原位间置搭桥术治疗颅内复杂动脉瘤18例

目的探讨原位间置搭桥术在颅内复杂动脉瘤中的应用。方法回顾性分析2015年7月至2022年9月,在天津医科大学神经内外科及神经康复临床学院神经外科用原位间置搭桥术治疗的18例颅内动脉瘤患者的临床资料。动脉瘤分别位于大脑中动脉(MCA)14例,大脑前动脉(ACA)2例,小脑后下动脉(PICA)1例,大脑后动脉(PCA)1例;间置移植血管分别取自桡动脉(RA)14例,颞浅动脉(STA)3例,枕动脉(OA)1例;所有患者均行动脉瘤切除后端-端吻合原位间置搭桥,其中间置血管形态为I型13例,V型3例,Y型2例。术后均行数字减影血管造影(DSA)或CTA复查,采用格拉斯哥结果量表(GOS)评估患者预后,并定期采用门诊、电话或网络随访。结果 2例患者术后出现偏瘫;1例出现短暂的失语,3个月后完全恢复;其余15例患者未出现新的神经功能障碍。术后DSA检查结果显示,1个吻合口术后重度狭窄,其余吻合口及移植血管均通畅,所有动脉瘤均未显影;随访3～89个月,无动脉瘤复发,GOS评分5分16例,3分2例。结论原位间置搭桥技术是治疗部分颅内复杂动脉瘤的一种安全有效的选择。     

椎基底动脉分支远端动脉瘤的治疗方法探讨

目的：探讨椎基底动脉分支远端动脉瘤的治疗方法与策略。方法33例患者经全脑血管造影术证实为椎基底动脉分支大脑后动脉、小脑上动脉、小脑前下动脉与小脑后下动脉之远端动脉瘤,分别为8例、6例、9例、10例。其中血管内栓塞治疗29例,直接行开颅动脉瘤夹闭术2例,数字减影血管造影（DSA）与磁共振成像（MRI）三维影像融合数据输入神经导航,在神经导航指引下行开颅动脉瘤灼闭手术1例,1例因血管内栓塞治疗失败未进行手术治疗。结果所有病例无手术相关死亡,2例患者行弹簧圈栓塞术,术后1 d 患者再出血死亡,1例栓塞未成功又未行手术患者病情好转出院,余30例患者未发生术后再出血。结论椎基底动脉分支远端动脉瘤多数手术治疗难度大,应首选血管内栓塞治疗。     

血管内带膜支架技术治疗椎动脉夹层动脉瘤及颈内动脉海绵窦瘘

目的 探讨血管内带膜支架治疗椎动脉夹层动脉瘤和颈内动脉海绵窦瘘(carotid cavernous fistula, CCF)的临床疗效. 方法 2006年3月-2007年5月,采用Jostent带膜支架治疗4例椎动脉夹层动脉瘤以及3例CCF.患者均为男性.椎动脉夹层动脉瘤患者年龄37～57岁;左侧3例,右侧1例.主要症状为突发头痛、呕吐;头部CT均示蛛网膜下腔出血;病程2 d～10年.CCF患者年龄35～51岁;左侧2例,右侧1例.主要症状为头痛,一侧眼球突出、胀痛,球结膜充血伴视力下降;1例有反复鼻腔大出血病史;出现症状前2 d～1个月均有头部外伤史;病程1周～2个月. 结果 椎动脉夹层动脉瘤均完全闭塞,椎动脉保持通畅,附近小脑后下动脉及小脑前下动脉保持通畅;无手术相关并发症发生.4例均获随访,随访时间8个月～2年,无症状复发及颅内再出血.CCF患者瘘口均完全闭塞,颈内动脉保持通畅;术后3 d患者眼球突出及球结膜充血表现均明显改善.3例均获随访,随访时间1～3个月;患侧视力均有不同程度改善. 结论 血管内带膜支架是治疗椎动脉夹层动脉瘤和CCF的有效方法 之一.     

