颅内动脉瘤术中瘤颈破裂或撕脱应急处理方法探讨

Emergency treatment of ruptured or avulsed aneurysms at their necks during intracranial aneurysm operation

目的 探讨显微手术夹闭颅内动脉瘤术中瘤颈破裂或撕脱的主要原因及处理方法,以期提高动脉瘤夹闭术中出现意外情况时的手术成功率。 方法 回顾性分析川北医学院附属医院神经外科自2009年1月至2013年9月实施颅内动脉瘤夹闭术时遭遇术中动脉瘤瘤颈破裂或撕脱的8例患者的病历资料和手术过程,总结术中出现瘤颈破裂或撕脱的原因及手术处理方法。结果 8例患者中,3例瘤颈破口较小,通过临时阻断载瘤血管近端,使用普通弧形动脉瘤夹夹闭瘤颈,术后很快恢复到术前水平,术后1月左右GOS评分5分;另5例普通动脉瘤夹不能夹闭瘤颈,使用跨血管夹夹闭瘤颈或夹闭瘤颈及部分载瘤血管后止住出血（每例患者使用l～2枚,共使用8枚）,术后1月左右GOS评分4例5分、1例4分。 结论 动脉瘤术中瘤颈破裂或撕脱可以预见和准备预案;正确应用动脉瘤夹可以提高疗效,减少并发症;对于出现瘤颈撕脱或破裂的动脉瘤,合理使用跨血管夹是一种行之有效的应急方法。

Objective To investigate the main reasons and treatment methods of ruptured or avulsed intracranial aneurysms at their necks during microsurgical clipping,and to increase the success rate of aneurysm surgery when unexpected event occurred,so as to improve the operative efficacy of intracranial aneurysms.Methods A retrospective analysis was performed in clinical data of 8 patients appeared ruptured or avulsed aneurysms at their necks during operation,admitted to our hospital from January 2009 to September 2013.Their clinical results of these patients were summarized.The characteristics of aneurysms,the reasons of ruptured or avulsed aneurysms during surgery,and the surgical treatments were analyzed.Results Eight patients with ruptured or avulsed aneurysms at their necks during operation belonged to normal internal carotid artery aneurysms,and the rupturing or avulsing just occurred in the process of separating or clipping of the necks of aneurysms.Three patients had small neck lacerations,by temporarily blocking the proximal parent vessels and clipping the necks of aneurysms using ordinary curved aneurysm clip,returning to preoperative levels soon; and the GOS scores were 5 points one month after operation.Another 5 patients could not be clipped the necks of aneurysms by ordinary aneurysm clip,only by using the cross-vascular clamp to clip the necks of aneurysms or/and a part of the parent vessels to stop bleeding; 1-2 pieces of cross-vascular clamp were used in each patient and totally 8 pieces were used; 5 points of GOS scores were got in 4 and 4 points were got in one patient one month after operation.Conclusions The rupture or avulsion of intracranial aneurysms at their necks during clipping can be foreseen and prepared well in advance.The correct application of aneurysm clip can improve operative efficacy and reduce postoperative complications.The rational use of cross vascular clips is an effective emergency measure to treat the avulsion or rupture of aneurysms at their necks.