复合手术术中评估技术在复杂颅内动脉瘤治疗中的应用效果

Application of intraoperative evaluation in hybrid operation of complex intracranial aneurysms:an effect analysis

目的探讨复合手术术中评估技术在复杂颅内动脉瘤治疗中的应用效果。方法回顾性分析2016年11月至2018年12月复旦大学附属华山医院神经外科通过复合手术术中评估技术进行治疗方案调整的20例(共20个动脉瘤)复杂颅内动脉瘤患者的临床资料。20例患者中,8例拟行开颅动脉瘤夹闭术,9例拟行颅内外血管搭桥+动脉瘤孤立或载瘤动脉近端阻断术,3例拟行球囊抽吸辅助动脉瘤夹闭术。术中通过直视观察、数字减影血管造影(DSA)血流分析及神经电生理评估对治疗方案进行了调整和改进。结合动脉瘤的特点分析引起治疗方案调整的原因、调整策略、最终手术结果及预后。预后评估采用改良Rankin量表评分(mRS)。结果20例患者术中调整治疗方案的原因包括:瘤颈钙化无法夹闭2例、近端血流阻断困难2例、动脉瘤残留6例、载瘤动脉狭窄2例、近端阻断或孤立后血流评估8例。其中4例患者改行血管内治疗,5例调整动脉瘤瘤夹的位置,7例改变原有的血流重建方式,3例通过血流阻断试验对近端或远端阻断做出决策,1例加行动脉瘤包裹术。调整治疗方案后,17个动脉瘤达到完全闭塞,3个动脉瘤部分残留。1例破裂动脉瘤患者术后5 d因出现严重的脑血管痉挛而死亡,5例术后出现对侧肢体功能障碍。术后6个月随访时,19例患者均未出现新发神经功能障碍,但1例海绵窦巨大动脉瘤术后残留者的动脉瘤复发。mRS 0分14例,3分1例,4分3例,5分1例。结论采用复合手术术中评估技术能够及时发现术中异常,并进行精准血流评估,可帮助优化治疗方案,改善患者的预后。

Objective To explore the value of hybrid intraoperative evaluation technique in treatment of complex intracranial aneurysms.Methods A retrospective analysis was conducted on the clinical data of 20 patients with 20 complex intracranial aneurysms who underwent adjustment of treatment strategy based on intraoperative evaluation during hybrid operation at Department of Neurosurgery,Huashan Hospital,Fudan University between November 2016 and December 2018.For the 20 patients,the original surgical plan included craniotomy plus aneurysm clipping(8 cases),extracranial-intracranial bypass plus aneurysm trapping or proximal occlusion of parent artery(9 cases)and balloon-assisted clipping(3 cases).Those plans were adjusted according to the results of intraoperative evaluation such as morphological observation,blood flow analysis by DSA and neurophysiological monitoring.The cause of adjustment,corresponding strategies,surgical results and outcome were analyzed according to the characteristics of aneurysms.The outcome was evaluated based on the modified Rankin scale(mRS).Results Among the 20 cases,the causes of adjustment included calcification in the aneurysm neck resulting in clipping failure(2 cases),difficulty in proximal occlusion of blood flow(2 cases),aneurysm residue(6 cases),parent artery stenosis(2 cases)and blood flow evaluation after proximal occlusion or trapping(8 cases).The surgical strategy was changed to endovascular embolization in 4 cases,the site of aneurysm clipping was adjusted in 5,the pattern of blood flow reconstruction was changed in 7,the choice of proximal occlusion or distal occlusion was made based on intraoperative blood flow occlusion test in 3,and additional aneurysm wrapping was applied in 1.There were 17 aneurysms completely occluded and 3 aneurysms which had partial residue.One patient with ruptured aneurysm died at 5 days post operation due to severe cerebral vasospasm.Five patients developed dysfunctions in the contralateral limbs post operation.No newly-developed neurologic dysfunction was reported in 19 patients at 6 months after operation.Aneurysm recurrence was indicated in 1 patient with giant cavernous sinus aneurysm who had residue post operation.The mRS score was 0 in 14 patients,3 in 1,4 in 3 and 5 in 1.Conclusion Under a hybrid operation mode,intraoperative evaluation could timely reveal intraoperative abnormalities,provide accurate blood flow assessment,help optimize the surgical strategy and thus improve the patient′s outcome.