颅内镜像动脉瘤17例临床分析

目的 探讨颅内镜像动脉瘤的临床特征和手术方法.方法 解放军第二五一医院神经外科自2006年1月至2010年6月行显微外科手术治疗颅内镜像动脉瘤患者17例,回顾性分析患者的临床资料和疗效.结果 本组动脉瘤直接夹闭35个,未作处理1个,患者行一期手术9例,夹闭动脉瘤20个.二期手术7例,第一次手术夹闭动脉瘤7个,第二次手术夹闭动脉瘤7个.1例患者行一侧动脉瘤夹闭后对侧动脉瘤未处理;11例患者术后行CTA复查,夹闭的23个动脉瘤中2例瘤颈残留,余动脉瘤均消失,载瘤动脉通畅.GOS评分显示恢复优良12例,轻残4例,重残1例.结论 显微外科手术治疗颅内镜像动脉瘤效果显著.正确判断责任动脉瘤并首先处理,根据动脉瘤的部位、Hunt-Hess临床分级及患者周身状况等选择一期、分期手术可达到良好效果.

Abstract：

Objective To study the clinical characteristics and microsurgical skills of intracranial mirror-image aneurysm. Methods The clinical data and post-operative outcomes of 17 patients with 36 intracranial mirror-image aneurysms who underwent microsurgical operation were analyzed retrospectively. Results Thirty-five aneurysms were clipped directly and 1 did not give any treatment. One-time surgery was performed in 9 patients and 20 aneurysms were clipped. Two-stage operation was performed in the other 7 patients: 7 aneurysms were clipped in the first surgery and 7 in the second one. One patient received aneurysm clipping only in one side of the brain. CTA was performed again on 11 patients, noting that residual aneurysm neck of the 2 aneurysms existed in 23 clipped aneurysms, that the other aneurysms disappeared, and that the parent arteries were clear. GOS indicated that good surgical outcomes were achieved in 12 patients, light disability in 4 and severe disability in 1.Conclusion The surgical outcomes of intracranial mirror-image aneurysm performed microsurgical operation are predominance. Criminal aneurysms should be determined correctly and clipped firstly; and according to the sites and grades of the aneurysms and the patient's condition, good outcomes can be achieved by choosing one-time operation or two-stage operation.     

基底动脉顶端动脉瘤的显微手术治疗策略

目的探讨基底动脉顶端动脉瘤的显微外科手术治疗策略。方法回顾性分析2010年1月至2020年1月天津市环湖医院神经外科采用显微手术治疗的55例(共64个动脉瘤)基底动脉顶端动脉瘤患者的临床资料。根据动脉瘤的大小、指向以及瘤颈与后床突的位置关系选择手术入路,分别采用经翼点入路(25例)、经眶颧入路(5例)、经颞下入路(19例)及颞前-经颧-经海绵窦入路(6例)夹闭动脉瘤。采用改良Rankin量表评分(mRS)评估预后;采用CT血管成像(CTA)评估手术夹闭效果。结果55例患者中,动脉瘤完全夹闭46例(83.6%),部分夹闭9例;手术时长为(4.4±1.1)h(2.8~7.1 h)。11例患者术后出现脑缺血症状,其中1例死亡;21例患者出现动眼神经麻痹,其中4例因脑积水行脑室-腹腔分流术。共42例患者获得随访,随访时间为0.8~9.7年(中位时间为4.7年)。42例患者术后6个月随访时的mRS 0分32例,1分4例,2分2例,3分2例,4分1例,6分1例(随访期间因肺栓塞死亡)。CTA随访结果显示,完全夹闭的动脉瘤未见复发,载瘤动脉血流通畅;部分夹闭的动脉瘤均未见瘤体明显增大。结论开颅夹闭手术仍是基底动脉顶端动脉瘤的主要治疗方式。选择个体化的手术入路处理基底动脉顶端动脉瘤,能够获得良好的治疗效果。     

