آنوريسم هاي مغزي و نتايج درمان جراحي آنها در بيمارستان قائم مشهد در طي سا لهاي 1386-1377

Brain Aneurysms and the Results of their Surgery in Mashhad Ghaem Hospital during 1998-2007

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﻫﺪﻑ ﺍﺯ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﮔﺬﺷﺘﻪ ﻧﮕـﺮ, ﺑﺮﺭﺳﻲ ﻧﺘﺎﻳﺞ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺯﻭﺩﺭﺱ ﻭ ﺗﺄﺧﻴﺮﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ﺁﻧﻮﺭﻳﺴﻢ ﻣﻐﺰﻱ ﭘﺎﺭﻩ ﺷﺪﻩ ﮐﻪ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﻗـﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﻧﺪ, ﺷﻨﺎﺧﺖ ﻋﻮﺍﻣﻞ ﻣﺆﺛﺮ ﻭ ﻳﺎﻓﺘﻦ ﺭﺍﻫﮑﺎﺭﻫﺎﻱ ﻣﻨﺎﺳﺐ ﺑﺮﺍﻱ ﺑﻬﺒﻮﺩﻱ ﻭ ﺍﺭﺗﻘﺎﻱ ﺩﺭﻣﺎﻥ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ ﻣﻲ ﺑﺎﺷﺪ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺼﻮﺭﺕ ﮔﺬﺷﺘﻪ ﻧﮕﺮ ﻭ ﺑﺮ ﭘﺎﻳﻪ ﺍﻃﻼﻋﺎﺕ ﺑﻴﻤﺎﺭﺳﺘﺎﻧﻲ ﻣﻮﺟﻮﺩ ﺩﺭ ﭘﺮﻭﻧﺪﻩ ﻫﺎﻱ ﺑﻴﻤﺎﺭﺍﻥ, ﺩﺭ ﻳﮏ ﺩﻭﺭﻩ ﺯﻣﺎﻧﻲ ﺩﻩ ﺳﺎﻟﻪ1377 -1386 ( ﺩﺭ ﺑﺨﺶ ﺟﺮﺍﺣﻲ ﻣﻐﺰ ﻭ ﺍﻋﺼﺎﺏ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﻗﺎﺋﻢ)ﻋﺞ( ﻣﺸﻬﺪ ﺻﻮﺭﺕ ﮔﺮﻓﺘﻪ ﺍﺳﺖ. ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ, ﻣﺸﺨﺼﺎﺕ ﻓﺮﺩﻱ, ﺑﻴﻤﺎﺭﻱ ﻫﺎﻱ ﺯﻣﻴﻨﻪ ﺍﻱ, ﻓﺎﺻﻠﻪ ﺯﻣﺎﻧﻲ ﺷﺮﻭﻉ ﺧﻮﻧﺮﻳﺰﻱ ﺗﺎ ﺑﺴﺘـﺮﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﻭ ﻳﺎﻓﺘﻪ ﻫﺎﻱ ﺗﺼﻮﻳﺮﻱ ﻣﻮﺟﻮﺩ ﺑﺮﺍﻱ ﻫﻤﻪ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ﺁﻧﻮﺭﻳﺴﻢ ﻣﻐﺰﻱ, ﺯﻣﺎ ﻥ ﻋﻤﻞ ﺟﺮﺍﺣﻲ, ﻧﻮﻉ ﻋﻤﻞ ﻭ ﻋﻮﺍﺭﺽ ﺍﻳﺠﺎﺩ ﺷﺪﻩ ﻭ ﻧﺘﺎﻳﺞ ﺁﻥ ﺩﺭ ﻣﺪﺕ ﺑﺴﺘﺮﻱ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺖ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﺩﺭ ﻣﺪﺕ ﺩﻩ ﺳﺎﻝ، 183 ﺑﻴﻤﺎﺭ ﺑﺎ ﺁﻧﻮﺭﻳﺴﻢ ﻣﻐﺰﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﺑﺴﺘﺮﻱ ﻭ ﺩﺭﻣﺎﻥ ﺷﺪﻧﺪ. ﺑﻴﺸﺘﺮﻳﻦ ﮔﺮﻭﻩ ﺳﻨﻲ، ﺩﺭ ﺳﻨﻴﻦ 50 -60 ﺳﺎﻝ ﻭ ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ 1/48± 48/06 ﺳﺎﻝ ﺩﺭ ﻣﺮﺩﺍﻥ ﻭ 1/09 ± 50/17 ﺩﺭ ﺯﻧﺎﻥ ﻭ ﻣﻴﺎﻧﮕﻴﻦ ﮐﻠﻲ 0/88 ± 49/05 ﺛﺒﺖ ﮔﺮﺩﻳﺪ. ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮﻥ ﻭ ﺍﺳﺘﻌﻤﺎﻝ ﺳﻴﮕﺎﺭ ﺷﺎﻳﻌﺘﺮﻳﻦ ﻋﻮﺍﻣﻞ ﺯﻣﻴﻨﻪ ﺍﻱ ﺩﺭ ﺍﻳﻦ ﺍﻓﺮﺍﺩ ﮔﺰﺍﺭﺵ ﺷﺪ ﻭ ﺳﺮﺩﺭﺩ ﻧﺎﮔﻬﺎﻧﻲ ﻭ ﮐﺎﻫﺶ ﻫﻮﺷﻴﺎﺭﻱ ﺷﺎﻳﻌﺘﺮﻳﻦ ﻋﻼﻣﺖ ﻭ ﻧﺸﺎﻧﻪ ﺑﻌﺪ ﺍﺯ ﭘﺎﺭﮔﻲ ﺁﻧﻮﺭﻳﺴﻢ ﺑﻮﺩ. ﺷﺮﻳﺎﻥ ﺭﺍﺑﻂ ﻗﺪﺍﻣﻲ ﻭ ﺷﺮﻳﺎﻥ ﻣﻐﺰﻱ ﻣﻴﺎﻧﻲ, ﺷﺎﻳﻌﺘﺮﻳﻦ ﻣﺤﻞ ﺍﺳﺘﻘﺮﺍﺭ ﺁﻧﻮﺭﻳﺴﻢ ﺑﻮﺩﻧﺪ. 