前交通动脉瘤的手术治疗

Surgical treatment for anterior communicating artery aneurysms

目的对1990年1月至2004年12月治疗的157例前交通动脉瘤患者作一回顾性分析。方法所有病例均在全麻下施行手术,经翼点入路手术152例,经前纵裂入路手术5例。其中施行瘤颈夹闭术者154例,另3例因动脉瘤较小或为前交通动脉的梭形扩张者施行动脉瘤包裹术。对26例IV、V级的动脉瘤手术中清除局部血肿后,对其中14例脑压较高者或术后因脑水肿反应严重者在首次手术时或再次手术行去骨瓣或颞肌下减压术。结果根据格拉斯哥预后分级(G lasgow ou tcom e score,GO S)判断,本组手术后近期恢复良好者140例(89.2%),中残5例(3.2%),重残4例(2.5%),死亡8例(5.1%,包括因病情危重家属放弃治疗的患者)。死亡的8例中有7例为IV、V级的患者,另1例为动脉瘤包裹术后因再出血死亡。严重残废的4例患者也均为IV、V级病例。结论对出血时间在数小时之内、具有典型前交通动脉瘤的CT表现、病情十分危重的患者,可直接进行手术探察;对出血后早期呈IV、V级状态的患者,积极手术可能挽救一部分患者的生命。

Objective To retrospectively analyse a series of 157 patients treated for anterior communicating artery （ACoA） aneurysms in our hospital from January 1990 to December 2004. Methods Operations were carried out in all patients under general anesthesia. Two basic microsurgical approaches （pterional and interhemispheric） were used. The pterional approach was performed in 152 cases and interhemispheric approach in 5 cases. Aneurysms clipping were performed in 154 patients, and aneurysms were wrapped in 3 patients with small or fusiform aneurysms. For the 136 patients with SAH, 35 patients were operated within 3 days after later subarachnoid hemorrhage, 68 during 3-21 days and the others 3 weeks or later. Results The overall postoperative recovery results, according to GOS, were as follows： 140 cases （89.20% ） with good recovery, 5 cases （3.2 % ） with moderate disability, 4 cases （2.5%） with severe disability and 8 cases （5.1%） death. 7 of 8 dead cases were in grade IV and V. The other case was dead of rebleeding after aneurysm wrapping. All the 4 poor cases were in grade IV and V. Conclusion Exploration is recommended for the severe patients who are in the early few hours of bleeding and have characteristic appearances of ACoA aneurysms on CT. Actively surgery may obtain satisfactory postoperative result even in some patients subject to grade IV and V in the early stage of hemorrhage.