing the brainstem. Left and right vertebral angiogram. The left and right PCA are well recognizable (L and R) as is the right superior cerebellar artery ( arrow with angle ). That on the left is very small. AICA is on the left. Well- developed PICA is on the left and small PICA on the right. Anterior spinal artery ( arrowheads ). Occlusion of the left vertebral artery with a balloon, proximal to the PICA, was performed to reduce the fl ow in the aneurysm. There was a partial clinical improvement, followed by a severe fatal subarachnoid hemorrhage 1 month later
图11.25由于基底动脉梭形动脉瘤压迫脑干，患者以进行四肢瘫痪为主要表现。左、右椎动脉造影。左、右PCA较好识别（L和R），由于是右小脑上动脉（角箭头）。左边很小。AICA在左边。左侧PICA发育较好，右侧PICA较小。脊髓前动脉（箭头）。球囊闭塞左椎动脉，靠近PICA近端，降低动脉瘤血流。有一部分临床改善，1个月后出现严重的致命的蛛网膜下腔出血。
Fusiform aneurysms can also occur in children and young non-atheromatous patients as aresult of collagen-dysplastic diseases,such the Marfan syndrome,Ehlers–Danlos syndrome,fibromuscular dysplasia,and alpha-glucosidasedefi ciency(Makos et al.1977)in which spontaneous dissection is frequently present(see alsoChap.16).The prognosis of these patients is frequently very poor.The progressive dilatation leads to compression of the brain parenchyma.Ischemia,especially involving the perforating branches,can occur.Hemorrhage is uncommon(Little et al.1981;Echiverri et al.1989;Pessinet al.1989),even though in some studies it hasbeen reported as being not so rare(Flemminget al.2004).
梭形动脉瘤也可以在儿童和年轻的非动脉粥样硬化患者，为胶原异常增生症结果，如马凡氏综合征，埃-斯综合症，肌纤维发育不良，和α-葡萄糖苷酶缺乏（Makos et 1977），经常出现自发性夹层（参见章节16）。这些患者的预后是经常很糟糕。进行性扩张导致脑实质受压。脑缺血，尤其涉及穿支血管可发生。出血是罕见的（(Little等. 1981 ; Echiverri等. 1989 ; Pessin等. 1989），尽管其在一些研究中被报道并不少见（Flemminget al. 2004）。
Giant aneurysms(11.26)are rare and can be found in the anterior circulation(cavernous,supraclinoid portion of the ICA,anterior and middle cerebral arteries)and posterior circulation(basilar artery and PCA aneurysm).They can grow in similar fashion to small erlesions owing to the weakness of the wall and the effect of the blood fl ow.Sometimes,however,the growth is a result of intramural hemorrhage from rupture of the vasa vasorum.The hemorrhage and resultant thrombus can lead to a dissection of the wall,which acts as a triggering factor and stimulates additional proliferation of the vessel in the wall with further hemorrhage(Schubiger et al.1987;Nagahiro et al.1995;Katayama et al.1991;Kaneko et al.2001;Krings et al.2007).This process also explains why sometimes the aneurysm continues to expand despite the fact that it appears completely occluded on the angiogram.In othercases where the aneurysm is partially thrombosed,hemorrhage can occur localized on the periphery adjacent to the thrombosed part of the aneurysm.Taking this into consideration,the ideal treatment should be the complete surgical excision.This is,however,not always possible and is linked with high risks.