140ﻧﻔﺮ )76/5 ﺍﺯ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺩﺭﻣﺎﻥ ﺷﺪﻧﺪ ﮐﻪ 21 ﻧﻔﺮ ﺩﺭ ﺳﻪ ﺭﻭﺯ ﺍﻭﻝ ﻭ 112 ﻧﻔﺮ ﺑﻌﺪ ﺍﺯ ﺩﻭ ﻫﻔﺘﻪ ﺗﺤﺖ ﻋﻤﻞ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﻣﻴﺰﺍﻥ ﻋﻮﺍﺭﺽ ﺷﺪﻳﺪ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﻭ ﻓﻮﺕ ﺩﺭ ﮔـﺮﻭﻫﻲ ﮐﻪ ﺩﺭ ﺳﻪ ﺭﻭﺯ ﺍﻭﻝ ﺯﻭﺩﺭﺱ( ﺗﺤﺖ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺑﻮﺩﻧﺪ 52/4 ﻭ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺗﺄﺧﻴـﺮﻱ 15/2 ﺑﻮﺩ. ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻣﻬﻤﺘﺮﻳﻦ ﻋﺎﻣﻞ ﺩﺭ ﺑﺮﻭﺯ ﻋﻮﺍﺭﺽ ﻭ ﻣﺮﮒ ﻭ ﻣﻴﺮ ﺩﺭ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺁﻧﻮﺭﻳﺴﻢ, ﮔﺮﻳﺪ ﻧﻮﺭﻭﻟﻮﮊﻳﮏ ﺑﻴﻤﺎﺭ ﻭ ﺯﻣﺎﻥ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺑﻮﺩﻩ ﺍﺳﺖ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺍﻳﻢ ﮐﻪ ﺍﻓﺰﺍﻳﺶ ﺩﺭ ﮔﺮﻳﺪ ﻧﻮﺭﻭﻟﻮﮊﻳﮏ Hunt&Hess ﺑﺎ ﺍﻓﺰﺍﻳﺶ ﻣﻴﺰﺍﻥ ﻋﻮﺍﺭﺽ ﻭ ﻓﻮﺕ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺭﻭﺵ ﺟﺮﺍﺣﻲ ﺗﺄﺧﻴﺮﻱ ﺑﺎ ﮐﺎﻫﺶ ﺩﺭ ﻣﻮﺭﺗﺎﻟﻴﺘﻪ ﻭ ﻋﻮﺍﺭﺽ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﻫﻤﺮﺍﻩ ﺑﻮﺩﻩ ﺍﺳﺖ. ﻓﺎﮐﺘﻮﺭﻫﺎﻱ ﺩﻳﮕﺮ ﺍﺯ ﺟﻤﻠﻪ ﺩﻳﺎﺑﺖ، ﻓﺸﺎﺭﺧﻮﻥ ﺑﺎﻻ، ﻣﺼﺮﻑ ﺳﻴﮕﺎﺭ ﻭ ﺍﻋﺘﻴﺎﺩ، ﺭﺍﺑﻄﻪ ﻣﻌﻨﻲ ﺩﺍﺭﻱ ﺑﺎ ﻣﻴﺰﺍﻥ ﻋﻮﺍﺭﺽ ﻭ ﻣﻮﺭﺗﺎﻟﻴﺘﻪ ﻧﺪﺍﺷﺘﻨﺪ. ﺍﮔﺮﭼﻪ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻭ ﮔﺰﺍﺭﺷﺎﺕ ﺩﻳﮕﺮ ﻣﺮﺍﮐﺰ ﺩﺭ ﺍﻳﺮﺍﻥ ﻧﺸﺎﻥ ﻣﻲ ﺩﻫﺪ ﮐﻪ ﻣﻴﺰﺍﻥ ﻣﺮﮒ ﻭ ﻣﻴﺮ ﻭ ﻋﻮﺍﺭﺽ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺯﻭﺩﺭﺱ ﺁﻧﻮﺭﻳﺴﻢ )ﺳﻪ ﺭﻭﺯ ﺍﻭﻝ ﺑﻌﺪ ﺍﺯ ﺧﻮﻧﺮﻳﺰﻱ( ﺑﻴﺸﺘﺮ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺗﺄﺧﻴﺮﻱ ﺁﻥ ﻣﻲ ﺑﺎﺷﺪ ﻭﻟﻲ ﺑﻪ ﺩﻟﻴﻞ ﺁﻧﮑﻪ ﺑﺨﺸﻲ ﺍﺯ ﺑﻴﻤﺎﺭﺍﻥ ﻗﺒﻞ ﺍﺯ ﺭﺳﻴﺪﻥ ﺑﻪ ﻣﺮﺣﻠﻪ ﺗﺄﺧﻴﺮﻱ ﺑﻪ ﻋﻠﺖ ﺧﻮﻧﺮﻳﺰﻱ ﻣﺠﺪﺩ ﻭ ﻳﺎ ﻭﺍﺯﻭﺍﺳﭙﺎﺳﻢ ﻓﻮﺕ ﻣﻲ ﮐﻨﻨﺪ, ﻧﻴﺎﺯ ﺑﻪ ﺑﺮﺭﺳﻲ ﺑﻴﺸﺘﺮ ﻧﺘﺎﻳﺞ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺯﻭﺩﺭﺱ ﻭ ﭘﻲ ﺁﻣﺪﻫﺎﻱ ﺗﺄﺧﻴـﺮ ﺩﺭﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻭﺟﻮﺩ دارد

Introduction & Objective: The purpose of this retrospective study is the assessment of the results of early and delayed surgery in patients who have been operated for ruptured aneurysms, and the cognition of the effective agents and the proper ways for recovery and promotion of treatment methods in these patients. Materials & Methods: This study is performed