摘要： 目的 探讨显微外科手术结合术中DSA的复合手术治疗急性出血性脑血管病的有效性和安全性。方法 回顾分析安徽医科大学附属安庆第一人民医院2020年4月至2021年2月采用复合手术治疗的11例急性出血性脑血管病患者的临床资料、影像学检查、治疗和预后，其中脑动静脉畸形3例（颞顶叶2例、右侧外侧裂1例）；颅前窝底硬脑膜动静脉瘘2例，瘘口均位于筛板；颅内动脉瘤6例（大脑中动脉分叉部动脉瘤3例、胼周动脉瘤1例、颈内动脉交通段动脉瘤2例）。结果 11例患者均顺利完成手术，手术成功率为100%。3例脑动静脉畸形均行脑动静脉畸形切除术+血肿清除术，1例首次切除后术中DSA提示畸形团少量残留，予补充切除后复查DSA提示全切除；2例颅前窝底硬脑膜动静脉瘘均行硬脑膜动静脉瘘切除术+血肿清除术，封闭瘘口后复查DSA可见动静脉瘘完全消失；6例颅内动脉瘤夹闭后DSA见4例完全夹闭，2例瘤颈残留予以调整或补充动脉瘤夹后夹闭完全，伴有颅内血肿的患者术中DynaCT均提示血肿完全清除。无一例发生手术相关再出血、脑梗死等严重并发症。平均随访8.45个月，改良Rankin量表（mRS）评分为4分者1例、2分者1例，其余9例mRS评分均为零；所有患者接受至少1次CTA或DSA复查，均未发现血管病变残留及复发表现。结论 复合手术作为一种新型治疗模式治疗急性出血性脑血管病安全、有效，有待进一步积累病例、总结经验。

关键词: 颅内动静脉畸形, 动静脉瘘, 颅内动脉瘤, 硬膜, 外科手术, 血管造影术,数字减影

Abstract: Objective To investigate the effectiveness and safety of hybrid surgery (microsurgery combined with intraoperative DSA) in the treatment of acute hemorrhagic cerebral vascular disease. Methods The clinical data, imaging data, treatment and prognosis of 11 patients with acute hemorrhagic cerebral vascular disease treated by hybrid operation from April 2020 to February 2021 in the Anqing First People's Hospital of Anhui Medical University were analyzed. The results showed 3 cases of cerebral arteriovenous malformation (CAVM), including 2 cases located in temporoparietal lobe and one case in right lateral fissure; 2 cases of dural arteriovenous fistula (DAVF) at the base of anterior cranial fossa while fistulaes located in sieve plate; 6 cases of intracranial aneurysms, including 3 cases in the middle cerebral artery (MCA) bifurcation, one case in the pericallosal artery, and 2 cases in the communicating segment of internal carotid artery (ICA). Results All 11 patients completed the surgery successfully, and the success rate was 100%. CAVM resection combined with hematoma removal were performed in 3 cases of CAVM, including one case that intraoperative DSA suggested a little residual malformed mass after initial resection, while DSA reexamination suggested total resection after supplementary resection. Dural arteriovenous fistula resection combined with hematoma removal were performed in 2 cases of anterior fossa, after the fistula was closed, DSA reexamination suggested the arteriovenous fistula disappeared completely. Intracranial aneurysm clipping was performed in 6 cases, DSA showed complete clipping in 4 cases, and complete clipping in 2 cases of aneurysm neck residual after adjustment or aneurysm clip supplement.DynaCT indicated satisfactory final removal of intracranial hematoma in all patients with intracranial hematoma. No patient had serious complications such as rebleeding and cerebral infarction. After a mean follow-up of 8.45 months, modified Rankin Scale (mRS) was 1 in 4 cases and 1 in 2 cases, and 0 in the other 9 cases. All patients underwent at least one CTA or DSA reexamination, and no residual or recurrent vascular lesions were found. Conclusions Hybrid operation as a new treatment mode for acute hemorrhagic cerebral vascular disease is safe and effective, and further accumulation of cases and experience are needed.

Key words: Intracranial arteriovenous malformations, Arteriovenous fistula, Intracranial aneurysm, Dura mater, Surgical procedures, operative, Angiography, digital subtraction