经额外侧锁孔入路治疗不同分型颈内动脉分叉部破裂动脉瘤的临床分析

Clinical analysis of treatment of different types of ruptured internal carotid artery bifurcation aneurysms via frontolateral keyhole approach

目的探讨经额外侧锁孔入路夹闭不同分型颈内动脉(ICA)分叉部破裂动脉瘤的治疗效果。方法回顾性分析2015年1月至2019年12月徐州医科大学附属连云港医院神经外科收治的28例ICA分叉部破裂动脉瘤患者(共31个动脉瘤)的临床资料。根据动脉瘤瘤颈发出的部位,将分叉部动脉瘤分为3个类型:ICA分叉上方动脉瘤,共5例;ICA分叉下方动脉瘤,共13例;夹角动脉瘤,共10例,其中位于ICA-大脑前动脉(ACA)夹角1例,ICA-大脑中动脉(MCA)夹角1例,ACA-MCA夹角8例。手术均采用额外侧锁孔入路。术中根据动脉瘤的不同分型,采用不同的动脉瘤夹及夹闭方法。夹闭后行吲哚菁绿荧光造影明确动脉瘤、载瘤动脉和分支血管的显影情况。观察围手术期并发症的发生情况。术后9~12个月随访,应用格拉斯哥预后评级(GOS)评估患者的临床预后,以及行影像学检查评估动脉瘤有无残留或复发。结果28例患者均顺利夹闭动脉瘤,术中发现1例脉络膜前动脉不显影(误夹),1例动脉瘤残留,均予以调整动脉瘤夹后,行吲哚菁绿荧光造影未见异常。2例术后头颅CT显示术侧豆纹动脉供血区域梗死,临床表现为对侧肢体偏瘫;1例头颅CT显示脑肿胀,中线结构移位<1 cm,脑干无明显受压表现;3例均行保守治疗后症状好转。随访期无一例出现新发脑梗死或脑积水,动脉瘤无残留或复发。至末次随访,GOSⅤ级25例,Ⅳ级2例,Ⅲ级1例。结论经额外侧锁孔入路手术是治疗不同分型ICA分叉部破裂动脉瘤安全、有效的方法,其并发症少,患者的预后较好。

Objective To investigate the clinical outcomes of microsurgical clipping of different types of ruptured internal carotid artery(ICA)bifurcation aneurysms via frontolateral keyhole approach.Methods A retrospective analysis was conducted on the clinical data of 28 patients with different types of ruptured internal carotid artery(ICA)bifurcation aneurysms(31 aneurysms in total)who were admitted to the Department of Neurosurgery,Lianyungang Hospital Affiliated to Xuzhou Medical University from January 2015 to December 2019.Based on the location of the aneurysmal neck,the aneurysms were categorized into three types as follows:aneurysms above the ICA bifurcation in 5 cases,aneurysms below the ICA bifurcation in 13 cases,aneurysms located at involved angles in 10 cases.Among the 10 cases with aneurysms located at involved angles,there were aneurysms at the ICA-ACA(anterior cerebral artery)angle in 1 case,at the ICA-MCA(middle cerebral artery)angle in 1 case,and at the ACA-MCA angle in 8 cases.All patients underwent microsurgical clipping via frontolateral keyhole approach.Different methods of clipping of ICA bifurcation aneurysms were used based on the different types of aneurysms.After clipping,indocyanine green fluorescence angiography was performed to assess the conditions of aneurysm,parent artery and branch vessels.The occurrence of perioperative complications was observed.The patients were followed up for 9 to 12 months after surgery.The follow-up methods included the Glasgow Outcome Scale(GOS)to evaluate the clinical outcomes of the patients,and the imaging evaluation was used to determine recurrence or residue of aneurysms subtraction angiography.Results The aneurysm was successfully clipped in all 28 patients.During the operation,it was found that the anterior choroidal artery was not visualized in 1 case(caused by misclipping)and there was 1 case of residual aneurysm.For both cases,aneurysm clips were adjusted and no abnormality was found in indocyanine green fluorescence angiography.Postoperative CT showed infarction of the lenticulostriate artery in 2 cases,and the clinical manifestation was hemiplegia of the contralateral limb.One case showed brain swelling,midline structure shift of<1 cm,and no obvious compression of the brain stem.All 3 cases underwent conservative treatment and their symptoms improved after treatment.No newly-developed infarction or hydrocephalus occurred during the follow-up period.The aneurysms did not remain or recur.At the last follow-up,25 cases were GOS gradeⅤ,2 cases were gradeⅣ,and 1 case was gradeⅢ.Conclusion The surgery via frontolateral keyhole approach is a safe and effective treatment for ICA bifurcation aneurysms with few complications and favorable outcomes.