基底动脉顶端动脉瘤的显微外科治疗体会

Experience in the microsurgical treatment of basilar artery bifurcation aneurysms

目的探讨不同手术入路夹闭基底动脉顶端动脉瘤的手术治疗策略及其效果。方法回顾性分析2014年6月至2019年4月十堰市太和医院神经外科采用显微手术治疗的19例基底动脉顶端动脉瘤患者的临床资料。其中未破裂动脉瘤4例,余15例均为破裂动脉瘤。根据动脉瘤的形态及其与后床突的关系等情况采用不同的手术入路,其中10例采用经额眶颧入路,5例采用经翼点入路,4例采用经颞下入路。术中采用吲哚箐绿荧光造影观察手术夹闭的效果,术后次日行CT血管成像复查;术后6个月开始进行随访,采用改良Rankin量表评分(mRS)评估患者的预后。结果19例患者中,动脉瘤完全夹闭17例,动脉瘤包裹加固2例。术后6例患者出现动眼神经麻痹,2例因小脑梗死导致眩晕和小脑性共济失调,1例偏瘫,1例昏迷。其中3例破裂动脉瘤患者术后2个月因脑积水行脑室-腹腔分流术。围手术期无死亡患者。19例患者均获得随访,随访时间为(20.0±8.1)个月(6〜50个月),1例患者于术后37d因肺部感染死亡。18例患者6个月随访时的mRS0〜1分10例,2分3例,3分3例,4分2例。结论开颅夹闭手术是基底动脉顶端动脉瘤的主要治疗方式,临床根据动脉瘤的具体形态学特征选择不同的手术入路,可获得良好的治疗效果。

Objective To explore the surgical strategies of clipping of basilar artery bifurcation aneurysms through various approaches.Methods We retrospectively reviewed the clinical data of 19 patients with basilar artery bifurcation aneurysms who underwent microsurgical clipping at Department of Neurosurgery,Taihe Hospital of Shiyan City from June 2014 to April 2019.Of all 19 cases,15 were ruptured aneurysms and 4 were unruptured.Various surgical approaches were used according to the shape of aneurysm and its relationship with posterior clinoid process.In this series,10 cases underwent transorbitozygomatic approach,5 cases underwent pterional approach,and 4 cases underwent infraorbital approach.The intraoperative indocyanine green(ICG)angiography was performed to confirm the efficacy,and imaging outcome was evaluated by CTA on the 2nd day post operation.Clinical and imaging follow-up was conducted at 6 months post operation.The modified Rankin scale(mRS)was used to assess the outcomes.Results Of all 19 aneurysms,17 cases were completely clipped and 2 case was wrapped and reinforced.Post operation,there were 6 cases of oculomotor nerve palsy,2 cases of cerebellar infarction resulting in vertigo and cerebellar ataxia,1 cases of hemiplegia and 1 case of coma.Three patients with ruptured aneurysms developed hydrocephalus at 2 months after operation and underwent ventriculoperitoneal shunting.No death was reported during perioperative period.All 19 patients were followed up for a period of 20.0±8.1 months(6 to 50 months).One patient died of pulmonary infection at 37 days post operation.The mRS scores of 18 patients were 0-1 in 10 cases,2 in 3 cases,3 in 3 cases,4 in 2 cases and 6 in 1 case at 6 months post operation.Conclusions Craniotomy for aneurysm clipping is the main treatment option for basilar artery bifurcation aneurysms.According to the morphological characteristics of aneurysms,different surgical approaches are selected and relatively good clinical outcomes could be achieved.