眶上锁孔入路治疗基底动脉上段动脉瘤的解剖学研究及初步临床应用

Anatomical study and preliminary clinical application of supraorbital keyhole approach for the upper basilar artery aneurysms

目的探讨眶上锁孔入路治疗基底动脉上段动脉瘤的可行性和适应证,并报告其初步临床应用经验。方法 8具福尔马林固定的尸头标本,完成眶上锁孔入路开颅后,通过视神经颈内动脉三角(即第二间隙),观察基底动脉上段的显露,并在神经导航系统辅助下完成解剖数据测量。在临床应用中,经眶上锁孔入路夹闭基底动脉上段动脉瘤9例。结果眶上锁孔入路通过第二间隙可显露基底动脉上1/3段,双侧小脑上动脉和大脑后动脉(P1段和部分P2段)。可观察到的基底动脉最低点与后床突水平间的直线距离为(5.0±1.2)mm,磨除后床突,距离可显著增加(3.4±1.0)mm(P<0.05)。可观察到的基底动脉延长线最远点到颅前窝的垂直距离为(12.4±2.3)mm,去除眉弓及部分眶顶,距离可显著增加(3.3±1.2)mm(P<0.05)。9例基底动脉上段动脉瘤通过眶上锁孔入路成功夹闭,术后随访6～12个月,病人恢复好。结论眶上锁孔入路可显露不高于颅前窝水平10mm,不低于后床突水平5mm的基底动脉。磨除后床突和切除眉弓及部分眶顶可分别增加基底动脉近端、远端的显露。眶上锁孔入路中,经第二间隙夹闭基底动脉上段动脉瘤是手术最佳路径。

Objective To explore the feasibility and indication of the supraorbital keyhole approach for upper basilar artery（BA） aneurysms and report the preliminary experience in clinical application.Methods Eight formalin-fixed adult cadaveric heads were dissected to observe the exposure of BA via opticocarotid triangle（the second space） by supraorbital keyhole approach.The anatomic data of BA were measured with the aid of neuronavigation system.In clinical application,9 patients with upper BA aneurysms were treated via supraorbital keyhole approach.Results The upper one third of the BA,bilateral superior cerebellar artery（SCA） and posterior cerebral artery（PCA） including P1 segment and a part of the P2 segment can be visualized through the second space by the supraorbital keyhole approach.The linear distance from visible lowest point of the BA to posterior clinoid process（PCP） level was 5.0±1.2 mm,which significantly increased by 3.4±1.0 mm after posterior clinoidectomy（P0.05）.The vertical distance from the visible apogee of the BA elongation to the cranial anterior fossa was 12.4±2.3 mm,which significantly increased by 3.3±1.2 mm after the removal of the superciliary arch and part of the vertical orbit（P0.05）.Nine upper BA aneurysms were completely clipped via supraorbital keyhole approach.During the following-up period from 6 to 12 months,all the patients recovered well.Conclusions The BA which was not higher than 10 mm above the anterior fossa level and not lower than 5 mm below the PCP level can be visualized by the supraorbital keyhole approach.The posterior clinoidectomy can increase the proximal exposure of the BA.The removal of the superciliary arch and part of the vertical orbit can increase the distal exposure of the BA.In the supraorbital keyhole approach,upper BA aneurysm clipping via the second space is the optimal surgical pathway.