大脑中动脉动脉瘤破裂合并巨大血肿的外科治疗

Surgical treatment of middle cerebral artery aneurysms associated with associated large intracrainal hematomas

目的 探讨大脑中动脉动脉瘤破裂合并颅内巨大血肿的外科治疗策略和经验.方法 15例大脑中动脉动脉瘤破裂合并巨大颅内血肿的患者,男6例,女9例,年龄17 ～65岁（平均45岁）,13例造影共计14个动脉瘤,1例合并后交通动脉动脉瘤.颅内血肿量25 ～ 60 ml,按术前Hunt - Hess分级：Ⅲ级3例,Ⅳ级11例,Ⅴ级1例.术前4例患者出现单侧瞳孔散大,1例发生双侧瞳孔散大,所有患者给予急诊手术治疗.结果 15例患者中,11例急诊行额颞开颅,血肿清除＋动脉瘤夹闭术,其中7例患者去除骨瓣；3例患者急诊造影时直接行介入栓塞,然后行小骨窗开颅；1例外院行开颅血肿清除术,转入我院造影后直接行介入治疗.随访14例,随访时间6 - 48个月.GOS预后评分显示可正常生活或工作,恢复良好7例；中度致残,生活自理4例；遗留偏瘫,但生活可基本自理,重度致残2例；生活不能自理,死亡2例.结论 早期手术清除血肿,夹闭动脉瘤,去骨瓣减压有助于术后神经功能恢复.术前Hunt - Hess分级较轻,年龄大,动脉瘤窄颈,行动脉瘤栓塞＋小骨窗开颅,血肿清除术是一种治疗选择.

Objective To investigate the surgical management of middle cerebral artery aneurysms （MCAAs） associated with large intracrainal hematoma.Method From 2006 to 2010,a total of 15 cases of MCAAs associated with larger intracranial hematoma were treated in our department,including 6 male patients and 9 female patients ranged from 17 to 65 years old（mean age of 45 years old）.Radiographic evaluations demonstrated 13 middle cerebral artery aneurysm and 1 internal carotid posterior communicating artery aneurysm among 15 cases.The associated hematoma was ranged from 25 to 60 ml and mean clot volume was 35 ml.The preoperative status on admission was Hunt - Hess grade Ⅳ in 11 patients,Ⅲ in 3 and Ⅴ in 1.Results 11 patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy for clot evacuation and aneurysm clipping,decompressive craniectomy was performed in 7 patients ;3 patients were treated with immediatd endovasculor embolism at the same session of angiographic examination and emergernt hematoma clearance by small - window of skull; 1 patient was treated with clot evacuation and decompressive craniectomy in other hospital and transferred to our hospital to undergo endovascular treatment.Postoperative follow up （ ranged from 6 - 48 months） with The Glasgow Outcome Scale showed good recovery,moderate recovery,severe disability,and death in 7,4,2,and 2,respectively.Conclusions The present series suggests that early evacuation of space - occupying hematoma,aneurysm clipping and emergent decompessive cranioctomy could lead to survival with good recovery in some patients ; for patients with low grade and narrow - neck regular aneurysm,endovascular embolism at the same session of angiographic examination and emergent colt evacuation by small - window of skull would be a alternative procedure.