一侧入路显露对侧后交通动脉瘤的显微解剖学研究

Unilateral approach to expose the contralateral posterior communicating artery aneurysm: a microanatomical study

目的探讨一侧入路显露并夹闭对侧后交通动脉瘤的可行性。方法对15具国人成年尸头标本经甲醛固定,采用显微解剖技术,经一侧入路显露和观察对侧后交通动脉起始部及其毗邻关系,以探求最佳显露途径,并回顾性分析1997年-2002年收治的9例包含后交通动脉瘤在内的双侧颅内多发动脉瘤患者的治疗结果。结果在15具尸头的30支后交通动脉中,对侧后交通动脉起始部成功显露15支(50%),后交通动脉起源于颈内动脉后外侧壁者16支(53.3%),后壁者6支(20.0%),后内侧壁者8支(26.7%)。后交通动脉起点至颈内动脉穿出硬脑膜的距离为(8.74±2.57)mm,后交通动脉主干直径为(1.67±0.39)mm,通常在视交叉前间隙内,轻轻向外牵拉对侧视神经,即可显露后交通动脉起始点内侧面。1具标本须经过视交叉上外侧,在对侧视神经-颈内动脉间隙内,轻轻向外牵拉颈内动脉才能显露对侧后交通动脉及其起始部。在视交叉前间隙,经过对侧视神经下方探查该部位是较理想的途径,切开对侧硬脑膜镰状韧带,避免损伤视神经至关重要。9例经手术夹闭的双侧颅内多发动脉瘤患者,经一侧翼点入路显露并夹闭对侧后交通动脉瘤者3例。结论严格选择的双侧颅内多发动脉瘤患者,经一侧入路显露并夹闭对侧后交通动脉瘤是可行、安全和有效的。

Objective To investigate the feasibility of surgical clipping of contralateral posterior communicating artery (PCOA) aneurysms via unilateral approach exposure. Methods Fifteen Chinese cadaver heads fixed with formalin were performed microanatomical technique via one side approach to expose the contralateral PCOA origin and its relationship with adjacent tissues, for the sake of searching the optimal exposing approach. The therapeutic result of 9 patients with bilateral multiple intracranial aneurysms including PCOA aneurysm admitted during 1997-2002 were retrospectively analyzed. Results The 30 PCOAs were searched in 15 cadaver heads and the contralateral PCOA origin was successfully exposed in 15 arteries (50%). These PCOAs were originated from the posterior lateral wall of the internal carotid artery in 16 arteries (53.3%), from posterior wall in 6 arteries (20%) and from posterior internal wall in 8 arteries (26.7%). The length from the origin of PCOA to the point of dural perforation by internal artery was (8.74±2.57) mm. The widest part of PCOA diameter was (1.67±0.39) mm. The internal aspect of PCOA origin was usually exposed when gently pulling the contralateral optic nerve. In one cadaver head the contralateral PCOA and its origin was only exposed when gently pulling the internal carotid artery laterally in contralateral opticocarotid space. In anterior space of optic chiasm performed operation via inferior aspect of contralateral optic nerve was an ideal approach to search that position. It was important to incise the contralateral dural falciform ligament for preventing from damaging the optic nerve. Of the 9 patients with the bilateral multiple intracranial aneurysms, their contralateral PCOA aneurysms were successfully clipped in three of them by exposure via unilateral pterion approch. Conclusion The surgical exposure and clipping of contralateral PCOA via unilateral approach is a fessible, effective and safe operation for the well selected patients with bilateral intracranial multiple aneurysms.