翼点入路手术治疗基底动脉顶端动脉瘤

目的 回顾分析基底动脉顶端动脉瘤的手术方法和疗效.方法 2002年1月至2006年1月手术治疗基底动脉顶端动脉瘤9例,其中男3例,女6例,年龄29～57岁(平均46.6±8.4岁).按照Hunt-Hess分级,Ⅰ级2例,Ⅱ级5例,Ⅲ级2例.全部患者采用翼点入路手术,术后复查脑血管造影,随访2个月-4年(平均19个月).结果 完全夹闭6例,不全夹闭1例,包裹2例.全部病人存活,按照GOS预后分级,Ⅴ级5例,Ⅳ级3例,Ⅲ级1例.结论 掌握手术技巧,熟悉脚间池的区域显微解剖,对具体病人进行个体化设计,是提高基底动脉顶端动脉瘤手术效果的关键.     

颅内动脉瘤的微侵袭手术治疗

目的 探讨颅内动脉瘤微侵袋手术治疗的方法及疗效。方法 对40例颅内动脉瘤患者共42个动脉瘤采用显微手术治疗,其中神经内窥镜辅助显微手术15例,神经导航技术2例,逆向抽吸技术2例。结果 夹闭动脉瘤36个、切除2个、包裹4个。应用内窥镜辅助手术,避免了动脉被误夹及载瘤动脉缩窄;采用逆向抽吸技术治疗2例大型床突旁动脉瘤,1例成功夹闭,另1例阻断失败,压迫颈动脉降低瘤内压后以动脉瘤夹重塑颈内动脉,夹闭瘤颈;神经导航技术准确定位2例末梢动脉瘤后予以切除。结论 显微神经外科技术与神经内窥镜、血管内介入技术及神经导航结合应用,可以有效地提高手术疗效、减少手术损伤。     

Research highlights from the literature

Never a dull moment in perusing the literature! In one study, the investigators tested an artificial baroreflex system in patients undergoing orthopedic surgery. Beat-by-beat blood pressure data was inserted into a computer system that served as an artificial vasomotor center. The vasomotor center regulated epidural catheter electrodes at the level of the lower thoracic spinal chord. The resulting constriction of splanchnic blood vessels attenuated experimental hypotension. In another study, the hypothesis that the sympathetic nervous system modulates granulocyte-colony stimulating factor (G-CSF)-induced release of hematopoetic stem cells from bone marrow was tested. The authors showed that G-CSF induces a bone-specific activation of the sympathetic nervous system. The sympathetic activation improves stem cell release through beta-adrenoreceptor stimulation. A third study tested the hypothesis that disordered sympathetic regulation at the tissue level may contribute to lipodystrophy in HIV patients on highly active antiretroviral therapies. Systemic sympathetic activity was not increased in these patients. However, interstitial norepinephrine was increased, particularly in adipose tissue. Excessive local sympathetic activity might redistribute fat from subcutaneous adipose tissue to other organs and other adipose tissue reservoirs. We can conclude that a machine can operate the baroreflex and that the immune system and adipose tissue will have to react accordingly.     

颅内微型动脉瘤诊断和治疗的临床研究

目的探讨颅内微型动脉瘤的临床特征和治疗方法。方法经DSA确诊的颅内微型动脉瘤（直径〈3mm）21例（22枚）中，1例放弃外科治疗；9例行开颅手术．其中动脉瘤夹闭5例，包裹3例（1例电凝动脉瘤后动脉瘤消失），孤立载瘤动脉（颈内动脉）1例；11例行血管内治疗，其中1例小脑上动脉瘤采用NBCA胶栓塞，10例（11枚动脉瘤）采用微弹簧圈栓塞，其中采用瘤颈成型技术6例（支架辅助2例，双导管技术3例，导丝辅助技术1例）。结果行开颅手术的9例中，死亡1例，治愈4例，好转2例，残废2例；术中动脉瘤破裂2例。行血管内治疗手术的11例中，死亡1例，治愈7例，好转1例，残废2例。血管内栓塞术中动脉瘤破裂2例。结论3D—DSA是诊断颅内微型动脉瘤最有价值的方法，手术和栓塞治疗的风险均较高，但采用适当的技术仍可以取得好的效果。     

High resting level and weak response of baroreflex-governed sympathetic outflow in amyotrophic lateral sclerosis

