显微手术治疗颅内前循环动脉瘤

Microsurgery for intracranial anterior circulation aneurysms

目的探讨颅内前循环动脉瘤的影像学诊断方法、手术时机、改良翼点人路的显微手术方法,术中和术后脑血管痉挛(CVS)的防治以及可能影响手术预后的因素。方法回顾性分析62例颅内前循环动脉瘤患者的临床资料。结果 62例患者均经DSA和(或)CTA检查后明确其诊断。61例行改良翼点入路开颅手术;1例行纵裂入路开颅手术。直接夹闭动脉瘤63个,包裹梭形动脉瘤1个,术中所见与影像学检查结果一致。术后随访51例,随访时间为1个月～2年。按照格拉斯哥预后评分(GOS),良好的有45例(88.2%),轻度残疾的有2例(3.9%),重度残疾的有1例(1.9%),死亡的有3例(5.9%)。随访的患者均未出现颞肌萎缩及面神经颞支损伤等情况。术后有1例患者因CVS死亡,术中应用罂粟碱处理的22例患者,术后均无明确的CVS发生。有15例患者术中行终板造瘘,术后配合腰大池引流术,在6个月至2年的随访中只有2例发生慢性脑积水。结论①术前应行高质量的全脑血管造影,有利于手术的进行。②颅内前循环动脉瘤一旦被确诊应早期治疗。③改良翼点入路可以减少颞肌萎缩的发生,术后面神经损伤减少。④CVS是影响手术预后的重要因素,术中终板造瘘和术后腰大池引流术等综合措施有利于减少CVS和慢性脑积水的发生。

Objective To investigate imaging diagnostic method, timing of surgery, modified pterional approach microsurgery, prevention and treatment of intraoperative and postoperative cerebral vasospasm （CVS） , and the factors that may affect the surgical results of intracranial anterior circulation aneurysms. Methods The clinical data of 62 patients with intracranial anterior circular aneurysms were analyzed retrospectively. Results After DSA and/or CTA examinations, 62 patients had clear diagnosis. Sixty-one patients underwent eraniotomy through modified pterional approach and 1 patient through interhemispheric approach. Sixty-three aneurysms were clipped directly and 1 fusiform aneurysm was wrapped. The intraoperative findings were in coincidence with those of imaging. Fifty-one patients were followed up for 1 month to 2 years. According to Glasgow outcome scale （ GOS ） , 45 patients （ 88. 2% ） recovered well, 2 （3.9%） had mild disability, 1 （ 1.9% ） had serious disability, and 3 （5.9%） died. No temporal muscle atrophy and temporal branch of facial nerve injury were found. One patient died of CVS after surgery. No CVS occurred after surgery in 22 patients treated with papaverine during the operations. Fifteen patients underwent intraoperative lamina terminalis fenestration and postoperative lumbar cistern drainage. Only 2 patients had chronic hydrocephalus during the 6 months to 2 years follow-up period. Conclusions （1）High quality cerebral angiography should be performed preoperatively, it is beneficial to conduct the operative management of the aneurysms. （2）Once the intracranial anterior circulation aneurysms are diagnosed, the patients should be treated early. （3）The modified pterional approach may reduce the occurrence of temporal muscle atrophy and facial nerve injury. （4）CVS is an important factor of affecting the surgical outcome. The comprehensive measures, such as intraoperative lamina terminalis fenestration and postoperative lumbar cis tern drainage are contributive to decrease the occurrence of CVS and chronic hydrocephalus.