床突上段血泡样动脉瘤临床诊疗分析

The clinical diagnosis and treatment of blood-blister-like cerebral aneurysms in supra-clinoid segmentof internal carotid artery

目的探讨颈内动脉床突上段血泡样动脉瘤的临床特点、外科治疗原则和治疗方法。方法回顾性分析2008年11月至2012年12月12例血泡样动脉瘤患者的临床资料。男性4例，女性8例；年龄38～56岁，平均46．6岁。11例动脉瘤以剧烈头痛为首发症状，1例为偶然发现。术前Hunt—Hess分级：0级1例，I级5例，Ⅱ级4例，Ⅲ级2例。DSA检佥示12枚动脉瘤，其中颈内动脉床突上段前肇4例，前内侧壁8例。4例行开颅手术治疗，8例行介入治疗．开颅手术采用动脉瘤直接夹闭、动脉瘤孤立及动脉瘤包裹等方法；介入治疗采用动脉瘤支架辅助栓塞、单纯支架置入等方法。开颅手术中常规使用脑电图及体感诱发电位进行监测。术中应用多普勒超声和荧光血管造影监测山流情况。术后每6个月随访1次，门诊行CT血管造影检查。结果进行开颅手术的4例患者中动脉瘤夹闭2例，动脉瘤孤立1例，动脉瘤包裹1例；孤立的1例术后出现偏瘫。介入治疗8例，其中支架辅助柃塞6例，单纯支架治疗2例。随访时间6～61个月，平均16个月。4例开颅手术治疗患者中，…院后6个月改良Rankin评分0～1分者3例，4分者1例；1例行包裹的动脉瘤复发转为介入治疗。8例介入治疗患者中，支架辅助栓塞6例患者6个月随访复发4例，再予支架辅助补充栓塞；2例单纯支架置入者未见复发。结论血泡样动脉瘤是一种特殊类型的颅内复杂动脉瘤，充分了解血泡样动脉瘤的临床特点是治疗成功的关键。，开颅手术风险高、难度大、并发症多，栓塞治疗复发率高，二者的治疗都没有达到满意的效果。

Objective To study the clinical characteristics, surgieal principles and treatment options of blood-blister-like cerebral aneurysms in supra-clinoid segment of internal carotid artery. Methods Twelve blood-blister-like aneurysms were retrospectively studied including 4 open-surgery cases and 8 endovascular-treated cases from November 2008 to December 2012. Patients comprised 8 temale and 4 male patients, whose mean age was 46. 6 （range 38-56） years. Eleven patients presented with severe headache as the primary symptom, and 1 patient was found with aneurysm incidentally. Preoperative Hunt-Hess graded 0 in 1 patient, graded I in 5 patients, graded II in 4 patients, and graded III in 2 patients. By DSA examinations, 4 blood-blister-like aneuCcsms located in anterior wall and 8 in medial-anterior wall of supra-clinoid segment of internal carotid artery. Open surgical treatment included direct clipping, trapping, or wrapping and interventional treatment included stent-assisted coiling or simple stent placement. Intra-operative electroencephalogram and somatosensory evoked potentials monitoring was regularly used. Microvascular Doppler ultrasonography and indocyanine green videoangiography were used to assess hlood flow in parent and branch vessels. The patients were followed up at 6 months by CT angiography（CTA） examination in outpatient clinic. Results For 4 open surgeries, 2 aneurysms were directly clipped, 1 was trapped and 1 was wrapped. The patient underwent trapping paralyzed postoperatively. For endovascular treatment, 6 patients were coiled assisted with stents and 2 patients were treated with simple stent placement. All the patients were followed with a mean follow-up time of 16 months （range, 6-61 months）. At 6 months follow-up, 3 out of 4 surgical treated patients had good outc.mne and 1 was moderately severe disabled by modified Rankin scale; 1 patient underwent wrapping recuned and was transfen＇ed to endovascular treatment. Of the 6 patients treated with stent-asslsted coiling, 4 patients were reeun＇ent anti coilreplacements were performed. Two patients with simple stent placement had no recurrences. Conclusions Blood-blister-like aneurysm is a special type of complex cerebral aneurysm. Comprehensive understanding of blood-blister-like aneurysm is the key to successful treatment. Open surgery is difficult procedure with high risk and complications while stent-assisted coiling has a high recurrent rate. To date, neither is the safe and effective treatment option.