巨大动脉瘤（11.26）是罕见的，可以发现在前循环（海绵窦段，床突上段ICA、大脑前动脉和大脑中动脉）和后循环（基底动脉和PCA动脉瘤）。由于血管壁的薄弱和血流影响，它们与小的病变生长方式相似。然而，有时生长是由营养血管破裂导致的血管壁内出血引起。出血和血栓可导致血管壁夹层，作为触发因子，刺激血管壁多余的血管增生，伴随进一步发生出血（Schubiger等. 1987 ; Nagahiro等. 1995 ; Katayama等. 1991 ; Kaneko等. 2001 ; Krings等. 2007）。这个过程也解释了为什么有的动脉瘤尽管血管造影完全闭塞，却会继续扩大。在另一些患者中，动脉瘤部分栓塞，出血可却能发生在相邻动脉瘤血栓部分的邻近部分。考虑到这一点，理想的治疗方法应该是彻底的手术切除。然而，这并非总是可能的，并与高风险相关。
Fig. 11.26 Giant aneurysm of the middle basilar artery presenting with brainstem syndrome in an older patient. The aneurysm was probably dissecting. The angiogram showed in addition several irregularities of the wall of the vertebral and basilar arteries owing to atheromasia. Left and right vertebral artery (L and R) pre- and posttreatment with occlusion using coils supported by balloon (remodeling technique). The clinical symptoms improved
图11.26基底动脉中段的巨大动脉瘤，以老年患者出现脑干综合征位置主要表现。可能是夹层动脉瘤。血管造影此外显示椎动脉和基底动脉由于动脉粥样变性出现动脉瘤壁的不规则。左右椎动脉（L和R）使用气囊后，弹簧圈闭塞前后（重塑技术）。临床症状的改善
诊断与治疗 Diagnosis and Treatment
In patients with SAH,CT angiography can be a very useful diagnostic method instead of convention alangiography.However,negative results,especially with small aneurysms near the base of the skull,do not exclude with certainty the presence of an aneurysm.MRI angiography can be employed as a screening method to detect aneurysms in particular groups of patients,such asthose with polycystic kidney or with a family incidence of aneurysms.MRI angiography is not commonly used in the acute phase of SAH.
在蛛网膜下腔出血（SAH）患者，CT血管造影（CTA）是非常有用的诊断方法，可以代替常规血管造影。然而，阴性结果，特别是在颅底附近的小动脉瘤，并不完全排除动脉瘤的存在。磁共振血管成像（MRA）可以作为一种筛查方法，用于检测特定人群中的动脉瘤，如多囊肾或有家族性动脉瘤。磁共振血管成像（MRA）不常用于急性期蛛网膜下腔出血检查。血管造影仍是金标准，尤其是诊断不明或血管内治疗时。
Vessel angiography remains the gold standard that is to be performed every time there is an unclear diagnosis or if an endovascular treatment is being considered.The introduction of the Guglielmi detachable coil in 1991 opened a new era in the treatment of cerebral aneurysms.Since then,the increasing quality of coils and microcatheters,the applicationin selected cases of new techniques(remodeling technique,Moret et al.1997),and the more recent introduction of stents associated with coils and flow-diverter stents have progressively expanded the indications for endovascular treatment and brought about an improvement in the results(Moretet al.1997;Boccardi et al.1998;Molineux et al.2002;Murayama et al.2003a;Henkes et al.2004;Bradac et al.2005,2007;Gallas et al.2005;Parket al.2005;Kurre and Berkefeld 2008;Wanke andForsting 2008;Loumiotis et al.2012;Berge et al.2012;Pierot et al.2012).
1991年弹簧圈的引进打开了脑动脉瘤治疗的新纪元。从那时起，弹簧圈和微导管质量提高，在选择患者中应用新技术（重塑技术Moret等. 1997）和最近弹簧圈支架与血流导向支架，扩大血管内治疗手段适应证及带来良好的结果（Moret等. 1997 ; Boccardi等. 1998 ; Molineux等. 2002 ; Murayama等. 2003a ; Henkes等. 2004 ; Bradac等. 2005 , 2007 ; Gallas等. 2005 ; Park等. 2005 ; Kurre and Berkefeld 2008 ; Wanke and Forsting 2008 ; Loumiotis等. 2012 ; Berge等. 2012 ; Pierot等. 2012）。
More problematic remains the treatment of giant and fusiform aneurysms.For these,different endovascular strategies can be applied:occlusion of the parent vessel with coils and balloon technology(Van der Schaaf et al.2002;Lin et al.2007;Clarençon et al.2011;Matouk et al.2012).
