颅内前循环动脉瘤夹闭术中破裂的原因及处理

The causes and strategies for intraoperative rupture during clipping the anterior circulation aneurysms

目的 探讨颅内前循环动脉瘤夹闭术中破裂的原因及处理策略.方法 回顾性分析河南省人民医院神经外科2012年11月至2014年2月显微外科手术夹闭术中破裂的19例前循环动脉瘤患者的临床资料,总结术中破裂的原因及术中处理方法.结果 19例患者中动脉瘤分离前期破裂2例（10.5％）,分离动脉瘤时破裂11例（57.9％）,夹闭时破裂6例（31.6％）.19例中17例术后复查计算机断层摄影血管造影（CTA）显示动脉瘤无明显残留.1例后交通动脉瘤夹闭时瘤颈撕裂严重无法夹闭,术中行动脉瘤孤立术,术后患者肢体偏瘫.1例分离前期破裂患者术后严重脑肿胀,术后8d死亡.术后3个月左右格拉斯哥预后评分（GOS）：恢复良好11例,生活自理5例,重度残疾2例,死亡1例.结论 术前充分评估术中破裂的危险因素,术中良好的显微手术技巧可以预防颅内动脉瘤术中破裂.采取综合措施迅速控制出血,明确动脉瘤及周围血管的解剖结构后再分离、夹闭动脉瘤是处理动脉瘤术中破裂出血的关键.

Objective To investigate the causes and strategies for intraoperative rupture during clipping the anterior circulation aneurysms.Methods Nineteen patients with anterior circulation aneurysms ruptured during clipping,who admitted to the Department of Neurosurgery,Henan Provincial People＇s Hospital from November 2012 to February 2014,were enrolled.Their clinical data were analyzed retrospectively to summarize the causes and strategies for intraoperative rupture.Results The aneurysms ruptured during predissection in 2 cases （10.5%）,during dissection in 11 cases （57.9%） and during clip application in 6 cases （31.6%）.There was no residual aneurysm confirmed by postoperative CTA in 17 patients.One case with posterior communicating artery aneurysm cannot be clipped because of the serious avulsion of the aneurysm neck during clipping.The aneurysm was trapped and the patient paralysed on one side after operation.One case died postoperative 8 days because of severe cerebral edema,whose aneurysm ruptured during predissection.The Glasgow Outcome Scale （GOS） of three months after operation showed good recovery in 11,moderate recovery in 5,severe disability in 2,and death in 1 cases,respectively.Conclusion Adequate preoperative evaluation for the risk factors of intraoperative rupture and excellent microsurgical techniques can prevent intraoperative rupture of intracranial aneurysms.Controlling the bleeding quickly and dissecting and clipping the aneurysm after definitely know the anatomy of the aneurysm and surrounding vasculature could be the keys to deal with intraoperative aneurysm rupture.