翼点锁孔手术处理颅内动脉瘤

Surgical treatment of intracranial aneurysms via the pterional keyhole approach

目的 以微创理念改良翼点手术入路,减少动脉瘤手术创伤.方法 苏州大学附属第二医院于2004年9月至2015年4月期间,通过翼点锁孔入路进行颅内动脉瘤夹闭术123例.以keyhole孔外侧2 cm的翼点为中心,沿发际设计4 cm长手术切口,沿侧裂方向纵行切开颞肌,按动脉瘤部位设计骨孔位置,铣下2.0～2.5 cm直径小骨瓣,磨除蝶骨嵴,分离侧裂,打开脑池释放脑脊液后显露手术部位.123例动脉瘤中,包括大动脉瘤6例,巨大动脉瘤4例,多发动脉瘤17例34个.3例双侧动脉瘤行双侧手术2例,单侧入路夹闭双侧动脉瘤1例.对侧入路1例,夹闭向内侧指向的眼动脉瘤.2例伴发的颅内肿瘤一并切除（大脑中动脉瘤伴发鞍结节脑膜瘤、后交通动脉瘤伴发中颅底脑膜瘤）.结果 123例患者140个动脉瘤行夹闭术139个,孤立术1个.术后复查发现4例动脉瘤颈残留.术后3例患者动眼神经不全麻痹,1例肢体轻偏瘫,渐恢复;术后意识障碍加深4例,3例因脑缺血,1例因脑水肿所致.1例Ⅳ级患者手术对侧脑血管痉挛致同侧肢体偏瘫.其余患者术后过程平稳.结论 翼点锁孔手术适合用于无需去骨瓣减压的动脉瘤夹闭术,可减少手术创伤,缩短手术时间,微创而有效.

Objective Modify the pterional approach for intracranial aneurysms clipping with minimally invasive concept to reduce the risk of iatrogenic surgical trauma.Methods A 4.0 cm skin incision was made along the temporal hairline and centered on the pterion, temporal muscle was incised along the sylvian fissure.A bone flap with 2.0 to 2.5 cm in diameter was milled after a bone hole was drilled just on the sphenoid ridge, which was drilled off as needed then.Aneurysms were exposed after dissection of sylvian fissure and cistern, as well as cerebrospinal fluid releasing.A total of 123 cases with 140 intracranial aneurysms were treated surgically via the pterional keyhole approach, including 6 large aneurysms, 4 giant aneurysms, and 17 cases with multiple aneurysms （34 aneurysms）.Of 3 cases with bilateral aneurysms, 2 were treated via bilateral approach as well as 1 via unilateral approach.Contralateral approach was used in 1 case with ophthalmic artery aneurysm, which pointed medial.Concomitant intracranial tumors were removed simultaneously in 2 cases, and one of them was diagnosed with middle cerebral artery aneurysm and tuberculum sellae meningioma, the other one with posterior communicating artery aneurysm and middle cranial fossa menigioma.Results Of the 140 aneurysms, 139 aneurysms were clipped and 1 was trapped.Postoperative image showed 4 cases had residual of aneurysm neck.3 cases had incomplete dysfunction of oculomotor nerve and 1 had mild hemiplegia after surgery and recovered eventually.4 cases presented with aggravated disturbance of consciousness, of whom 3 cases were caused by ischemia and 1 by brain edema.Unusual ipsilateral hemiplegia occurred in 1 case in Hunt＆amp;Hess grade Ⅳ, which caused by contralateral vasospasm.Postoperative courses in other cases were uneventful.Conclusions As a minimally invasive and effective approach, the pterional keyhole approach is applicable to intracranial aneurysms clipping for patients without any necessary for decompressive craniectomy.Surgical related complications and operative duration can be reduced significantly.