巨大梭形动脉瘤的治疗仍有许多问题。对于这些患者，不同的血管内策略可以应用：载瘤动脉弹簧圈或者球囊闭塞（Van der Schaaf等. 2002 ; Lin等. 2007; Clarençon等. 2011 ; Matouk等. 2012）。
This has been frequently used in paraclinoid ICA aneurysms with excellent results,provided that the test occlusion is clinically well tolerated by the patient and there is a good collateral circulation at the circle of Willis.In spite of the introduction of new devices,this technique still remains an effective option in the treatment of these aneurysms.The same technique is also useful in the occlusion of one VA in cases of giant or fusiform aneurysms where the posterior circulation is guaranteed by the contralateral VA.In addition,more distal aneurysms can be treated with this method when a good leptomeningeal collateral circulation is present.If this is insufficient,the parent vessel occlusion can be preceded by bypass surgery(VanRoij and Sluzewski 2009).The introduction of stents,associated with coils and fl ow-diverter stents,has opened new way in the treatment of these lesions(Yang et al.2007;Lubicz et al.2008;Liebig and Henkes 2008;Gall et al.2009;Chapotet al.2009;Fiorella et al.2009b;Szikora et al.2010;Deutschmann et al.2012)(See also Sect.16.6:Treatment of dissecting aneurysms).Considering the fl ow-diverter stent,there is nodoubt about its utility in treatment of some aneurysms;however,some problems linked with this device remain unsolved at this time,as described in a recent study(Bing et al.2013;Roszelle et al.2013).
该方法常用于治疗床突旁ICA动脉瘤，疗效非常好，只要患者临床闭塞试验耐受性良好及Willis环有良好的侧支循环。尽管引进了新的设备，这项技术仍然是治疗这些动脉瘤的有效方法。同样的技术在后循环巨型或梭形动脉瘤一侧椎动脉（VA）闭塞，而对侧VA循环较好，此外，更多远端动脉瘤可以用这种方法治疗，尤其是当一个好的软脑膜侧支循环存在。如果这不够，载瘤动脉闭塞前可进行搭桥手术（Van Roij and Sluzewski 2009）。支架的应用与弹簧圈及血流导向支架，开辟了治疗这些病变的新途径（Yang等. 2007 ; Lubicz等. 2008 ; Liebig and Henkes 2008 ; Gall等. 2009; Chapot等. 2009 ; Fiorella等. 2009b ; Szikora等. 2010 ; Deutschmann等. 2012）（另见章节16.6：夹层动脉瘤的治疗）。考虑到血流导向支架，它在治疗某些动脉瘤方面的效用，然而，与相关设备相关的一些问题，仍然没有解决（Bing 2013；Roszelle 2013）。特别的是，改进应该的是一方面保证足够多的孔隙，一方面完全排除动脉瘤血液，另一方面允许血流进入小穿支血管。
In particular,improvement should be directed in the attempt to guarantee an adequate porosity which should on one hand exclude the flow into the aneurysm and on the other hand allow a fl ow into small adjacent perforators.In conclusion,the introduction of the endovascular treatment and its positive evolution due to the development of new devices and progressive better experience has certainly improved the treatment and prognosis of many patients.However,we are far from an ideal endovascular treatment and one should be cautious(Van Rooij 2012 c)in the selection of patients and in the choice of the device in the given case.The aneurysm remains an insidious pathology and its treatment is still burdened by a certain degree of morbidity and mortality.This is especially true for large,giant,and fusiform aneurysms which still have a little unpredictable,sometimes also very bad evolution inspite of the apparently technically successful treatment(Kulcsar et al.2011;Velat et al.2011;Chowet al.2012;Cruz et al.2012;Leung et al.2012;Fargen et al.2012;Brinjikji et al.2013;Chalouhiet al.2013).