自膨式支架贴覆治疗症状性巨大梭状椎基底动脉瘤

目的 尝试应用自膨式微支架贴覆治疗,以对症状性椎基底动脉巨大梭状动脉瘤提供帮助.方法 回顾性分析2007年10月至2009年10月治疗的5例巨大椎基底动脉梭状动脉瘤病例.经患侧椎动脉途径送入Neuroform支架2枚和LEO支架6枚,分别贴覆成形5例巨大的椎基底动脉梭状瘤,同时对1例合并瘤体破裂局部辅助应用Orbit螺旋圈3枚栓塞止血.结果 5例手术均获成功;随访3～26个月,3例患者后组脑神经损害症状基本消失,1例患者三叉神经痛显著缓解但并发单侧轻偏瘫,1例蛛网膜下腔出血患者无复发迹象.3例获数字减影血管造影复查,2例于术后1个月和4个月复查,影像学显示瘤体原膨大部分缩小并较前形态规则;1例于术后2年复查,显示动脉瘤被支架贴覆部分形态较规则,近端原支架未贴覆到的部分瘤体有轻度扩大.结论 应用自膨式支架贴覆成形治疗症状性椎基底巨大梭状动脉瘤的方法可行,瘤体生长得到控制,近期效果较肯定.     

左小脑后下动脉瘤夹闭术后再出血一例

病情:患者邹荣英,女性,56岁.因“突发意识不清好转后1月余”人院.患者在爬楼梯回家后突发意识不清,伴有非喷射性呕吐,之后出现四肢抽搐伴有大小便失禁,被镇江市康复医院救治,查头颅CT提示:蛛网膜下腔出血,伴有双侧侧脑室及第三、四脑室出血.治疗好转后查脑血管DSA提示:左侧小脑后下动脉瘤.之后为求手术治疗就诊我科.完善术前准备后在全麻下行左侧小脑后下动脉瘤夹闭术,术中见动脉瘤位于小脑后下动脉第5段,约4mm×5mm,呈暗红色,与载瘤动脉稍粘连,暂时阻断载瘤动脉,分离瘤颈后,“迷你夹”夹闭瘤颈.取下暂时阻断夹.见载瘤动脉充盈良好,瘤壁未见明显出血.术后给予抗炎、止血等治疗.术后患者短期内恢复意识,但出现持续低烧,不超多38.5℃.腰椎穿刺脑脊液检查未见明确感染迹象.2周后患者在上厕所后突发非喷射性呕吐,继之出现意识不清,伴有小便失禁,呼吸急浅快.经积极抢救,待患者生命体征平稳后,复查头颅CT提示:原动脉瘤夹周围,小脑内,第三脑室及两侧侧脑室内可见高密度影,考虑出血.入院48天患者复查头颅CT提示:左侧小脑后下动脉瘤夹闭术后脑室系统扩大.在全麻下行右侧脑室-腹腔分流术.术后经积极治疗痊愈出院.     

颅内后循环动脉瘤的显微手术

目的　回顾性分析颅内后循环动脉瘤的临床表现和手术入路。　方法　后循环动脉瘤２０ 例,占同期颅内动脉瘤的９３ ％ ,其中大脑后动脉瘤１２ 例,基底动脉瘤６ 例,小脑前下动脉和小脑后下动脉瘤各１ 例。１６ 例经显微手术,主要经翼点入路和颞下经小脑幕入路。　结果　动脉瘤夹闭加切除８ 例,孤立加切除６ 例,包裹２ 例,血管内治疗２ 例,２ 例未治。１６ 例优良,２ 例轻残,无手术死亡。　结论　后循环动脉瘤大多瘤体较大,瘤内多含血栓。翼点入路对基底动脉远端、大脑后动脉 Ｐ１ ～２ 段动脉瘤显露优良,颞同步入路用于夹闭大脑后动脉 Ｐ２ ～３ 段动脉瘤,显露优良     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

