采用枕下肌肉分层法远外侧入路治疗椎-基底动脉瘤

Treatment of vertebrobasilar aneurysms using suboccipital muscle stratification via far lateral approach

目的探讨显微外科手术采用枕下肌肉分层法远外侧入路治疗复杂椎-基底动脉瘤的技术要点。方法回顾性分析2015年8月至2017年1月首都医科大学宣武医院采用枕下肌肉分层法远外侧入路治疗的8例椎-基底动脉瘤患者的临床资料,其中5例为蛛网膜下腔出血(HuntHess分级Ⅱ级3例、Ⅲ级1例、Ⅳ级1例),3例为症状性夹层动脉瘤。对6例患者行枕动脉-小脑后下动脉或小脑前下动脉旁路移植术及动脉瘤孤立术,另2例在术中直接夹闭动脉瘤。分析术野暴露情况,以改良Rankin量表(mRS)评价临床疗效。结果术后DSA检查示桥血管均通畅。术中实际测量枕动脉获取长度为(12.5±1.1)cm;6例旁路移植的吻合深度为(50±6)mm。术后随访4~21个月,7例患者mRS评分0~1分,2例新发声音嘶哑,术后3个月内完全恢复;另1例术后小脑半球支配区域脑梗死,mRS评分4分。无一例发生术后伤口愈合不良、感染及脑脊液漏。结论枕下肌肉分层法远外侧入路,可有效地获取较长的枕动脉,减少了肌肉的占位效应和增加术野深度,利于病变显露及深部吻合手术操作,是神经外科治疗椎-基底动脉瘤较为安全实用的技术方法。

Objective To discuss the technical essentials of microsurgery using suboccipital muscle stratification for the treatment of complex vertebrobasilar aneurysms via far lateral approach. Methods The clinical data of 8 patients with vertebrobasilar aneurysm underwent suboccipital muscle stratification via far lateral approach at the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University were analyzed retrospectively,including 5 patients with subarachnoid hemorrhage （Hunt-Hess grade Ⅱ 3 cases; grade Ⅲ 1 case ; grade Ⅳ 1 case） , and 3 with symptomatic dissecting aneurysm. Six patients underwent occipital artery-posterior inferior cerebellar artery and anterior inferior cerebellar artery bypass grafting, and aneurysm trapping,and the aneurysms of the other 2 cases were clipped directly in the operation. The modified Rankin scale （mRS） was used to evaluate the clinical efficacy. Results Postoperative digital subtraction angiography （DSA） revealed that all the bridge vessels were patent. The obtained length of occipital artery in the actual measurement of the operation was 12.5 ± 1.1 cm. The distance between the anastomosis site and the skin incision in 6 cases was 50 ± 6 mm. They were followed up for 4 -21 months after procedure. The mrs score in 7 cases was 0 -1. Two patients had new-onset hoarseness and recovered completely within 3 months after procedure. Another patient had postoperative cerebellar hemisphere dominant regional cerebral infarction and the mrs score was 4. None of them had poor wound healing,infection and cerebrospinal fluid leakage after procedure. Conclusion Suboccipital muscle stratification via far lateral approach can effectively obtain a longer occipital artery, reduee the occupation effect of muscle and depth of field. It is beneficial to expose lesions and operation of deep anastomosis. It is a more safe and practical technique in neurosargery for the treatment of vertebrobasilar artery aneurysms.