颈动脉体瘤的诊断与手术治疗

目的：探讨颈动脉体瘤的临床特点、诊断和治疗方法,以利于提高诊断和治疗水平。方法：回顾21例（23侧）颈动脉体瘤患者的临床资料,包括术前检查、手术方法和要点及术后处理。结果：DSA和MRI对颈动脉体瘤的确诊率达100%。17例（19侧）接受手术治疗,其中动脉外膜下分离单纯颈动脉体瘤切除术8侧,肿瘤并颈外动脉节段切除术9侧,颈动脉体瘤和颈总动脉分叉并颈内外动脉节段切除及颈动脉结扎1侧,颈动脉体瘤和颈动脉切除及人工血管重建颈动脉1侧。术后1例患者术前药物治疗未控制的室性心律失常自愈;1例出现声嘶,1周后完全恢复;1例颈动脉切除未重建的患者,术后出现经常性头痛,3个月后逐渐消失;其余患者无明显并发症。结论：DSA和MRI是目前诊断颈动脉体瘤的最佳手段。外科切除是首选的治疗措施,肿瘤和颈总动脉分叉及颈内动脉节段切除后,人工血管重建颈动脉是一种安全、有效的治疗方法。     

颈动脉体瘤的个体化序贯治疗应用评价

目的探讨颈动脉体瘤的个体化序贯治疗。方法回顾性分析1999年1月～2009年7月诊治的23例(29侧)颈动脉体瘤患者,其中单侧颈动脉体瘤17例,双侧6例;经确诊后采用术前Matas试验-BOT试验-手术的序贯治疗方式。手术方法包括瘤体剥脱、瘤体与颈外动脉同时切除、颈内动脉切除后颈外动脉与颈内动脉远心端吻合或颈内动脉自体血管重建及颈内动脉单纯结扎。结果患者术前Matas试验结果:能持续按压阻断30 min无特殊不适者1周内17侧、2周内26侧、4周内29侧。其中2例女性患者在通过Matas训练后,于术前行BOT试验检测时出现阳性反应。所有患者颈动脉体瘤11侧肿瘤切除后动脉完好,5侧肿瘤切除同时结扎颈外动脉,6侧肿瘤切除后行颈内动脉破损直接修补,2侧肿瘤行颈外动脉与颈内动脉对端吻合,3侧肿瘤取大隐静脉及1侧取颈外静脉行颈总,颈内动脉搭桥,1侧单纯结扎颈内动脉。术后患者出现局灶性脑梗塞1例,Horner综合征5例,迷走神经麻痹6例,舌下神经麻痹3例,面神经麻痹2例,副神经麻痹1例。采用静脉重建的颈内动脉术后3～6个月复查彩超均见重建血管通畅。结论术前Matas试验-BOT试验-手术的序贯治疗方式能有效促进大脑侧枝循环建立;该序贯治疗对术中颈动脉重建是否需要采用转流手术方式提供准确依据,术中颈动脉破裂后单纯颈动脉修补及颈外动脉与颈内动脉端端吻合均不需要行颈动脉转流;仅行大隐静脉搭桥重建颈内动脉时才需要转流手术。颈动脉体瘤的个体化序贯治疗不仅避免了不转流导致造成脑缺血而产生偏瘫、昏迷等严重并发症,而且减少了盲目使用转流管所带来的血管损伤、血栓形成等风险及相关材料的浪费。     

