大脑中动脉分叉部动脉瘤术中载瘤动脉控制的策略

Surgical strategies of parent artery control for middle cerebral bifurcation aneurysm

目的:探讨大脑中动脉分叉部动脉瘤夹闭术中载瘤动脉(大脑中动脉M1)暴露的策略及对应的外侧裂开放技巧。方法:回顾性分析经显微手术治疗的112例大脑中动脉分叉部动脉瘤患者的临床资料、术前影像学结果及手术方法等。结果:本组患者平均年龄51.2(36~81)岁。女性发病多见,女∶男=1.87∶1。动脉瘤位于左侧者49例,右侧者63例。蛛网膜下腔出血患者42例,占37.5%。脑血管造影前后位和(或)颅脑CT血管造影(CTA)冠状位上患侧大脑中动脉M1段为上凸型的病例最多,有77例(68.8%),其次为直线型24例(21.4%),下凸型有11例(9.8%)。术中从背侧控制M1有75例(67.0%),从腹侧控制M1有37例(33.0%)。上凸型中有63例(81.8%)从背侧控制M1;直线型和下凸型中分别有15例(62.5%)和8例(72.7%)需从腹侧控制M1。本组无手术操作导致的静脉梗塞及未成熟动脉瘤破裂。结论:在上凸型中,大多数病例从背侧控制M1是安全的。在远端外侧裂入路暴露载瘤动脉(M1)困难的情况下,追加近端外侧裂的开放,可以从腹侧控制M1。

Objective:To investigate the surgical strategies for securing the middle cerebral artery(MCA)horizontal segment(M1)and surgical nuances for dissecting the sylvian fissure.Methods:A total of 112 patients with middle cerebral bifurcation aneurysms treated surgically were included.Medical records,preoperative imaging studies,and surgical techniques were reviewed retrospectively.Results:The mean age in our series was 51.2 years(range:36-81 years).There was a female preponderance(female-male ratio=1.87).Of all the 112 cases,49 suffered from left MCA bifurcation aneurysms,while the others(63 cases)suffered from the right side.Subarachnoid hemorrhage was identified in 42(37.5%)patients.The upward convex course of MCA M1 segments was identified in 77 cases(68.8%)based on preoperative digital subtraction angiography(A-P view)or computed tomography angiography(coronal view),followed by the straight M124 cases(21.4%).The down convex M1 segments were found in 11 cases(9.8%).During surgery,M1 were secured from the dorsal side in 75 patients(67%),while the remaining 37 cases(33.0%)were secured from the ventral side.In upward convex group,there were 63 cases(81.8%)in which M1 were secured from dorsal side.Ventral control of M1 were identified in 15 cases(62.5%)in the straight group and 8 cases(72.7%)in down convex group respectively.Neither venous infarction nor intra-operative aneurysm rupture resulting from surgery was found in our cohort.Conclusion:In the upward convex M1 group,proximal control from the dorsal side of M1 can be safely achieved in the majority of cases.Additional proximal sylvian fissure dissection can be applied to secure ventral M1 when it is difficult to control the parent artery in the distal sylvian fissure approach.