锁孔手术治疗合并颅内血肿的前循环破裂动脉瘤

Keyhole approach for anterior circulation aneurysms associated with intracranial hematomas

目的 探讨经锁孔入路手术治疗合并颅内血肿的前循环破裂动脉瘤的可行性和安全性.方法 回顾性纳入2012年12月至2015年8月福建医科大学附属第一医院神经外科收治的32例合并颅内血肿的前循环破裂动脉瘤患者,对所有患者经锁孔入路行动脉瘤夹闭术和血肿清除术治疗,意识较差且脑室系统扩大的患者行侧脑室外引流术.术后当天复查头颅CT,术后3d内复查头颅CT血管成像（CTA）.对所有患者行门诊随访,进行改良Rankin量表评分（mRS）.结果 32例患者共34个颅内动脉瘤均一期夹闭完全,夹闭率为100％.术后当天复查头颅CT,2例血肿扩大,其余血肿均已清除或部分清除.术后3d内复查头颅CTA,34个颅内动脉瘤均夹闭完全.术后并发血肿扩大2例（6.3％）,脑疝形成4例（12.5％）,肺部感染11例（34.4％）,脑血管痉挛12例（37.5％）,脑梗死6例（18.8％）,深静脉血栓形成1例（3.1％）,电解质紊乱6例（18.8％）,无肺梗死.16例行侧脑室外引流者,颅内感染的发生率为25.0％（4/16）,未行外引流者颅内感染发生率为12.5％（2/16）,两者间的差异无统计学意义（P〉0.05）.32例患者的随访时间为6-24个月,平均（16.0±5.4）个月.术后6个月mRS评分为：3例为6分,1例为4分,1例为3分,2例为2分,9例为1分,16例为0分.其中84.4％（27/32）的患者预后良好.结论 经锁孔入路行手术治疗合并颅内血肿的前循环破裂动脉瘤患者的疗效理想,可作为一种有效、安全的选择.

Objective To assess the feasibility and safety of keyhole approach for the anterior circulation aneurysms associated with intracranial hematomas.Methods Thirty-two patients with anterior circulation aneurysms associated with intracranial hematomas were admitted to Department of Neurosurgery at the First Hospital Affiliated to Fujian Medical University who underwent aneurysm clipping and hematoma evacuation via keyhole approach from December 2012 to August 2015.For patients with hydrocephalus and poor consciousness,external ventricular drainage was performed.Postoperative CT scan was performed within 24 hours,and CT angiography was performed within 72 hours.The clinical data were collected and analyzed.Functional outcomes were assessed according to the modified Rankin Scale （mRS） at 6 months post surgery.Results Thirty-four cerebral aneurysms were successfully clipped and intracranial hematomas were evacuated via keyhole approach in 32 patients.Postoperative complications included hematoma expansion in 2 cases （6.3%）,brain herniation in 4 （12.5%）,pulmonary infection in 11 （34.4%）,cerebral vasospasm in 12 （37.5%）,cerebral infarction in 6 （18.8%）,deep venous thrombosis in 1 （3.1%） and electrolyte disturbances in 6 （18.8%）.External ventricular drainage （EVD）-related infections were observed in 4/16 （25.0%） patients.Intracranial infections were found in 2/ 16 （12.5%） patients without extemal ventricular drainage.No statistical significance was identified （P 〉 0.05）.With 3 deaths excluded,the functional outcomes were assessed at follow-up after 6-24 months,and the average follow-up period lasted 16.0 ± 5.4 months.The outcome was assessed according to the modified Rankin Scale and the score of 6 was determined in 3 patients,4 in 1,3 in 1,2 in 2,1 in 9 and 0 in 16.Good recovery was reported in 84.4% （27/32） of the patients.Conclusions Keyhole approach for patients with anterior circulation aneurysms associated with intracranial hematomas seems to be a safe,feasible and minimally invasive procedure which is worth being promoted.