Both altered sympathetic function and insulin resistance have been observed in amyotrophic lateral sclerosis (ALS). Insulin is a sympathetic stimulator. We recorded muscle sympathetic nerve activity (MSNA) by microneurography in 9 patients with ALS and 9 healthy controls during rest. We also initiated a number of sympathoexcitatory maneuvers, including intake of 100 g of glucose. Patients showed reduced glucose tolerance and a higher heart rate and higher level of MSNA at rest than controls (61.0 ± 15.2 vs. 41.2 ± 5.8 bursts/min, P = 0.006); baroreflex inhibitory influence was present. In contrast, MSNA in ALS patients responded more weakly to maneuvers. This inverse relationship is interpreted as a "ceiling effect," as ALS patients use nearly maximal MSNA capacity already at rest and do not have sympathetic failure. The increased level of MSNA may be a primary feature of ALS, but insulin stimulation may also contribute. Our findings are assessed in relation to previous, sometimes seemingly contradictory observations.     

国际蛛网膜下腔出血动脉瘤试验:栓塞与夹闭后迟发性脑缺血的发生与影响(英文)

Delayed cerebral ischemia(DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage(SAH).We studied differences in incidence and impact of DCI as defined clinically after coiling and after clipping in the International Subarachnoid Aneurysm Trial.We calculated odds ratios(OR) for DCI for clipping versus coiling with logistic regression analysis.With coiled patients without DCI as the reference group,we calculated ORs for poor outcome at 2 months and 1 year for coiled patients with DCI and for clipped patients without,and with DCI.With these ORs,we calculated relative excess risk due to Interaction(RERI).Clipping increased the risk of DCI compared to coiling in the 2,143 patients OR 1.24,95% confidence interval(95% CI 1.01-1.51).Coiled patients with DCI,clipped patients without DCI,and clipped patients with DCI all had higher risks of poor outcome than coiled patients without DCI.Clipping and DCI showed no interaction for poor outcome at 2 months: RERI 0.12(95% CI-1.16 to 1.40) or 1 year: RERI-0.48(95% CI-1.69 to 0.74).Only for patients treated within 4 days,coiling and DCI was associated with a poorer outcome at 1 year than clipping and DCI(RERI-2.02,95% CI-3.97 to-0.08).DCI was more common after clipping than after coiling in SAH patients in ISAT.Impact of DCI on poor outcome did not differ between clipped and coiled patients,except for patients treated within 4 days,in whom DCI resulted more often in poor outcome after coiling than after clipping.     

Differentiation of autonomic nervous activity in different stages of coma displayed by power spectrum analysis of heart rate variability

The analysis of heart rate (HR) variability offers a noninvasive method to investigate autonomic nervous system activity in comatose patients. We analyzed three components of the HR variability in a group of comatose patients: the low-frequency band (LF), representing mainly sympathetic influence, the mid-frequency band (MF), representing sympathetic and parasympathetic influence, and the high-frequency band (HF), representing the parasympathetic influence. A value for sympathovagal balance was defined as LF/HF and MF/HF ratio. Moreover, the skin conductance level (SCL) and the skin conductance resistance (SCR) variability were recorded. The patient group consisted of 22 patients with traumatic brain injuries. Coma depth was assessed by the Glacow Coma Scale and artifact-free HR, SCL, and SCR were measured 75 times in the patient group. The results documented a significant gain in sympathetic nervous system activity corresponding with the state of emerging from coma. This gain was most pronounced in the HF component of the HR and in the sympathovagal balance between LF/HF. The findings in SCL and SCR variability endorsed this result. It is concluded that emerging from coma is accompanied by an increasing influence of the sympathetic nervous system on HR control. This leads to a change in the sympathovagal balance, i.e., a reintegration of parasympathetic and sympathetic activity. Received: 7 February 1996 / Accepted: 8 October 1997     

