临时阻断夹短暂误夹动脉瘤毗邻分支导致脑梗死的临床分析

Cerebral infarction caused by accidental incarceration of aneurysm-adjacent branches with temporary clips

目的 探讨临时阻断夹短暂误夹动脉瘤周围毗邻分支导致脑梗死的可能原因,以指导临床合理使用临时阻断夹.方法 回顾性分析2004年1月至2016年12月福州总医院神经外科因临时阻断夹误夹载瘤动脉分支或穿支的10例颅内动脉瘤患者的临床资料.在显微镜下观察分支、穿支血管被损伤的情况和术中操作过程以及术后相应供血区不同程度的脑梗死情况.2例后交通动脉动脉瘤和2例颈动脉分叉部动脉瘤均发现床突上段动脉外膜有不同程度的动脉粥样硬化,误夹脉络膜前动脉、Heubner回返动脉和豆纹动脉,4例前交通动脉动脉瘤和2例大脑中动脉动脉瘤误夹A1或A2和M1段毗邻穿支.结果 10例患者术后2-4d复查CT均发现动脉瘤毗邻的分支、穿支供血区有不同程度的脑梗死灶.意识障碍较术前恶化2例,肢体肌力短期内明显减退5例,不完全运动性失语1例,出现脑梗死但是未出现临床症状2例.随访4个月至3年,遗留痴呆2例,肢体永久性偏瘫2例,生活不能自理、需要长期护理3例.结论 临时阻断夹引起分支或穿支血管梗死的原因不仅与夹闭的时限、年龄和血管硬化的情况有关,还与小血管的过度收缩以及临时阻断夹的闭合力相关.因此,在使用临时阻断夹时应高度关注这些因素.

Objective To explore the potential reasons of cerebral infarction caused by accidental incarceration of aneurysm-adjacent branches with temporary clips,and to give guidance to the appropriate application of temporary clips.Methods A retrospective analysis was conducted on the clinical data of 10 patients with accidental incarceration of branches of parent artery or aneurysm-adjacent perforator vessels who were admitted to Department of Neurosurgery of Fuzhou General Hospital from January 2004 to December 2016.Under microscopes,we observed the definite lesions of branches and perforator vessels during the procedures,features of temporary clips and the intraoperative procedure,and postoperative cerebral infarction with varying degrees in corresponding territories.Two cases of posterior communicating artery aneurysm and 2 cases of carotid bifurcation aneurysm were found on the extracranial superior mesenteric artery adventitia with varying degrees of atherosclerosis,misclipping occurred at the anterior pre-choroidal artery,recurrent artery of Heubner and lenticulostraiate artery.For 4 cases of anterior communicating artery aneurysms and 2 cases of middle cerebral artery aneurysm,mis-clipping was found at A1 or A2 and M1 segments adjacent to perforation.Results Among the 10 patients,CT review 2-4 days post surgery demonstrated cerebral infarction with varying degrees adjacent to the aneurysm branches,perforating branch of blood supply.Disturbance of consciousness occurred in 2 cases.Compared with preoperative state,short-term significant decrease in strength of limb muscles was observed in 5 cases,incomplete motor aphasia in 1 and asymptomatic cerebral infarction in 2.At follow-up ranging from 4 months to 3 years,2 cases reported dementia and 2 cases had permanent hemiplegia,out of which 3 were disabling and needed long-term care.Conclusions Cerebral infarction caused by accidental incarceration of branches or perforator vessels with temporary clips could be related not only to the incarceration duration,age and vascular sclerosis,but also to the over-contraction of small blood vessels and the closing force of a temporary clip.Therefore,caution should be warranted regarding those factors in the use of temporary clips.