retrospectively based on hospitalized information in patient files in Ghaem neurosurgical departments since, 1998 to 2007. In this study we classified personality features, background diseases, the time between hemorrhage to admission, imaging findings in patients with brain aneurysm, time of surgery, kind of surgery, complications and the results of them. Results: 183 Patients were admitted in hospital in 10 years. Most of them were between 50 -60 years old and the mean age was 48.06± 1.48 for men and 50.17± 1.09 for women (overall mean age: 49.05 ±0.88). Hypertension and smoking were the most common underlying factors in these patients. Sudden headache and unconsciousness were the most common symptom and sign after rupture of aneurysms. The most common location for their aneurysms was Ant. Com and MCA. 140 cases (76.5%) were operated upon 21 cases (15%) in first three days and 112 patients (80%) after two weeks. In early operated group, severe complication and death was in 52.4 % cases, but in delayed operated group, severe complication and death was in 15.2% cases. The most common factor in mortality and morbidity in this study were neurologic grades of the patients and the time between aneurysmal rupture to surgery. Conclusions: In this study we have shown that increasing in Hunt & Hess grade, increases morbidity and mortality, and that delayed surgery reduces the mortality and complications after surgery in the patients with brain aneurysmal rupture. Other factors such as diabetes, high blood pressure, addiction and smoking, had no significant relationship with the complication rate and mortality. Although the results of this study and other reports implicate that the mortality, morbidity and complications after early surgery of aneurysms (in the first three days) is more than late surgery, but because some of the patients die from rebleeding or vasospasm before late period, we are still in need of comparing the results of early surgery and outcome of patients in late surgery group.