颅内巨大动脉瘤的显微手术治疗

Microsurgical Treatment of Giant Intracranial Aneurysms

目的：探索颅内巨大动脉瘤的手术治疗方式。方法：对我科采取显微手术治疗的颅内巨大动脉瘤44例作一回顾性分析，包括动脉瘤颈夹闭或载瘤动脉塑形35例，动脉瘤孤立术4例，动脉瘤腔填塞术2例，动脉瘤孤立并颢浅动脉-大脑中动脉吻合术1例，动脉瘤包裹术2例。其中，2例基底动脉瘤采取闭合式深低温停循环夹闭动脉瘤颈。结果：术后早期恢复按Glasgow Outcome Scale（GOS）预后评分Ⅴ级28例，Ⅳ级6例，Ⅲ级4例，Ⅱ级2例，Ⅰ级4例。随访8月～5年，2例Ⅱ级病人均在术后1月及3月死于肺部感染．4例Ⅲ级病人中，2例死亡，1例恢复至Ⅱ级，1例无变化，余病人均恢复良好。故总有效率（Ⅴ级＋Ⅳ级）79．5％（35／44），死亡率18％（8／44）。结论：颅内巨大动脉瘤的外科手术治疗仍是当今神经外科的难题之一，对不同部位的动脉瘤应采取不同的术式，术中行脑电监护及术后行“3H”（即Hypervolemia高血容量、Hemodilution高稀释度、Hypertension控制性提高血压）治疗能降低患者的致残率，提高生存质量。对深低温停循环处理巨大动脉瘤值得深入总结和探讨。

Objective： To investigate the surgical strategies, postoperative management of giant intracranial aneurysm. Metheds： To introduce the experience of treatment of 42 patients with giant intracranial aneurysms. Direct clipping of theaneurysms or reconstruction of parent artery lumens were accomplished in 35 cases, aneurysms trapping in 4 cases, aneurysms stuffing in 2 cases, aneurysms trapping with artery anastomsis in 1 cases, aneurysms wrapping in 2 cases. Among the direct clipping eases, 2 aneurysms located on vertebrobasilar artery were clipped followed by hypothermic circulatory arrest. Results： Early postoperative neurological function was evaluated using Glasgow Outcome Scale. An excellent or good outcome （grade Ⅴ） was achieved in 28 patients, moderate disability （ Ⅳ grade） in 6, severe disability （ Ⅲ grade） in 4, vegetative state （ Ⅱ grade） in 2, 4 died （ Ⅰ grade） during the perioperation. The follow- up of the all patients ranged from 8 months to 5 years, 2 vegetative state patients died of inflammation of lung; Among the 4 severe disability patients, 2 died, 1 recovered to moderate disability, and 1 had no change. The others recovered to good or excellent state. 79.5 % of the patients had good outcomes, the totally surgical mortality rate was 18%. Conclusion： Surgical treatment of giant intr＇acranial aneurysms is still difficult for neurosurgeon. Variant surgical strategies should be chosen properly based on the location of the aneurysms. Electrophysiological monitoring during the operation, hypervolemic hemodilution and induced arterial hypertensive （3H） treatment of the aneurysms after the operation can reduce the morbidity and improve the patients, living quality. Hypothermic circulatory arrest should be cautiously done.