显微手术治疗颈内-后交通动脉瘤53例

目的探讨显微手术治疗颈内-后交通动脉瘤的方法、时机、并发症以及术中动脉瘤破裂和多发动脉瘤的处理。方法采用常规翼点及其改良入路,显微手术夹闭颈内-后交通动脉瘤51例,其中1例双侧后交通动脉瘤从一侧入路夹闭;行动脉瘤孤立术2例。结果本组51例均顺利夹闭瘤颈。术中有6例出现动脉瘤破裂,其中2例因动脉瘤无法夹闭而行动脉瘤孤立术,1例患者术后死亡,总死亡率1.89%(1/53)。结论显微手术仍具有介入治疗无法替代的优点,早期手术不仅可以降低等待手术期间再次出血的机率,还有利于动眼神经麻痹的恢复。     

Unilateral craniotomy for bilateral cerebral aneurysms

Multiple intracranial aneurysms located bilaterally in the anterior circulation are usually clipped sequentially by separate craniotomies or a bilateral craniotomy. However, in selected patients, bilateral aneurysms can be clipped on both sides in a single sitting through a unilateral approach and unilateral craniotomy without causing morbidity. We present our technique and results of bilateral aneurysms clipped through a unilateral craniotomy from the ruptured aneurysm side. Ten patients (between 2006 and 2008) aged 20 years to 67 years with bilateral supratentorial anterior circulation saccular aneurysms, World Federation of Neurological Surgeons Scale (WFNS) score subarachnoid hemorrhage (SAH) grades 1 and 3, Fisher grades 2 and 3, were operated with unilateral orbito–pterional craniotomy and clipping of bilateral aneurysms. A total of 23 aneurysms, 12 located contralaterally, were successfully clipped with a good outcome in nine patients and no mortality at all. We therefore conclude that the unilateral orbito–pterional approach can be safely employed in selected patients harboring bilateral supratentorial saccular aneurysms and presenting with SAH, having WFNS grade 1 to 3, Fisher grade up to grade 3. The brain must be lax intra-operatively. Wide opening of the basal cisterns, 3rd ventriculostomy, and clipping of ruptured aneurysms are the important steps to be performed first before clipping the contralateral aneurysm thus avoiding a second craniotomy.     

Effect of oxidative stress in rostral ventrolateral medulla on sympathetic hyperactivity after traumatic brain injury

Sympathetic hyperactivity occurs in a subgroup of patients after traumatic brain injury (TBI). The rostral ventrolateral medulla (RVLM) is a key region for the activity of sympathetic nervous system. Oxidative stress in the RVLM is proved to be responsible for the increased level of sympathetic activity in animal models of hypertension and heart failure. In this study, we investigated whether oxidative stress in the RVLM contributed to the development of sympathetic hyperactivity after TBI in rats. Model of diffuse axonal injury was induced using Sprague‐Dawley rats, and level of mean arterial pressure (MAP) and plasma Norepinephrine (NE) was measured to evaluate the sympathetic activity. For the assessment of oxidative stress, expression of reactive oxygen species (ROS), malondialdehyde (MDA), and superoxide dismutase (SOD) in the RVLM was determined. Microinjection of Tempol into the RVLM was performed to determine the effect of oxidative stress on sympathetic hyperactivity. According to the results, TBI led to elevated MAP and plasma NE in rats. It also induced a significantly increased level of ROS, MDA production and decreased level of SOD in the RVLM. The sympathetic activity, ROS, and MDA in the RVLM decreased significantly after microinjection of Tempol. Therefore, the present results suggested that oxidative stress in the RVLM was involved in the development of sympathetic hyperactivity following TBI.     

大脑中动脉动脉瘤的显微手术治疗

目的探讨大脑中动脉（MCA）动脉瘤的临床特点及手术方法。方法回顾性分析108例MCA动脉瘤的临床特点、影像学特征及手术方法。9例未破裂动脉瘤MRI检查表现为中颅窝占位,99例破裂动脉瘤CT检查均示蛛网膜下腔出血。入院时患者Hunt—Hess分级：0级9例,I级3例,Ⅱ级21例,Ⅲ级58例,Ⅳ级15例,V级2例。脑血管造影提示MCA主干动脉瘤10例,分叉部92例,MCA远端6例,均经改良翼点入路进行手术。结果动脉瘤夹闭93例,动脉瘤切除7例,夹闭加包裹8例。2例术前Hunt—Hess分级V级病人,术后1例死亡,1例植物生存;术前Hunt—Hess分级Ⅳ级的15例病人中,11例长期昏迷。随访6～36个月,平均随访14-3个月,按照GOS评定预后,其中5分为40例,4分48例,3分7例,2分12例,1分1例。结论MCA动脉瘤的治疗首选动脉瘤夹闭术,术中保护MCA及保持周围相关血管的通畅是手术的关键。     

