复杂型后交通动脉动脉瘤的显微外科夹闭治疗

Microsurgical clipping for complex posterior communicating artery aneurysms

目的探讨复杂型后交通动脉（posterior communicating artery，PCoA）动脉瘤的临床特点和显微外科夹闭治疗的转归。方法回顾性分析经开颅显微外科夹闭治疗的PCoA动脉瘤患者的临床和影像学资料，根据其是否存在手术夹闭治疗的复杂因素将其分为复杂型组和简单型组。根据格拉斯哥转归量表评分将患者分为转归良好组和转归不良组。结果共纳入55例PCoA动脉瘤患者，其中17例（30．9％）为简单型，38例（69．1％）为复杂型。简单型组Fisher分级较高的患者比例显著性低于复杂型组（Z=-2．068，P=0．019），但两组年龄、性别、术前破裂、Hunt—Hess分级的构成比无显著性差异（P均〉0．05）。在复杂型组中，复杂夹闭（73．68％）和前床突切除（42．11％）是最常见的复杂因素，24例（63．16％）存在多个复杂因素。在复杂型病例中，32例转归良好，6例转归不良（其中3例死亡）；在简单型病例中，15例转归良好，2例转归不良（其中1例死亡）；复杂型组转归良好率与简单型组无显著性差异（84．21％对88．24％；X^2=0．153，P=0．696）。55例PCoA患者中，转归良好组年龄显著性低于转归不良组[（58．23±12．41）岁对（68．38±8．68）岁；t=-2．212，P=0．031]，而性别、Fisher分级、Hunt—Hess分级、手术复杂性因素以及手术夹闭程度均无显著性差异（P均〉0．05）。多变量logisitc回归分析显示，仅年龄是PCoA动脉瘤转归不良的独立危险因素（优势比1．142，95％可信区间1．029～1．266；P=0．012）。结论采用先进的显微外科技术，如前床突切除、脉络膜前动脉显微分离、复杂夹闭等治疗复杂型PCoA动脉瘤的效果并不逊于简单型，而年龄是PCoA动脉瘤转归不良的独立危险因素。

Objective To investigate the clinical features of complex posterior communicating artery aneurysms and the outcome of microsurgical clipping. Methods The clinical and imaging data of the patients with posterior communicating artery aneurysm treated by craniotomy microsurgical clipping were analyzed retrospectively. The patients were divided into either a complex type group or a simple type group according to whether they had complex factors of surgical clipping or not. They were divided into a good outcome group and a poor outcome group according to their Glasgow Outcome Scale scores. Results A total of 55 patients with posterior communicating artery aneurysm were enrolled, and 17 （30. 9% ） of them were in the simple type group and 38 （69. 1% ） were in the complex type group. The proportion of higher Fisher grade in the patients of the simple type group was significantly lower than that of the complex type group （Z = -2. 068, P =0. 019）. However, there were no significant differences in the proportions of age, sex, preoperative rupture, and Hunt-Hess grade between the two groups （all P 〉 0. 05）. In the complex type group, the complex clipping （73.68%） and anterior clinoidectomy （42. 11%） were the most common complex factors. Twenty-four patients （63.16%） had a number of complex factors. In the complex type cases, 32 had good outcome, 6 had poor outcome （3 of them died）; in the simple type cases, 15 had good outcome, 2 had poor outcome （1 of them died）. There was no significant difference in the good outcome rate between the complex type group and the simple type group （84. 21% vs. 88.24%;X2 = 0. 153, P = 0. 696）. In 55 patients with posterior communicating artery aneurysm, the age of the good outcome group was significantly lower than that of the poor outcome group （58.23 ± 12.41 years vs. 68.38± 8.68 years, t = -2. 212; P =0. 031）, and there were no significant differences in sex, Fisher grade, Hunt-Hess grade, factors of surgical complexity, and surgical clipping level （all P 〉 0. 05）. Multivariate logistic regression analysis showed that only age was the independent risk factor for poor outcome of the complex posterior communicating artery aneurysm （odds ratio 1. 142, 95% confidence interval 1. 029 - 1. 266; P = 0. 012）. Conclusions Using the advanced microsurgical techniques, such as anterior clinoidectomy, anterior choroidal artery microdissection, and complex clipping for the treatment of complex posterior communicating artery aneurysm are no less favorable than the simple type, and age is an independent risk factor for the poor outcome of posterior communicating artery anenrvsm.