总之，血管内治疗的引入和由于新设备的发展与逐步积累的经验产生的积极演变，更好改善了患者的治疗和预后。然而,我们离理想的血管内治疗还很远。在患者和在给定情况下的设备选择一定要谨慎（Van Rooij 2012）。动脉瘤仍然是病理学不明及其治疗仍然有一定程度的发病率和死亡率。对于大的，巨大的，尤其是梭形动脉瘤还有一点不可预知，尽管有时技术上取得成功，但也会出现结局演化不良（Kulcsar等. 2011 ; Velat等. 2011; Chow等. 2012 ; Cruz等. 2012 ; Leung等. 2012; Fargen等. 2012; Brinjikji等. 2013 ; Chalouhi等. 2013）。
破裂动脉瘤 Unruptured Aneurysms
Modern diagnostic methods have revealed an increasing number of unruptured aneurysms,raising the question of whether they should be treated or not.The rupture of an aneurysm can have catastrophic clinical consequences for the patient.Technical improvements in surgery and endovascular treatment today mean that unruptured aneurysms can be treated and good results obtained,with a low rate of complications,though they are not completely excluded(Roy et al.2001;Henkeset al.2004;Bradac et al.2007).
现代诊断方法发现未破裂动脉瘤越来越多，同时也带来是否应该处理的问题。动脉瘤破裂可能给患者带来灾难性的临床后果。外科手术技术的进步，血管内治疗技术改进意味着未破裂动脉瘤是可以治疗的，并取得较好的结果，并且并发症率很低，尽管它们未能完全排除并发症（(Roy等. 2001 ; Henkes等. 2004 ; Bradac等. 2007）。
Some factors that can influence the decision have been reported in an international study(Wiebers et al.2003)of unruptured aneurysms that appeared in Lancet(2003).According to this study,the risk of hemorrhage is low in aneurysms with a diameter of less than 7 mm,but it increases progressively with greater diameters.
已发表在Lancet（2003）上的一项国际研究中，一些因素被报道影响未破裂动脉瘤的决策（Wiebers等. 2003）。根据这项研究表明，动脉瘤出血的风险很低，尤其当直径小于7毫米时，但随着逐渐增大直径，破裂风险逐渐增加。考虑到动脉瘤的大小与经验相矛盾（大多数诊断为蛛网膜下腔的动脉瘤直径相对较小）。然而，目前通常认为动脉瘤发展的急性期出血风险特别高，而在这个时候直径通常比较小（Wiebers等. 2003）。如果动脉瘤在这个阶段不破裂，其后血管壁强化和出血风险降低。后来，一些未破裂动脉瘤生长和与此相关的血管壁变化，逐渐增加出血风险。
This consideration about the size of the aneurysm seems to be in contradiction with the experience that them ajority of the aneurysms diagnosed in patients with SAH are relatively small.However,it is today commonly assumed that the risk of hemorrhageis particularly high in the acute phase when the aneurysm develops,and at this time it is commonly relatively small(Wiebers et al.1987).If the aneurysm does not rupture in this phase,the wall fortifies and the risk of hemorrhage decreases.Later,some of these unruptured aneurysms can grow and this associated with changesin their wall increases progressively the risk of hemorrhage.Independent of the diameter,the risk of rupture is greater in aneurysms of the posterior circulation and in patients who have already undergone treatment for another ruptured aneurysm.In an attempt to clarify this matter,further studies have been performed related to the morphology of the aneurysm(irregular shape,multilobar,presence of blebs)as well as to the perianeurysmal environment.The latter involves constraintson the shape of the aneurysm that could favor its rupture(Rüfenacht 2005).Another factor could be the transmission of pressure and fl ow rates within the aneurysm,which are reported to be higher in bifurcation aneurysms than in the sidewall(Sorteberg and Farhoudi 2006).Post processing analysis of 3D visualization of the angiogram has shown the possible influence of the fl ow within the aneurysm being dependent on its location(Cebralet al.2005)and also on its geometry,particularly when the aneurysm has a main axis parallel to the parent artery(Szikora et al.2008).
