前循环动脉瘤术中皮质和头皮脑电监测对手术策略的影响

Effect of cortical and scalp electroencephalographic monitoring on surgical strategy during anterior circulation aneurysm surgery

目的探讨皮质和头皮脑电联合监测在前循环动脉瘤术中对手术策略的影响，以及患者术后因临时阻断载瘤动脉发生缺血事件的情况。方法对行开颅手术的52例患者（58个前循环颅内动脉瘤）同时进行术中皮质和头皮的脑电监测。前者用于监测载瘤动脉临时阻断后可能的皮质缺血，后者用于监测麻醉药物对脑电影响。综合分析术中双相脑电变化对手术决策及患者术后病情的影响。结果对52例患者中的40个动脉瘤的41支主要动脉采用了临时阻断，其中34例皮质和头皮脑电均无明显改变，18例患者的19支动脉临时阻断后，皮质脑电出现明显抑制，头皮脑电无明显变化。在皮质脑电明显变化的18例患者中，发生术后阻断载瘤动脉相关缺血事件9例，其中永久神经功能障碍5例。脑电信息影响手术策略19次，其中因皮质脑电明显变化改变吻合方式1例，预防性去骨瓣减压2例，采用分次阻断7例，快速夹闭7例，另有2例阻断30min皮质脑电无明显变化而安全永久性闭塞载瘤动脉。52例中有1例因未充分理解脑电明显变化信息而行术后二次手术。结论前循环动脉瘤术中阻断载瘤动脉时，皮质和头皮脑电联合监测可实时监测局部皮质血流，为手术决策提供参考。重视并理解脑电提供的信息，可以减少阻断血管相关并发症及避免复杂的血管重建、二次手术等。

Objective To investigate the effect of the combination of cortical and scalp electroencephalographic （EEG） monitoring on surgical strategy amt postoperative condition of patients during anterior circulation aneurysm surgery. Methods Simuhaneous cortical and scalp EEG monitoring was performed during surgery in 52 patients with 58 anterior circulation aneurysms. The cortical EEG was used for monitoring of potential cortical ischemia after the parent arteries were occluded temporarily, the scalp EEG was used for monitoring the effect of anesthetics on EEG. The effect of biphasic EEG changes on surgical decision-making and the conditions of the patients after the surgery were analyzed. Results Temporary occlusion were performed in 41 main arteries of 40 aneurysms in 52 patients, there were no significant changes on both cortical and scalp EEG in 34 patients. In the other 18 patients, their scalp EEG had no significant change, but their cortical EEG had significant change after temporary occlusion of the parent artery of the aneurysms were developed ischemic events after operation, 5 of them left permanent neurological deficit. The EEG information lead to change the surgical strategy for 19 times, including changing the anastomotic mode in 1 patient ; decompressive craniectomy in 2 patients ; intermittent reperfusion in 7 patients ; rapid clipping of aneurysmal neck in 7 patients; and anotber 2 did not have significant cortical EEG change after being occluded for 30 minutes and their parent arteries were safely occluded. One patient was reoperated because of misunderstanding the changes of EEG. Conclusion When the parent arteries of anterior circulation aneurysms are occluded in the operation , the combination of cortical and scalp EEG monito- ring can real-time monitoring the focal cortical blood flow, and provide a information for the surgical decision-making. Pay attention and understanding the information provided by the ECG may reduce the complications associated with the occlusion of blood vessels and avoid complicated revascularization procedures or reoperation.