经翼点入路显微手术治疗前交通动脉瘤临床分析

The Clinical Analysis of Microsurgical Treatment for Anterior Communicating Artery Aneurysm Via Pterional Approach

目的总结经翼点入路显微手术夹闭前交通动脉瘤治疗经验.方法回顾性分析昆明医科大学第一附属医院神经外二科2008年10月至2014年12月经翼点入路显微手术夹闭治疗82例前交通动脉瘤患者的临床资料,按Hunt-Hess病情分级,0级11例,Ⅰ级7例,Ⅱ级30例,Ⅲ级25例,Ⅳ8例,Ⅴ级1例;SAH患者早期(≤3 d)手术21例,中期(4 d^2周)手术15例,延期(>2周)手术35例.患者出院时疗效按GOS分级标准进行预后评定.结果 82例患者共发现85个ACo AA并全部夹闭,同时切除动脉瘤3个,穿刺及切开清除血栓11个.术中15个(占17.6%)动脉瘤发生再破裂.术中临时阻断73例次,最短阻断时间2 min,最长达40min,平均9.26 min.根据GOS评分,总预后良好率79.3%(65/82),轻残率12.2%(10/82),重残率3.7%(3/82),植物生存率0%,病死率4.9%(4/82);其中,早期、中期和延期手术预后良好率分别为85.7%、73.3%和82.3%;0级~Ⅴ级患者预后良好率分别为90.9%、85.6%、86.7%、84.0%、25.0%和0.0%.55例患者出院时或出院后3月内复查DSA或CTA均证明瘤蒂夹闭或动脉瘤消失,50例自术后随访4月至7 a,1例动脉瘤复发.失访32例.结论熟练掌握显微神经外科技术和前交通动脉复合体的显微解剖是获得良好手术疗效的关键.翼点入路可以满足不同瘤体指向、位置、大小前交通动脉瘤的夹闭且夹闭瘤颈可靠,术后并发症少,是一种易行、有效、可靠的方法,值得推广.在具备手术条件下,前交通动脉瘤无论病情分级高低应积极争取早期手术.

Objective To summarize treatment experiences of microsurgical clipping for anterior communicating artery aneurysm via pterional approach. Methods Clinical data of 82 cases undergoing mierosurgical clipping for anterior communicating artery aneurysm via pterional approach in the first affiliated hospital of Kunming Medical University from October 2008 to December 2014 were collected and retrospectively analyzed. The patients were divided into different groups by Hunt-Hess illness grading scale, with 11 cases for level 0, 7 cases for level I, 30 cases for level II, 25 cases for level III, 8 cases for level IV, and 1 cases for level V. Twenty-one patients underwent operation at early stage of SAH （〈3d） , 15 at late stage of SAH （4d-2W） , and 35 at prolonged stage of SAH （〉2W） . The prognosis of patients was evaluated according to GOS classification criteria at discharge. Results A total of 85 ACoAA were found in 82 patients and all of them were clipped and, at the same time, 3 aneurysms were resected and 11 thrombuses were punctured, cut and removed. In theoperation, 15 （ 17.6% ） aneurysms ruptured again and temporary blocking happened for 73 times, with the shortest blocking time of 2 min, the longest of 40 min, and the average of 9.26min. According to GOS score, good recovery rate was 79.3% （65/82） moderate disability rate was 12.2% （10/82） , severe disability rate was 3.7% （3/82） , vegetative state rate was 0%, and death rate was 4.9% （4/82） . Good recovery rates for the operations at early, late and prolonged stage of SAH were 85.7%, 73.3% and 82.3% respectively and for level 0 to level V were 90.9%, 85.6%, 86.7% and 84.0%, 25.0% and 0.0% respectively. Results of DSA or CTA re-examination upon 55 patients followed-up at discharge or three months after discharge showed that tumor pedicle were clipped and aneurysm disappeared. Fifty cases were followed up from four months to seven years after the operation, with one case of aneurysm recurrence. Another thirty-two cases were lost to follow-up. Gonclusions Microsurgical techniques and microdissection are keys to successful operation. Pterional approach can guarantee successful clipping of aneurysms with different directions, locations and sizes. It is also an easy, effective and reliable approach with less postoperative complications. Operation for anterior communicating artery aneurysm should be performed as early as possible.