破裂小脑前下动脉动脉瘤的外科治疗

Surgical treatment for ruptured anterior inferior cerebellar artery aneurysms

研究背景小脑前下动脉动脉瘤临床罕见,破裂出血后果严重。本文回顾分析12例小脑前下动脉动脉瘤患者(共13个动脉瘤)的临床诊断与治疗经过,分析总结其临床特点、影像学表现、手术方法及预后,以为临床提供参考。方法回顾分析2004年6月-2012年6月治疗的小脑前下动脉动脉瘤患者的临床资料。结果 12例共13个动脉瘤,约占同期颅内动脉瘤总病例数的0.19%(12/6467),平均年龄54岁。动脉瘤形态以囊状居多(10个),梭形少见(3个);分别位于小脑前下动脉起始部即小脑前下动脉基底动脉交界处(3个)、内听道前段(3个,均位于小脑前下动脉第一分叉部)、内听道段(3个)和内听道后段(4个);动脉瘤直径平均为3.90mm。其中3例(4个动脉瘤)行外科手术治疗[动脉瘤夹闭术(2例)、孤立术(1例)],其余9例均行血管内治疗(动脉瘤栓塞术2例、支架辅助动脉瘤栓塞术3例、动脉瘤和载瘤动脉闭塞术4例)。术后并发症包括面瘫(1例)、吞咽困难伴饮水呛咳(1例)和双眼对侧视野缺损(1例);平均随访36.41个月,Glasgow预后分级3分1例、4分2例、5分9例,均达良好标准。结论小脑前下动脉动脉瘤临床罕见,外科手术治疗者需综合评价手术夹闭与血管内治疗适应证,从而选择最佳治疗方法。

Background Anterior inferior cerebellar artery （AICA） aneurysm is an extremely rare tumor, which can cause severe results after ruptured. This article retrospectively analyzed the clinical symptoms, imaging manifestations, surgical approaches, endovascular therapy and postoperative outcomes of 12 cases with AICA aneurysms, so as to provide reference for clinical practice. Methods Clinical data of patients with AICA aneurysms, who were treated in our hospital between June 2004 and June 2012, were carefully collected and studied. Glasgow Outcome Scale （GOS） scores were used to evaluate the patients living status. Results There were 12 patients （the average age was 54 years old） with 13 ruptured aneurysms, accounting for 0.19% of all aneurysms （6467 cases） treated in the same period. CT showed simple subarachnoid hemorrhage （SAH） in 6 patients, simple ventricular hemorrhage in 1 patient and SAH complicated with ventricular hemorrhage in 5 patients. According to Hunt-Hess Grade, 2 patients were classified as Grade I ; 7 were Grade H ; 3 were Grade HI. Digital subtraction angiography （DSA） showed there were 10 saccular aneurysms and 3 fusiform aneurysms. Three aneurysms were located in the proximal segment of AICA （the junction of AICA and basilar artery）, 3 premeatal segment （first bifurcation of AICA）, 3 meatal and 4 postmeatal. The mean diameter was 3.90 mm. Three patients with 4 aneurysms were treated with microsurgery, of which clipping was carried out in 2 patients with 3 aneurysms and trapping in 1 case. Other 9 patients were treated with endovascular therapy, of which 2 cases underwent coil embolization, 3 stent- assisted coil, and 4 parent artery occlusion （PAO）. Postoperative complications included facial paralysis （1 case）, dysphagia and coughing when drinking （1 case） and contralateral hemianopia in both eyes （1 case）. Follow-up was available in all of these cases for a mean of 36.41 months, with GOS scores 3 in 1 case, 4 in 2 cases and 5 in 9 cases. All the patients recovered well. Conclusion AICA aneurysms are rare. The treatment includes microsurgery and endovascular therapy. For proximal, premeatal and meatal aneurysms, the retrosigmoidal approach is recommended; for the distal ones, thesuboccipital approach with a center incision reverse to the ipsilateral （inverted 7 shaped） would be better for its minimal disturbance to cranial nerves. The endovascular therapy is recommended for all. For premeatal aneurysms, coiling or stent-assisted coiling would be good, even the aneurysms with wide neck arc treated well; for distal ones, PAO is effective but the decision should be made very carefully for its potential risk of neurological deficits.