前交通动脉瘤显微手术技巧探讨

目的总结显微手术治疗破裂前交通动脉瘤的适应证、手术技巧要点及并发症的防治。方法回顾性分析应用显微手术治疗的36例破裂前交通动脉瘤患者的临床资料。结果本组36例中,33例行瘤颈夹闭满意,2例动脉瘤和前交通动脉一起被夹闭,1例行动脉瘤包裹术。出院时治疗结果好31例,差3例,死亡2例。所有患者术后随访3-36个月均无再出血发生。结论翼点入路手术治疗前交通动脉瘤暴露充分、术式成熟、并发症少;夹闭动脉瘤前充分分离、清晰暴露“H”形的前交通动脉复合体是手术成功的关键;合理的选择动脉瘤夹及血管穿通支的保护尤其重要。     

经一侧翼点入路夹闭1例伴大脑中动脉镜像动脉瘤的多发动脉瘤

目的：总结经右侧翼点入路夹闭合并大脑中动脉镜像动脉瘤的多发动脉瘤的诊治经验。方法回顾性分析1例经右侧翼点入路夹闭双侧大脑中动脉 M1分叉部合并前交通动脉动脉瘤病人的临床资料,并复习文献。结果所有动脉瘤顺利夹闭,术后病人无任何并发症。术后2个月,病人检查发现胃癌,放弃进一步检查和治疗。结论选择合适的病例和手术器械,通过一侧翼点入路夹闭双侧大脑中动脉镜像动脉瘤是可行的。     

Occurrence and impact of delayed cerebral ischemia after coiling and after clipping in the International Subarachnoid Aneurysm Trial (ISAT)

Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). We studied differences in incidence and impact of DCI as defined clinically after coiling and after clipping in the International Subarachnoid Aneurysm Trial. We calculated odds ratios (OR) for DCI for clipping versus coiling with logistic regression analysis. With coiled patients without DCI as the reference group, we calculated ORs for poor outcome at 2 months and 1 year for coiled patients with DCI and for clipped patients without, and with DCI. With these ORs, we calculated relative excess risk due to Interaction (RERI). Clipping increased the risk of DCI compared to coiling in the 2,143 patients OR 1.24, 95% confidence interval (95% CI 1.01–1.51). Coiled patients with DCI, clipped patients without DCI, and clipped patients with DCI all had higher risks of poor outcome than coiled patients without DCI. Clipping and DCI showed no interaction for poor outcome at 2 months: RERI 0.12 (95% CI −1.16 to 1.40) or 1 year: RERI −0.48 (95% CI −1.69 to 0.74). Only for patients treated within 4 days, coiling and DCI was associated with a poorer outcome at 1 year than clipping and DCI (RERI −2.02, 95% CI −3.97 to −0.08). DCI was more common after clipping than after coiling in SAH patients in ISAT. Impact of DCI on poor outcome did not differ between clipped and coiled patients, except for patients treated within 4 days, in whom DCI resulted more often in poor outcome after coiling than after clipping.     

Sympathetic skin responses (SSRs) in monofocal brain lesions: topographical aspects of central sympathetic pathways

Lesions of the central sympathetic pathways are likely to be of clinical relevance. In patients with acute stroke, in particular, they may be responsible for the partially deleterious cardiac arrhythmia. There is little knowledge of the central organization of sympathetic pathways above the brainstem level for both cardio-efferent and sudomotor fibers. We studied the sympathetic skin response (SSR) in 29 patients with brainstem stroke or infarction in the territory of the middle cerebral artery (MCA) in order to evaluate the pathways mediating emotional sweating. In 24 patients (82.8%) the SSR was pathological. These abnormalities were bilateral with no clear asymmetry in 10 patients (34.5%), bilateral with marked contralateral pathology in 8 patients (27.6%), purely contralateral in 5 patients (17.2%) and purely ipsilateral in one patient (3.5%). Bilateral abnormalities were more frequent and more marked in brainstem than in MCA stroke. This is probably indicative of a more generalized sympathetic dysfunction. In contrast, contralateral abnormalities were more pronounced in MCA than in brainstem infarcts. Our results show that sympathetic skin responses are suppressed in the majority of stroke patients. Asymmetric responses may indicate that sudomotor fibers mediating emotional sweating have their origin or receive input from the contralateral MCA territory.     

