颅内动脉瘤夹闭术中荧光血管造影、血管超声、诱发电位联合监测的应用研究

Application of Indocyanine Green Angiography and Other Intraoperative Monitoring Techniques in Clipping of Intracranial Aneurysms

目的 探讨实时颅内血管超声（CDU）,吲哚青绿荧光血管造影（ICGA）及诱发电位（CMEP）联合监测在颅内动脉瘤夹闭术中的应用价值,以进一步提高脑动脉瘤的手术疗效. 方法 对228例共276个动脉瘤的显微手术进行实时CDU,ICGA及CMEP联合监测,分析比较动脉瘤夹闭前后的监测指标,及时发现问题并指导术者采取相应的干预措施. 结果 58例动脉瘤夹闭后CMEP出现异常变化,表现为对侧运动诱发电位的波幅下降或消失;46例夹闭后,CDU发现载瘤动脉血流异常;ICGA发现6例载瘤动脉狭窄,14例瘤颈夹闭不全,5例荧光造影剂外溢,4例后交通动脉被误夹,2例穿支动脉闭塞,术中及时调整动脉瘤夹之后,仅11例运动诱发电位未能恢复如初,其余异常现象均及时纠正.术后16例出现对侧肢体0～3级的偏瘫,经治疗后症状均有明显好转. 结论 颅内动脉瘤显微手术过程中进行CDU,ICGA及CMEP联合监测,可充分发挥其各自优势,指导术者采取相应的干预措施,有效降低手术并发症,提高手术疗效和术后生活质量.

Objective To evaluate the efficacy of combined multiple intraoperative monitoring techniques including cerebrovascular Doppler ultrasonography （CDU）,indocyanine green angiography （ICGA） and somatosensory evoked potential （SSEP） and motor evoked potential（MEP） in the surgical management of cerebral aneurysms.Methods Electroencephalogram（EEG）,SSEP,MEP were monitored intraoperatively,ICGA was used to visualize blood flow and CDU was used to examine the blood flow velocity before and after aneurysm clipping in 228 patients （276 aneurysms）.Monitoring results have been utilized for verifying proper clip placement.Results Intraoperative MEP changed in 58 patients.CDU disclosed abnormal blood flow in 46 patients,and did not disclose blood flow in 4 patients.ICGA detected artery stenosis in 6 patients,neck remnant in 14 patients,dye extravasation in 5 patients,clip PComA （posterior communicating artery） in 4 patients and branch occlusion in 2 patients,which directed neurosurgeons to re-adjust aneurysmal clips for its recovery,but MEP did not recover in 11 patients.16 patients were observed hemiparalyzed after operation and were significantly improved by proper treatment.4 patients had permanent neurological deficit.Conclusion Combined CDU,ICGA and CEMP may disclose better vessels shape,blood flow and neuroelectrophysiological activities in aneurysm,parent,branching and adjacent vessels during aneurysm surgery.They can provide complementary information for verifying proper operation.The combination monitoring can potentially reduce surgical complications of intracranial aneurysm and improve surgical quality.