独立因素比如动脉瘤直径、后循环动脉瘤及别处已经接受了治疗的破裂动脉瘤的患者中，破裂风险增加。为了阐明这一问题，进一步的研究已经涉及了动脉瘤的形态（形状不规则，多叶，存在血管泡）以及对动脉瘤周围的环境。后者涉及到动脉瘤的形状上因素可能有利于它破裂（Rufenacht 2005）。另一个因素可能是压力和动脉瘤内血流量的传递，据报道分叉动脉瘤多于侧壁动脉瘤（Sorteberg，Farhoudi 2006）。血管造影图像3D可视化分析显示了动脉瘤内部血流的可能影响依赖于它的位置（Cebral 2005）以及它的几何学形状，特别是动脉瘤主轴与载瘤动脉平行（Szikora等人2008）。
In spite of such interesting findings,there is today no consensus for or against the preventive treatment of an unruptured aneurysm(Raymondet al.2008).The decision still depends on the experience and attitude of the medical team involved and also on the emotional reaction of the patient who is aware of the pathology.
尽管有如此有趣的发现，今天还是没有达成反对未破裂动脉瘤的预防性治疗的共识（Raymond等. 2008）。决定仍然取决于医疗团队的经验和态度，也涉及患者知晓病情的情绪反应。
SAH患者血管造影阴性 Negative Angiogramsin Patients with SAH
In about 15–20%of patients with SAH,the aneurysm is not detected on the angiogram.In some patients,particular in cases with a perimesencephalic pattern of bleeding,the SAH is frequently not due to the aneurysm(Rinkel et al.1991).In other cases,the aneurysm can be definitely thrombosed at the time of the bleeding and thus no longer recognizable,even in later controls.
在大约15 - 20%的SAH患者中，血管造影未发现动脉瘤。在一些患者，特别是中脑周围蛛网膜下腔出血患者，SAH经常不是由动脉瘤引起（Rinkel 1991）。在其他情况下，动脉瘤可以在出血时甚至在治疗后形成血栓，因此无法辨认。
Vasospasm and large hematoma can temporarily hide the presence of an aneurysm that is demonstrated later.In rare cases,however,where no spasmor hematoma is present,the aneurysm is not visualizedon the angiogram performed in the acute phase,but it can be detected 1 or 2 weeks later.This has been reported in about 10–19%of the cases in which the first angiogram was negative(Bradac et al.1997;Urbach et al.1998;Alves et al.2005)(Fig.11.27).
血管痉挛和大血肿可以暂时隐藏动脉瘤的存在，但稍后证明其存在。然而，在罕见的情况下，没有痉挛或血肿，动脉瘤在急性期的血管造影中看不出来，但它可以在以后1-2周检测到。据报告在大约10 - 19%的患者中第一次血管造影阴性（Bradac等. 1997 ; Urbach等. 1998 ; Alves等. 2005）（图11.27）。
The cause of this phenomenon is not completely known.A temporary thrombosis of the aneurysm could occur.Other cases could be due to a dissection involving the wall of the artery responsible for the bleeding,but not recognizable on the angiogram.Later,this leads to the formation of ananeurysm.This probably occurs in the so-called blister aneurysms of the dorsal wall of the ICA.
造成这种现象的原因还不完全清楚。动脉瘤内血栓暂时性血栓形成时可发生。其他患者可能是由于导致出血的动脉壁出现夹层，但血管造影中不能辨认。后来，导致了动脉瘤形成。这可能是所谓的颈内动脉背壁泡状动脉瘤。
Fig. 11.27 Middle-aged woman with SAH, in which a complete angiographic study did not reveal a vascular malformation. A second SAH occurred 2 weeks later. The angiographic study then revealed the aneurysm. ( a ) First right carotid angiogram. ( b ) Repeated angiogram showing the AcomA aneurysm ( arrow ). There was also a minimal spasm involving the A1 and A2 segment of the right
anterior cerebral artery
图11.27SAH的中年女性，完整的血管造影研究没有发现血管畸形。2周后再次发生SAH。血管造影显示动脉瘤。（a）首先右侧颈动脉造影。（b）重复造影显示前交通动脉瘤（箭头）。因此，右侧ACA的AI和A2段有轻微的血管痉挛。
血管痉挛 Vasospasm
This is a frequent complication of SAH,with an incidence as high as 70%of cases.Among them,symptomatic ischemia occurs in about 35%(Wintermark et al.2006;Komotar et al.2007;Hanggi et al.2008).Symptomatic ischemia can occur in every SAH,but younger patients and those with a severe hemorrhage,visible on CT,are more at risk of developing vasospasm.