上纵隔暴露术在颈部晚期癌手术中的应用

目的　研究累及颈根部和上纵隔区域的颈部晚期肿瘤根治性手术的方法。方法　 1992～ 1999年对 18例颈部晚期癌行不同方式的上纵隔暴露术和肿瘤根治性切除术。其中晚期气管造口复发癌 10例 ,晚期复发甲状腺癌 2例 ,晚期颈段气管癌 2例 ,锁骨上巨大转移癌 4例。根据肿瘤的部位和侵及范围行单纯胸骨柄切除 10例 ,切除一侧胸锁关节和锁骨内侧 1 2者 4例 ,切除胸骨柄和双侧锁骨内侧 1 3者 4例。其中 1例锁骨上窝肿瘤因其侵犯左侧锁骨下动脉而实行了锁骨下动脉部分节段性切除加肿瘤全切除和人工血管锁骨下动脉重建术。对 10例气管造口复发癌在肿瘤切除后以胸大肌肌皮瓣修复局部大块组织缺损 ,覆盖并保护下颈部和上纵隔大血管。结果　通过上纵隔暴露与清扫术 ,16例患者的肿瘤得以完整切除。 2例因肿瘤在上纵隔内过度向后下延伸而行大部分切除术 ,其中 1例在分离肿瘤时术中发生气胸。术后 2例发生咽瘘 ,其中 1例因伤口感染发生右侧颈总动脉假性动脉瘤 ,均经及时处理后治愈。 1例于术后 2个月发生无名动脉出血死亡。术后 1年、2年和 3年生存率分别为 72 2 % ( 13 18)、2 2 2 % ( 4 18)和 11 1% ( 2 18)。结论　上纵隔暴露术对切除累及上纵隔的颈部晚期癌是一种必要、安全和可靠的手术路径     

肿瘤累及颈动脉的外科治疗

目的 探讨颈部肿瘤累及大血管的手术中血管处理方法及注意事项.方法 分析8例颈部肿瘤累及颈动脉患者一期整块切除肿瘤及颈动脉以及颈动脉重建手术的方法、效果和术后并发症.结果 患者均在颈动脉转流(颈总动脉-颈内动脉)下切断颈总动脉及颈内动脉,行颈部清扫手术或肿瘤切除术.2例患者采用膨体聚四氟乙烯(expanded polytetrafluoroethylene,ePTFE)人造血管移植,6例患者采用自体大隐静脉移植.全组患者无缺血性脑卒中发生.2例患者术后发生伤口感染,再次手术探查发现均有咽瘘发生.结论 采用术中转流、肿瘤连同受累颈动脉整块切除、颈动脉重建的方法治疗累及颈动脉的颈部进展期肿瘤安全有效并可明显改善患者生活质量.移植血管首选自体静脉.应特别注意防止术后感染.对于手术后局部组织广泛切除,移植血管床无软组织填充、血液供应及侧支循环差或已经暴露咽腔者,应采用转移肌皮瓣覆盖.     

侵犯喉气管或/和下咽颈段食管的甲状腺癌的外科治疗

目的探讨侵犯喉气管或/和下咽颈段食管的甲状腺癌的有效治疗方法。方法对21例伴气管或/和下咽、颈段食管受侵的甲状腺癌患者行Ⅰ期肿瘤扩大根治切除。21例患者均有不同程度喉或气管受侵犯,其中4例同时伴有下咽侵犯,11例伴有颈段食管侵犯。所有病例根据原发肿瘤大小及侵犯范围行甲状腺癌根治切除、受侵器官的扩大切除及功能修复术。其中16例术后病理为乳头状癌行131Ⅰ辅助治疗;差分化癌3例,髓样癌2例,术后辅助放疗,放疗剂量60GY。结果 21例患者手术顺利,术后病理乳头状腺癌16例,髓样癌2例,差分化腺癌3例。本组病例中有11例术后行气管造瘘,3个月后,有7例去除气管套管。1例术后食道瘘伴颈部感染行换药处理后清创加食道修补术后痊愈;5例手术后发生暂时的低钙抽搐,补钙后控制;1例复发再手术病例术后发生永久性的低钙抽搐,1年后死于颈部大出血;1例术后6年,发现肺部转移,带瘤生存2年死亡;1例1年半后死于颈段食管局部复发。术后随访1~10年,5年生存率92.3%。结论对于侵犯喉气管或/和下咽颈段食管的晚期甲状腺癌患者积极的手术切除及修复重建并配合个体化辅助治疗,可以提高患者的治愈率,延长生存时间,提高生活质量。     