椎动脉重建术后远期疗效的实验研究

为探讨椎动脉重建术的远期疗效，用２３只成年杂种犬制成椎动脉闭塞模型，实施椎动脉颈总动脉端侧吻合重建椎动脉，用定量方法监测术后３个月（远期）疗效。结果表明，术后远期全数字化Ｘ线血管造影仪显示椎动脉吻合口保持通畅，侧支循环已逐步建立；彩色多普勒超声显像仪测得椎动脉内血流的动力保持良好，供血量稳定；氢清除法测得局部小脑血流量较术后５分钟（近期）进一步提高１５．８６％；核磁共振仪示在椎动脉供血区无梗塞灶。认为，椎动脉重建术的远期疗效良好，小脑组织供血远期优于近期     

小脑静脉血管畸形并发反复脑出血一例

患者男性,37岁,因"突发意识障碍伴头痛、呕吐5 h"于2009年10月1日入院.体检:嗜睡,颈强直,脑膜刺激征阳性.四肢肌力、肌张力正常,病理反射未引出.头颅CT示小脑蚓部、第三、四脑室和侧脑室出血.入院后行脱水、止血、补液治疗后病情平稳,意识转清,肢体活动可.头颅MRI示左侧小脑病灶(图1).数字减影血管造影(DSA)示左侧小脑后下动脉较对侧稍增粗,静脉期小脑实质内见一粗大的静脉影及髓静脉,状如"水母头",考虑为血管畸形(图2).     

血管腔内治疗在椎动脉夹层动脉瘤中的应用体会

目的总结血管腔内治疗在椎动脉夹层动脉瘤中的应用体会,探讨不同动脉瘤的治疗策略。方法回顾性分析我科进行血管腔内治疗的10例椎动脉夹层动脉瘤病人的临床资料和治疗效果。结果 10例病人均为椎动脉夹层动脉瘤,其中破裂出血9例,未破裂1例,所有动脉瘤均成功采用血管腔内方法进行治疗:椎动脉内单支架辅助弹簧圈栓塞6例,椎动脉与小脑后下动脉双支架辅助弹簧圈栓塞3例,覆膜支架植入1例。术后因迟发性脑出血及硬膜下血肿死亡1例,发生脑梗塞1例。结论充分分析每个动脉瘤的影像特点,采用个体化的血管腔内治疗方式可以获得满意的治疗效果。     

Management strategy for bilateral complex vertebral artery aneurysms

Bilateral complex vertebral artery aneurysms (BCoVAAns) have no established strategy of management. We retrospectively reviewed five consecutive patients with unruptured BCoVAAns between January 2006 and December 2012. Considering surgical risks of lower cranial nerve (LCN) injuries and eventual growth of an opposite side lesion after unilateral vertebral artery (VA) occlusion, we proposed a strategy of combined open and interventional treatment using revascularization. We applied the following several specific techniques: (1) proximal clipping and occipital artery-posterior inferior cerebellar artery (OA-PICA) and/or superficial temporary artery (STA)-superior cerebellar artery (SCA) bypasses; (2) Distal blood pressure, motor evoked potentials (MEPs), and somatosensory evoked potentials (SEPs) monitoring after parent artery temporary occlusion for safe permanent occlusion of the proximal portions of VA and PICA; (3) V3 to V4 bypass using radial artery (RA) graft with proximal clipping or trapping, two of them combined with OA-PICA bypass; (4) VA fenestration as an opportunity to preserve the flow of the parent artery. Two patients were treated bilaterally and 3 unilaterally, with modified Rankin scale assessed at 39 months postoperatively in average 0 in 2, 1 in 2, and 2 in 1, respectively, and the untreated opposite side lesions without regrowth or bleeding. Two patients with patent V3-RA-V4 bypass complained of dysphagia due to LCN palsies. One of them however suffered a cerebellar infarction due to occlusion of the OA-PICA bypass. When BCoVAAns require surgical treatment, revascularization or preservation of the VA should be considered at the first operation. By doing so, the opposite aneurysm can be effectively occluded by coil embolization, even with VA sacrifice if required.     