这是蛛网膜下腔出血（SAH）的常见并发症，发病率高达70%。其中，症状性缺血发生约35%（Wintermark等. 2006 ; Komotar等. 2007 ; Hanggi等. 2008）。缺血症状可发生在每一个SAH患者，但年轻患者，尤其是出血严重者，在CT上可见，更易发生血管痉挛。
Diagnosis.All patients with SAH should beclosely monitored for vasospasm in the days after SAH.This can be done using daily transcranial Doppler(TCD),followed on the third or fourth day by CT and perfusion CT whenever the TCD shows an increased velocity(more than 120–130 cm/s),especially when this occurs over a short period oftime.Independently of and/or in association with these technical controls,every clinical worsening of the patient that is not due to rebleeding or hydrocephalus,excluded by CT examination,can be an indirect sign of spasm.In all these cases,angiography should be performed,followed by confirmationof vasospasm by endovascular therapy.
诊断：所有SAH患者均应密切监测蛛网膜下腔出血（SAH）后几天的血管痉挛。日常工作中可通过经颅多普勒（TCD），随访第三天或第四天行CT和灌注CT（CTP），此时TCD显示增加的血流速度（超过120 - 130厘米/秒），特别是在短时间内发生患者。单独和/或技术控制，每一个患者的临床恶化不因再出血或脑积水，经CT检查排除在外时，可以是痉挛间接征象。在所有这些病例中，都要进行血管造影，并通过血管内治疗证实血管痉挛。
Therapy.Medical therapy consists of prophylacticnimodipine,oral or intravenous,depending on the grade of risk for a given patient.Nimodipine is a calcium antagonist that acts by reducing the constriction of smooth muscle and by decreasing the release of vasoactive factors from the endothelium and platelets(Pickard et al.1987).In many centers,this is associated with monitored hypertensive,hypervolemic,and hemodilution(“triple-H”)therapy.With confirmed spasm on angiography,the most used therapy today is the injection of nimodipine into the ICA uni-or bilaterally at adose of 1–2 mg per vascular territory(Fig.11.28).Selective injection in the A1–M1 segments can be useful in certain cases as well as injection into the vertebrobasilar sector.A partial or complete resolution is obtained in 60–70%of cases(Boker et al.1985;Bracard et al.1999;Biondi et al.2004;Bandeira et al.2007;Hanggi et al.2008).The resolutionof the spasm may be only temporary,and soa second or additional administrations can be necessaryover the following days(Biondi et al.2004).In selected cases of severe spasm not responsive to nimodipine,balloon angioplasty of the distal segment of the ICA(A1–M1 segment)can be performed.Improvements in the endovascular material make it possible today to perform this treatment with a low risk(Murayama et al.2003b;Abruzzoet al.2012).
治疗：药物治疗包括预防性尼莫地平，口服或静脉注射，依赖患者的风险级别。尼莫地平是钙拮抗剂，通过减少钙离子而减弱平滑肌收缩和减少血管内皮细胞和血小板释放血管活性因子作用（Pickard等. 1987）。在许多中心，监测高血压，高血容量，与血液稀释（3“H”）治疗。血管造影证实痉挛，现在最常用的疗法是单侧或双侧ICA内注射尼莫地平，每血管面积1 - 2毫克（图11.28）。在A1 - M1段选择性注射，可以在某些情况下为椎-基底动脉系统。部分或完整的解决措施约60–70%患者（Boker等. 1985 ; Bracard等. 1999 ; Biondi等. 2004 ; Bandeira等. 2007 ; Hanggi等. 2008）。痉挛的解决可能只是暂时的，所以额外或后续的监测在接下来的几天里是必要的（Biondi等. 2004）。在个别的严重痉挛病例中，对尼莫地平不敏感，ICA远端（A1 - M1段）球囊成形术可以执行。今天，血管内材料的改进可以进行这种治疗，具有较低的风险（Murayama等. 2003b ; Abruzzo等. 2012）。
