颈内动脉床突旁动脉瘤复合手术的球囊阻断技术分析

Analysis of balloon-assisted occlusion technique in hybrid operation of paraclinoid aneurysms of internal carotid artery

目的评估复合手术球囊辅助夹闭床突旁动脉瘤(PA)的安全性及有效性。方法回顾性连续纳入2011年7月至2018年7月四川大学华西医院神经外科在复合手术室完成的球囊辅助PA夹闭患者119例。收集患者年龄、性别、Hunt-Hess分级、入院眼部症状及动脉瘤部位、大小等。采用球囊辅助开颅夹闭动脉瘤,其中95例采用可脱球囊在动脉瘤近心端阻断,24例以封堵球囊在动脉瘤颈骑跨阻断。观察患者术中、术后出院时状态及出院后6个月随访结果,评估手术效果及并发症发生情况。结果 119例患者中,男25例,女94例;年龄27~82岁,平均(57±15)岁;29例(24. 4%)患者表现为视力下降,62例(52. 1%)有头晕、头痛症状,余28例无明显症状;Hunt-HessⅢ级3例(2. 5%),Ⅰ~Ⅱ级42例(35. 3%),余74例(62. 2%)为未破裂动脉瘤;床突段动脉瘤21例(17. 6%),眼段动脉瘤82例(68. 9%),后交通动脉动脉瘤16例(13. 4%);动脉瘤最大直径5~35 mm,平均(19±7) mm,112例(94. 1%)动脉瘤直径> 10 mm。术中111例(93. 3%)均顺利夹闭动脉瘤; 5例患者夹闭时瘤颈及颈内动脉撕裂; 1例患者因瘤颈部钙化明显无法夹闭; 1例Hyperglide球囊骑跨阻断后,在穿刺抽吸瘤腔时发生球囊破裂; 1例球囊骑跨阻断时,球囊在反复充盈调整动脉瘤夹时发生移位,远端脱入动脉瘤腔被动脉瘤夹夹闭。出院时3例患者死亡,均为瘤颈及颈内动脉撕裂,孤立后大面积脑梗死患者; 5例昏迷,6例有偏瘫症状,余105例(88. 2%)患者出院时无明显神经功能缺损。出院后6个月对出院时神经功能缺损的11例患者进行电话随访,5例昏迷患者中,3例于出院后1周内死亡,2例意识由昏迷转为淡漠,左侧肢体肌力Ⅲ级,视物模糊同术前; 6例出院时偏瘫患者中,1例于出院后3个月死亡,余5例意识清楚,视物模糊同术前,均有肢体偏瘫,肌力Ⅰ~Ⅱ级。结论复合手术球囊辅助夹闭技术可以有效治疗复杂床突旁大动脉瘤。

Objective To evaluate the safety and effectiveness of balloon-assisted clipping of paraclinoid aneurysms with hybrid operation.Methods From July 2011 to July 2018,119 consecutive patients treated with the balloon-assisted clipping of paraclinoid aneurysms at the Hybrid Operation Room,Department of Neurosurgery,West China Hospital,Sichuan University were enrolled retrospectively.Patients′age,gender,Hunt-Hess grade,ocular symptoms at admission,and location and size of aneurysms were collected.Balloon-assisted craniotomy for clipping aneurysms was used,95 of them were treated with detachable balloon at the proximal end of the aneurysms,and 24 were blocked by balloons in the aneurysm neck straddles.During the operation,the state of discharge after surgery,and the follow-up results at 6 months after discharge of the patients were observed.The operation effect and complications were evaluated.Results Of the 119 patients,94 were female and 25 were male;aged 27-82 years(mean 57±15 years).Twenty-nine patients(24.4%)showed decreased vision,62(52.1%)had dizziness and headache symptoms.The remaining 28 had no obvious symptoms.Hunt-Hess grade III in 3 cases(2.5%),grade I-II in 42 cases(35.3%),the remaining 74(62.2%)were unruptured aneurysms.Twenty-one patients(17.6%)had clinoid segment aneurysms,82(68.9%)had ophthalmic segment aneurysms,and 16(13.4%)had posterior communication aneurysms.The maximum diameter of the aneurysms was 5 to 35 mm(mean 19±7 mm),and the aneurysm diameter of 112 patients(94.1%)were>10 mm.The aneurysms were successfully clipped in 111 cases(93.3%)during the operation.Five patients had aneurysm neck and internal carotid artery lacerations during the clipping,and one was obviously unable to be clipped due to the neck calcification.After Hyperglide balloon saddle block,1 patient occurred balloon rupture during the puncture and aspiration of the aneurysmal cavity.When the balloon was blocked in 1 case,balloon displacement occurred during repeated filling adjustment of aneurysm clips and the distal end detached into an aneurysm cavity and was clipped by an aneurysm clip.Three patients died at discharge,they were all aneurysm neck and internal carotid artery lacerations,and they were patients with massive cerebral infarction after aneurysm tapping.Five patients were in a coma;another 6 had hemiplegia symptoms.The remaining 105 patients(88.2%)had no obvious neurological deficits at discharge.Six months after discharge,11 patients with neurological deficits were followed up by telephone.Among the 5 comatose patients,3 died within one week after discharge.The consciousness of 2 cases changed from coma to indifference,their left limb muscle strength was grade III,and blurred vision was the same as before operation.Of the 6 hemiplegic patients,1 died 3 months after discharge,and the other 5 had clear consciousness and their blurred vision was the same as before operation,all had limb hemiplegia,and their muscle strength was gradeⅠ-Ⅱ.Conclusion Hybrid surgery with balloon-assisted clipping technique may effectively treat complex paraclinoid aneurysms.