显微手术治疗基底动脉顶端动脉瘤的策略和疗效

Therapeutic strategy and effect of different approaches for microsurgical treatment of basilar artery bifurcation aneurysms

目的探讨显微手术治疗基底动脉顶端动脉瘤的策略和疗效。方法回顾性分析中南大学湘雅二医院神经外科2011年4月至2018年4月采用显微手术治疗的43例基底动脉顶端动脉瘤患者的临床资料。基底动脉顶端动脉瘤破裂者32例,未破裂者11例。17例采用经颞下入路、26例采用经侧裂入路(包括经额眶颧入路、颞下结合翼点的"一半一半"入路及单纯翼点入路)夹闭动脉瘤。术中联合运用多种技术进行监测。术后6个月开始行影像学和临床随访。结果43例患者中,动脉瘤完全夹闭者38例,部分夹闭者4例,包裹1例。术后偏瘫2例(4.7%),昏迷1例(2.3%),动眼神经麻痹14例(32.6%),围手术期无死亡患者。37例(86.4%)患者获得随访,随访时间为(25.0±10.1)个月(6个月至4年)。影像学随访显示,35例未见动脉瘤残留,1例部分夹闭患者再次行血管内栓塞治疗,1例行动脉瘤包裹加固者未见动脉瘤明显增大。末次随访格拉斯哥预后评级Ⅴ级者34例,Ⅳ级者1例,Ⅲ级者1例,Ⅰ级者1例(术后42 d死于严重肺部感染)。14例术后出现动眼神经麻痹的患者中,随访11例,其中8例症状改善。结论术前根据动脉瘤的解剖学特点和形态特征选择不同的手术入路治疗基底动脉顶端动脉瘤,疗效良好;术中多项技术联合监测是提高手术安全性的重要保证。

Objective To investigate the strategy and effect of microsurgical treatment of basilar artery bifurcation aneurysms with different surgical approaches.Methods We retrospectively reviewed the clinical data of 43 patients with basilar artery bifurcation aneurysms who underwent microsurgical clipping at Department of Neurosurgery,the Second Xiangya Hospital,Central South University from April 2011 to April 2018.Of all 43 cases,32 cases had ruptured basilar aneurysms and 11 cases had unruptured basilar aneurysms.According to the different morphological and anatomical locations of aneurysms,17 cases underwent infraorbital approach,26 cases underwent transsyvian approach(including the transorbirozygomatic approach,the'half-half’approach which combined the subtemporal approach with pterion approach and the simple pterion approach)to conduct microsurgical clipping.Intraoperative monitoring was performed using the combination of multiple technologies.Clinical and imaging follow-up was conducted over 6 months post surgery.Results Of all 43 cases with basilar artery bifurcation aneurysms,38 cases were completely clipped,4 cases were partially clipped,and 1 case was wrapped.There were 2 cases(4.7%)of hemiplegia after operation,1 case(2.3%)of coma,14 cases(32.6%)of oculomotor nerve palsy and no death during perioperative period.Thirty-seven patients(86.4%)were followed up for 25.0±10.1 months(range:6 months to 4 years).Among them,35 patients underwent radiographic review without aneurysm residual and 1 patient with partial clipping was treated with second-stage interventional embolization.In 1 case with wrapped aneurysm,the significantly enlargement of aneurysm was not observed in the follow-up image.Of 14 cases with oculomotor nerve palsy after operations,11 were followed up and 8 of them improved significantly afterwards.Glasgow′s outcome scale(GOS)showed that grade V was reported in 34,grade IV in 1 case,grade III in 1 case,grade II in 0 and grade I in 1 case who died from severe pulmonary infection at 42 days post operation.Conclusions The superior treatment of the basilar artery bifurcation aneurysm could be achieved through subtemporal and transsyvian approach.Preoperative evaluation of anatomical and morphological characteristics of aneurysm seems important for the choice of surgical approach.The application of various assistive techniques during surgery is an important part of ensuring the safety of surgery.