内镜辅助眶上锁孔入路显微手术治疗前循环动脉瘤

目的探讨内镜辅助眶上锁孔入路显微手术治疗前循环动脉瘤的临床效果及可能存在的风险与对策。方法对28例前循环动脉瘤病人经眶上锁孔入路在显微镜引导下置入内镜观察动脉瘤颈与周围结构的局部解剖关系,辅助分离瘤颈与周边的粘连,夹闭瘤颈,此后再次用内镜观察了解夹闭情况。结果28例动脉瘤均成功准确夹闭,27例恢复良好,1例中残。结论内镜辅助眶上锁孔入路手术可明显增加动脉瘤及周围结构的可视范围,减少对脑组织的牵拉或无效脑暴露,创伤小,减少和避免了重要结构的损伤,并发症少,提高了动脉瘤的手术夹闭率,     

多重术中监护在前交通动脉瘤手术中的应用

目的 探讨经颅多普勒超声、吲哚菁绿荧光血管造影及神经电生理学等多重术中监测技术在前交通动脉动脉瘤显微外科手术中的应用价值.方法 回顾分析23例单发性前交通动脉动脉瘤夹闭术患者的临床资料、手术方式及术中监测过程,改良Rankin量表评分评价术后神经功能缺损程度.结果 23例患者动脉瘤均夹闭成功.其中,6例术中阻断A1段时运动诱发电位出现异常变化.恢复血流待缺血程度改善后继续手术;2例动脉瘤夹闭过程中经颅多普勒超声及吲哚菁绿荧光血管造影分别探及A2段及前交通动脉血流不畅,1例探及动脉瘤瘤颈残留,经调整动脉瘤夹位置后血流恢复或动脉瘤彻底夹闭,1例术后发生短暂性一侧肢体瘫痪,出院时遗留轻度神经功能障碍.改良Rankin量表评分为1分;其余患者术后均未发生脑出血或脑缺血性改变,出院时改良Rankin量表评分为0分.结论 术中多重监测技术可为前交通动脉动脉瘤夹闭术提供A1段临时阻断是否耐受缺血、动脉瘤是否残留,以及载瘤动脉和穿通支是否损伤,继而造成的脑缺血事件等重要信息.从而提高手术安全性.     

颈内动脉大型和巨大型动脉瘤的手术策略

目的探讨颈内动脉巨大动脉瘤的特点和手术策略。方法回顾性分析48例颈内动脉大型和巨大型动脉瘤的手术经验。手术均采用翼点人路，床突旁动脉瘤病例预先暴露颈部颈内动脉以备临时阻断。从硬脑膜内磨除前床突、视神经管上壁以及外侧嵴，以显露动脉瘤的近侧角。术中采用逆向抽吸法使动脉瘤塌陷，如动脉瘤内含机化血栓，则在临时阻断后切开瘤体，用CUSA和取瘤镊去除瘤内血栓，再将动脉瘤夹闭并达到视神经减压的目的。术中监测脑电图和体感诱发电位，并采用术中超声多普勒检查动脉血流。结果46例动脉瘤直接夹闭，2例海绵窦段动脉瘤行动脉瘤孤立并分别做颞浅动脉-大脑中动脉和大隐静脉移植颈外动脉-大脑中动脉搭桥手术。43例术后行DSA检查，绝大多数动脉瘤夹闭满意。按GOS评分术后良好为41例（85．4％），差为5例，死亡2例。结论充分显露、合理应用临时阻断技术、有效的动脉瘤减压，以及术中应用电生理监测和超声多普勒检查等辅助措施，能够取得动脉瘤的满意夹闭。