锁孔手术入路在后循环动脉瘤夹闭术中的初步应用

Preliminary application of keyhole approach for the treatment of posterior circulation aneurysms

目的探讨锁孔入路微创手术治疗后循环动脉瘤的可行性及其疗效。方法后循环动脉瘤患者12例，包括基底动脉（BA）6例（基底动脉分叉部1例，基底动脉-小脑上动脉3例，基底动脉．大脑后动脉1例，大脑后动脉-基底动脉-小脑上动脉1例），大脑后动脉（PCA）5例（PCA1-2段1例，PCA2段2例，PCA2-3段2例），小脑后下动脉（PICA）1例。6例BA远端动脉瘤及2例PCA1-2段动脉瘤均采用经眉弓锁孔入路，3例PCA2-3段动脉瘤采用颞下锁孔入路，1例PICA动脉瘤采用枕下外侧锁孔入路。结果12例手术中，动脉瘤完全夹闭9例，2例PCA2-3段巨大动脉瘤行孤立术及血栓切除术，术后脑血管造影（DSA）复查发现1例PICA动脉瘤夹闭不全，该动脉瘤呈葫芦形，手术中夹闭了动脉瘤远端大半，随访6个月无再出血。所有患者术中无动脉瘤破裂出血，出院时，患者均神志清楚，无肢体活动障碍等残疾。结论锁孔入路下，可磨除前床突或后床突骨质，增加对后循环动脉瘤夹闭操作的空间；载瘤血管近端球囊导管控制可增加手术的安全性；神经导航有助于对PCA远端动脉瘤的快速定位。个体化的锁孔手术入路应用于后循环动脉瘤手术行之有效：

Objective To evaluate the feasibility and efficacy of minimally invasive keyhole approach for the treatment of posterior circulation aneurysms. Methods Twelve posterior circulation aneurysms were treated via the keyhole approach. Aneurysms were located in basilar artery （BA） in 6 patients （1 in BA bifurcation, 3 in BA-SCA [ superior cerebellar artery], 1 in BA-PCA [ posterior cerebral artery], 1 in PCA-BA-SCA）, in PCA in 5 patients （1 in PCA1-2 segment, 2 PCA2 segment and 2 PCA2- 3 segment） and in PICA [ posterior inferior cerebellar artery ] in 1 patient. The supraorbital keyhole approach was performed in 6 BA and 2 PCA1-2 segment aneurysms, the subtemporal approach in 3 PCA2-3 segment aneurysms and the lateral suboccipital keyhole approach in one PICA aneurysm. Results Among those 12 posterior circulation aneurysms, 9 aneurysms were completely clipped, 2 thrombotic PCA2-3 segment giant aneurysms trapped with thrombectomy, one gourd-shaped aneurysm in PICA incompletely clipped with no recurrent hemorrhage in during a 6-month follow-up. No intraoperative rupture of aneurysms occurred in any operation. All patients were discharged without neurological deficits. Conclusion Anterior or posterior clinoid process may be drilled off under the keyhole approach to increase the manipulating space while clipping the posterior circulation aneurysms. Controlling the proximal parent artery by balloon catheter increases the operative safety. Neuronavigation is helpful in rapidly locating the distal PCA aneurysm. The individualized keyhole approaches can be applied feasibly and effectively for the treatment of posterior circulation aneurysms.