对侧入路夹闭颅内动脉瘤的手术探讨

Surgical investigation of clipping of intracranial aneurysms via contralateral approach

目的 探讨对侧入路夹闭颅内动脉瘤的适应证及手术技巧.方法 回顾性分析201 1年4月至2015年4月苏州大学附属第二医院神经外科收治的13例采用对侧入路夹闭颅内动脉瘤患者的临床资料,13例患者包括双侧多发动脉瘤10例（对侧眼动脉动脉瘤1例、大脑中动脉动脉瘤4例、后交通动脉动脉瘤4例、大脑前动脉A2 ～ A3动脉瘤1例）,眼动脉动脉瘤2例,伴发动静脉瘘1例（对侧大脑中动脉动脉瘤）.采用经纵裂锁孔入路1例（前交通动脉动脉瘤破裂伴发对侧大脑前动脉2～3段动脉瘤）,眉弓锁孔入路9例,翼点锁孔入路2例,额部小骨窗1例（同侧额部动静脉瘘出血,伴发对侧大脑中动脉动脉瘤）.必要时建立CT、CTA、MRI影像融合三维模型或3D打印实体模型进行术前设计.结果 13例对侧动脉瘤完全夹闭11例,不完全夹闭1例,对侧探查因夹闭困难未行夹闭1例.术中同侧嗅神经损伤2例,动脉瘤术后脑缺血2例,其余患者平稳出院.出院时格拉斯哥预后分级（GOS）Ⅴ级11例,Ⅳ级1例,Ⅱ级1例.结论 对侧入路可兼顾双侧病灶,适当选择可减少手术次数;对内侧指向的眼动脉动脉瘤,对侧入路可更好地显露,减少手术创伤.嗅神经解剖分离有助于行对侧手术入路时减少对神经牵拉,保护嗅神经的完好.影像融合三维重建模型有助于精准的术前设计.在熟练掌握对侧入路手术技术后,也可利用锁孔技术将入路微创化.但对侧入路应顺势而为,量力而行.

Objective To investigate the indications and surgical skills of clipping of intracranial aneurysms via contralateral approach.Methods The clinical data of 13 patients with intracranial aneurysm treated via contralateral approach at the Department of Neurosurgery,the Second Affiliated Hospital of Soochow University from April 2011 to April 2015 were analyzed retrospectively.In 13 patients,10 had bilateral multiple aneurysm （1 contralateral ophthalmic artery aneurysm,4 middle cerebral artery aneurysms,4 posterior communicating artery aneurysms,and 1 anterior cerebral artery A2-A3 aneurysm）,2 had ophthalmic artery aneurysm,and 1 accompanied with arteriovenous fistula （contralateral middle cerebral artery aneurysm）.One patient was treated via interhemispheric keyhole approach （ruptured anterior communicating artery aneurysm accompanied with contralateral anterior cerebral artery A2-A3 segment aneurysm）,9 via supraorbital keyhole approach,2 via pterional keyhole approach,and 1 via frontal small bone window approach （ipsilateral frontal arteriovenous fistula bleeding accompanied with a contralateral middle cerebral artery aneurysm）.ACT,CTA,and MRI-based image fusion 3-D model or 3D space entity model would be established when necessary.Results Of these 13 contralateral aneurysms,11 were clipped completely,1 was clipped incompletely,and 1 did not undergo clipping in contralateral exploration due to the difficulty of clipping.Two patients had ipsilateral olfactory nerve injury during operation;2 had cerebral ischemia after aneurysm surgery,other patients discharged uneventfully.Glasgow outcome scale （GOS） evaluation：grade Ⅴ 11 cases,grade Ⅳ 1 case,and grade Ⅱ 1 case.Conclusions The contralateral approach can take account of the bilateral lesions,the appropriate selection of it can reduce the number of operations.For medial directed ophthalmic artery aneurysms,the contralateral approach can better expose them and reduce surgery-related injury.The olfactory nerve dissection contributes to reduce nerve stretch for contralateral approach and protects the integrity of the olfactory nerve.The 3-D fused image reconstruction model contributes to accurate preoperative design.After mastering the contralateral approach surgical techniques,the keyhole technique can also be used for microinvasive approach.It should be noted that the contralateral approach should improve the occasion and do what is possible.