Vertebral dissecting aneurysm treated with trapping and bilateral posterior inferior cerebellar artery side-to side anastomosis; case report

A case is reported of ruptured dissecting aneurysm of the intracranial vertebral artery (VA) operated on with VA trapping and bilateral posterior inferior cerebellar artery (PICA) side-to-side anastomosis. A 42-year-old male suddenly developed severe headache and vomiting. On admission, 3 hours later, he was in a state of moderate confusion (Japan Coma Scale 3) and had neck stiffness. Computed tomography (CT) revealed diffuse subarachnoid hemorrhage, especially thick in the posterior fossa with right side dominance. Right vertebral angiography disclosed a fusiform dilatation with proximal narrowing of the right VA which originated just proximal to the VA-PICA junction. Lateral suboccipital craniectomy was undertaken with the patient in a left park bench position. Right VA was dilated and discolored black, and right PICA arose from the proximal portion of this aneurysmal dilatation. Since it was impossible to clip the VA distal to the PICA for the proximal clip-occlusion, the VA including the VA-PICA junction was trapped. Considering the risk of developing infarction at the PICA territory, bilateral PICA was anastomosed at their posterior medullary segment in a side-to-side fashion because the occipital artery (OA) had been cut at the skin incision and could not be used for the OA-PICA anastomosis. The postoperative course was benign, but a mild lateral medullary syndrome developed. CT revealed no abnormal low density area and left vertebral angiography demonstrated the patency of the bypass. Thereafter, the deficit subsided gradually and the patient was discharged. He is presently working without neurological deficit.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dissecting aneurysms of the vertebral artery: a management strategy

OBJECT: The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA). METHODS: Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)-PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA-PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%. CONCLUSIONS: Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.     

Usefulness of V3-Radial Artery Graft-V4 Bypass in Bilateral Fusiform Aneurysms of Vertebral Artery: Case Report

A 55-year-old woman with bilateral vertebral artery (VA) aneurysms was transferred to our hospital. She suffered from a minor stroke. Magnetic resonance imaging (MRI) for the stroke incidentally revealed bilateral VA aneurysms. Due to its size, more observation was recommended, and the patient was found eager to be treated. Both side surgeries were found inappropriate because of severe lower cranial nerve disturbances. The right aneurysm involved the posterior inferior cerebellar artery (PICA) and the V4 segment was deviated to the right side. Therefore, the smaller right aneurysm was treated first with an occipital artery (OA)-PICA bypass and a V3-radial artery graft (RAG)-V4 bypass followed by proximal clipping of the PICA and the right VA. The right VA was successfully remade by RAG and the right aneurysm was not revealed on postoperative examination. By doing so, the opposite aneurysm was able to be eliminated by the parent artery occlusion even by using an interventional radiology (IVR). The V3-RAG-V4 bypass is a useful method for treating bilateral VA aneurysms. This is a new bypass which has not been reported so far to the best of our knowledge.     

Dissecting Aneurysm of the Peripheral Posterior Inferior Cerebellar Artery

Dissecting aneurysms of intracranial posterior circulation have recently been shown to be less uncommon than previously thought. However, those involving the posterior inferior cerebellar artery (PICA) and not vertebral artery at all are extremely rare. We report here a case of a patient with a dissecting aneurysm of the lateral medullary segment of PICA which presented as subarachnoid haemorrhage. The aneurysm was treated by trapping surgery and the distant PICA was anastomosed to the occipital artery. The patient showed a slight ataxia immediately after surgery but recovered fully. Recovery from immediately postoperative cerebellar symptoms due to intra-operative ischemia seemed to be due largely to recovery of flow in the region of cortical branches of PICA.     

Three-dimensional CT angiography for the surgical management of the vertebral artery-posterior inferior cerebellar artery aneurysms

Summary Background. Surgery of vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms is not easy because there is a close anatomical relationship between aneurysms and the surrounding neurovascular structures, and bony structures in the lateral foramen magnum. The preoperative evaluation for a circumstantial comprehension of anatomical relationships is very important for the surgical treatment of the VA-PICA aneurysms. Our experience in using three-dimensional CT angiography (3D-CTA) for the surgical management of VA-PICA aneurysms is herein reported.Methods and findings. We successfully performed neck clipping in 5 cases of VA-PICA aneurysm using 3D-CTA. On 3D reconstructed images, we could see the characteristics of the aneurysms such as their relationships to the jugular tubercle and hypoglossal canal, the projecting direction of the dome, and the configuration of the neck in each case. 3D-CTA also provided a clear surgical view as well as the relationships of the aneurysms to the VA and origin of the PICA. Based on such information, we selected the most appropriate surgical approach among the transcondylar fossa approach, the transcondylar approach, or the far lateral approach with a C1 laminectomy.Conclusions. Since 3D-CTA demonstrates the surgical anatomy of VA-PICA aneurysms in detail, it is very useful for helping surgeons to select the optimal approach.     

