翼点入路夹闭低分级后交通动脉瘤术中动脉瘤破裂出血的预防及手术策略

Prevention and surgical strategy of low-grade posterior communicating artery aneurysm rupture and bleeding by clipping via pterional approach

目的探讨翼点入路夹闭低分级(Hunt-Hess 0~Ⅲ级)后交通动脉瘤术中动脉瘤破裂出血的预防及手术策略。方法回顾性分析2013年8月至2020年3月我院收治的38例行翼点入路夹闭治疗的后交通动脉瘤患者的临床资料。所有术中动脉瘤破裂患者于术后1、3、6个月及每年以电话及门诊复查的方式随访,复查头颅CT、CTA或DSA,采用Glasgow评分评估预后。结果本研究38例患者行翼点入路夹闭后交通动脉瘤过程中,15例(39.5%)出现动脉瘤破裂出血,其中动脉瘤暴露前破裂3例(7.9%),分离动脉瘤过程中破裂10例(26.3%),动脉瘤夹闭过程中破裂2例(5.3%)。住院期间3例患者出现脑积水,行脑室-腹腔分流术后好转;2例患者术后出现肢体偏瘫;1例患者出现感觉性失语;1例患者术后CT提示脉络膜前动脉供血区梗塞,经CTA予以证实;其余患者好转。Glasgow评分显示:术中动脉瘤破裂的15例患者中,5例术后恢复良好,3例轻度残疾,4例重度残疾,2例植物生存,1例死亡。结论采用翼点入路处理低分级后交通动脉瘤时,充分的术前评估及精细规范的术中操作可降低术中动脉瘤破裂出血的概率。一旦术中破裂出血需要及时妥善处理,以减少并发症,提高患者预后。

Objective To study the prevention and surgical strategy of low-grade(Hunt-Hess grade 0 toⅢ)posterior communicating artery aneurysm rupture and bleeding by clipping via pterional approach.Methods The clinical data of 38 patients with posterior communicating artery aneurysm who underwent surgical clipping via pterional approach in our hospital from August 2013 to March 2020 were retrospectively analyzed.All patients with intraoperative aneurysm rupture were followed up at 1,3,and 6 months and annually after surgery by telephone and outpatient review.Cranial CT,CTA,or DSA were reviewed,and Glasgow score was used to assess the prognosis.Results Among 38 patients with posterior communicating artery aneurysm underwent surgical clipping via pterional approach,15 cases(39.5%)had rupture and bleeding,of which 3 cases(7.9%)had rupture before exposure,10 cases(26.3%)had rupture during aneurysm separation,and 2 cases(5.3%)had rupture during aneurysm clipping.During the hospitalization period,3 patients developed hydrocephalus and improved after ventriculoperitoneal shunt,2 patients developed hemiplegia,1 patient developed sensory aphasia,postoperative CT showed that 1 patient had anterior choroidal artery infarction,which was confirmed by CTA,the rest patients improved.Glasgow score showed that among 15 patients with intraoperative aneurysm rupture,5 patients recovered well after operation,3 patients with mild disability,4 patients with severe disability,2 patients with plant survival,1 patient died.Conclusion In the treatment of low-grade posterior communicating artery aneurysm by pterional approach,adequate preoperative evaluation,and precise and standardized intraoperative operation can reduce the rate of intraoperative aneurysm rupture and bleeding.Once intraoperative aneurysm rupture and bleeding,timely and proper treatment is required to reduce complications and improve the prognosis of patients.