Fig. 11.28 Middle-aged patient with severe SAH due to rupture of a PICA aneurysm that was occluded with coils. The asymptomatic patient deteriorated a few days later owing to severe spasm involving, in particular, the anterior circulation. Left carotid angiogram ( a ) showing the severe spasm involving the A1 and M2 segments ( arrows ). Also, there is minimal spasm of the M1 segment. A similar pattern was seen on the right. The patient was treated with an injection of nimodipine in the ICA, with excellent angiographic results, demonstrated on the left angiogram ( b ). Similar result on the right
图11.28中年患者出现严重的SAH，由于弹簧圈闭塞PICA动脉瘤。由于前循环血管出现血管痉挛，几天后无症状患者病情恶化。左颈动脉血管造影（a）显示A1和M2段（箭头）出现严重痉挛。此外，M1段还有小血管痉挛。右侧可见相似表现。患者经颈动脉注射尼莫地平，有良好的的血管造影结果，左血管造影（b）。右边可见类似结果。
儿童动脉瘤 Aneurysms in Children
Intracranial aneurysms in children are rare.They differ from those in adults in the localization,etiology,and clinical presentation.They are more frequent in boys,whereas among adults there is predominance among women.This seems to indicate a gender influence(Ostergaard andVoldby 1983;Laughlin et al.1997;Proust et al.2001;Lasjaunias et al.2005;Huang et al.2005).The commonest site is reported to be the ICA(cavernous portion,carotid bifurcation)(Heiskanen 1989;Laughlin et al.1997;Proustet al.2001;Huang et al.2005).A relatively high frequency also of aneurysms of the basilar and PCA has been reported(Meyer et al.1989;Huanget al.2005;Aryan et al.2006;Vaid et al.2008;Luet al.2009;Gandolfo 2012).At the time of diagnosis,the aneurysm is frequently large,with clinical symptoms frequently not due to hemorrhage but to the mass effect(Lasjaunias et al.2005;Luet al.2009).
儿童颅内动脉瘤罕见。在位置、病因和临床表现上，他们不同于成人。男孩经常出现，而成年人则女性好发。似乎表明性别的影响（Ostergaard and Voldby 1983 ; Laughlin等. 1997 ; Proust等. 2001 ; Lasjaunias等. 2005 ; Huang等. 2005）。据报道，最常见的位置是ICA（海绵状部分，颈动脉分叉）（Heiskanen 1989 ; Laughlin等. 1997 ; Proust等. 2001 ; Huang等. 2005）。据报道，基底动脉瘤和PCA动脉瘤相对较常见（Meyer等. 1989 ; Huang等. 2005 ; Aryan等. 2006 ; Vaid等. 2008 ; Lu等. 2009 ; Gandolfo 2012）。在诊断时，动脉瘤常常是巨大的，临床症状常常不是由于出血，而是由于占位效应（(Lasjaunias等. 2005 ; Lu等. 2009）。
Unlike in adults,a frequent cause of aneurysms in children is trauma,even minor(Yazbaket al.1995;Ventureyra and Higgins 1994).Other causes are infectious,collagen diseases,hemoglobinopathies as well as a family history of aneurysm(Ostergaard and Voldby 1983;Roche et al.1988;Meyer et al.1989;Pasqualin et al.1986).
和成年人不同，儿童动脉瘤的常见原因是外伤，即使是轻微的外伤（Yazbak等. 1995 ; Ventureyra and Higgins 1994）。其他原因是传染病，胶原性疾病，血红蛋白病以及家族动脉瘤史（Ostergaard and Voldby 1983 ; Roche等. 1988 ; Meyer等. 1989 ; Pasqualin等. 1986）。
More recently,spontaneous dissection has been increasingly recognized as a cause of cerebral aneurysm in children(Laughlin et al.1997;Massimi et al.2003;Lasjaunias et al.2005;Vilela and Goulao 2006;Bradac et al.2008a;Gandolfo 2012)
最近，自发性夹层被越来越多的人认为是儿童脑动脉瘤的病因（Laughlin等. 1997 ; Massimi等. 2003 ; Lasjaunias等. 2005 ; Vilela and Goulao 2006 ; Bradac等. 2008a ; Gandolfo 2012）。
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