Superficial temporal and occipital artery bypass pedicles to superior, anterior inferior, and posterior inferior cerebellar arteries for vertebrobasilar insufficiency

Eighty-three patients underwent 85 intracranial to extracranial pedicle bypass anastomosis procedures to the posterior circulation. There were 15 patients with occipital artery (OA) to posterior inferior cerebellar artery (PICA) anastomosis, 20 patients with OA to anterior inferior cerebellar artery (AICA) anastomosis, and 50 patients with superficial temporal artery (STA) to superior cerebellar artery (SCA) anastomosis. All patients had transient ischemic attacks (TIA's) suggestive of vertebrobasilar ischemia. Twenty-seven patients had crescendo TIA's or stroke in evolution and were considered to be clinically unstable. All patients had severe bilateral distal vertebral artery or basilar artery disease. Twenty-two patients had bilateral vertebral artery occlusion and three had basilar artery occlusion. In this series, 69% had complete resolution of symptoms; the mortality rate was 8.4% and the morbidity rate 13.3%. Clinically stable patients did better than unstable patients. The STA-SCA anastomosis was well tolerated and technically less demanding than the OA-PICA or OA-AICA anastomosis procedures. Patients with symptomatic severe bilateral vertebral or basilar artery disease have a grave prognosis and the option of a surgical arterial pedicle revascularization procedure should be offered to them.     

Dissecting posterior inferior cerebellar artery aneurysm presenting with subarachnoid hemorrhage right after anticoagulant and antiplatelet therapy against ischemic event

BACKGROUND: Dissecting aneurysms with initial ischemic manifestations may present with subsequent subarachnoid hemorrhage (SAH), and their treatment is controversial. This is a case report that illustrates the dilemma when dealing with an immediate post-SAH period dissecting posterior inferior cerebellar artery (PICA) aneurysm initially presenting with an ischemic event. METHODS: We present a 57-year-old man with a dissecting PICA aneurysm who had SAH right after anticoagulant and antiplatelet therapy for cerebral infarction. The aneurysm was not detected by magnetic resonance angiography performed at the time of admission. RESULTS: On admission, he was treated with both anticoagulant and antiplatelet therapy. After the SAH episode, he underwent emergent resection of the dissecting aneurysm and left OA-PICA anastomosis. CONCLUSION: If hemorrhagic transformation occurs at the site of an ischemic dissecting aneurysm, surgical or endovascular intervention should be considered immediately. Although the optimal treatment of dissecting aneurysms with ischemic onset remains controversial, anticoagulant and antiplatelet therapy should not be rejected out of hand.     

Cerebellar hemorrhage after coil embolization for a ruptured vertebral dissecting aneurysm

BACKGROUND: We present a case of ruptured vertebral dissecting aneurysm that exhibited cerebellar hemorrhage after successful embolization of the vertebral artery including the dissected site. CASE PRESENTATION: A 59-year-old man suffered a sudden onset of severe occipital headache when he looked up. Computed tomography demonstrated subarachnoid hemorrhage. Angiography revealed a right vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery. Endovascular embolization of the aneurysm was performed with preservation of the posterior inferior cerebellar artery. The next day, the patient suffered a cerebellar hemorrhage in the vermis. The intracranial pressure was controlled by external ventricular drainage. The patient was discharged with mild cerebellar ataxia and bilateral abducens nerve palsy. CONCLUSION: In a case of vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery, blood circulation in the vertebral arterial system may change after embolization of the aneurysm. In our case, the preserved posterior inferior cerebellar artery might have been hemodynamically stressed postoperatively, resulting in cerebellar hemorrhage. Therefore, strict control of blood pressure is essential in the acute stage after occlusion of the aneurysm.