颈动脉体瘤2例诊治体会

1　临床资料例 1:患者男 ,36岁。因右上颈部无痛性肿块缓慢生长 1年入院。查体 :右颈动脉三角区 5ｃｍ× 5ｃｍ大小搏动性肿块 ,未闻及血管杂音 ,触压肿块可引起呛咳。右颈总动脉造影 :颈总动脉分叉处微血管团块影 ,结构模糊 ,颈内动脉虹吸部及大脑前、中动脉各分支未见异常。初步诊断 :颈部肿块性质待查 (右颈动脉体瘤 ,神经鞘瘤 )。手术治疗 :术中见肿瘤包绕颈总动脉分叉及颈内、外动脉 ,解离肿瘤失败 ,结扎颈总动脉 ,整块切除肿瘤。术后对侧偏瘫、失语 ,呛咳 ,患侧面瘫、舌瘫。术后 2个月 ,面瘫及舌瘫恢复。术后 1年 ,偏瘫恢复 ,可胜任一…     

上纵隔暴露术在颈部晚期癌手术中的应用

目的 研究累及颈根部和上纵隔区域的颈部晚期肿瘤根治性手术的方法。方法 1992～1999年对18例颈部晚期癌行不同方式的上纵隔暴露术和肿瘤根治性切除术。其中晚期气管造口复发癌10例，晚期复发甲状腺癌2例，晚期颈段气管癌2例，锁骨上巨大转移癌4例。根据肿瘤的部位和侵及范围行单纯胸骨柄切除10例，切除一侧胸锁关节和锁骨内侧1／2者4例，切除胸骨柄和双侧锁骨内侧1／3者4例。其中1例锁骨上窝肿瘤因其侵犯左侧锁骨下动脉而实行了锁骨下动脉部分节段性切除加肿瘤全切除和人工血管锁骨下动脉重建术。对10例气管造口复发癌在肿瘤切除后以胸大肌肌皮瓣修复局部大块组织缺损，覆盖并保护下颈部和上纵隔大血管。结果 通过上纵隔暴露与清扫术，16例患者的肿瘤得以完整切除。2例因肿瘤在上纵隔内过度向后下延伸而行大部分切除术，其中1例在分离肿瘤时术中发生气胸。术后2例发生咽瘘，其中1例因伤口感染发生右侧颈总动脉假性动脉瘤，均经及时处理后治愈。1例于术后2个月发生无名动脉出血死亡。术后1年、2年和3年生存率分别为72．2％(13／18)、22．2％(4／18)和11．1％(2／18)。结论 上纵隔暴露术对切除累及上纵隔的颈部晚期癌是一种必要、安全和可靠的手术路径。     

一期结扎切除双侧颈内静脉治疗累及颈内静脉的恶性肿瘤

目的:探讨颈部恶性肿瘤侵及双侧颈内静脉可否一期切除双侧颈内静脉提高肿瘤切除的彻底性并避免二次手术.方法:总结1992至1998年5例保留颈前静脉及颈外静脉一期切除双侧受颈部恶性肿瘤侵及的颈内静脉的临床资料,5例中喉癌4例,下咽癌1例.结果:双侧颈内静脉结扎的5例全部保留双侧颈外静脉及颈前颈脉,结扎切除双侧颈内静脉.术后24h内面部稍肿胀,4～6d肤色转为正常,无严重并发症出现.5例患者随访5～18个月.存活18个月2例,10个月1例,8个月1例,死亡原因为癌复发及颈动脉破裂.1例随访6个月,健在,偶有头晕及直立性晕厥.结论:保留颈前静脉及颈外静脉一期结扎双侧颈内静脉是可行的.     

头颈部癌的颈动脉重建

对头颈部癌侵及颈动脉2例,施行扩大的颈部廓清术,切除和重建颈动脉。 病例1,49岁,男性。喉癌术后,因右颈部淋巴结转移,颈部超声波检查,右颈深部有边缘不整,内部回声不均,的肿物,颈总动脉壁听     

头颈肿瘤术后并发颈动脉破裂4例报告

目的：探讨头颈部恶性肿瘤侵犯颈动脉的手术治疗方法。方法：对4例颈动脉与转移瘤粘连患者，采用从颈动脉壁上剥离切除肿瘤保留血管的术式。结果：术后1周内4例都发生了颈动脉破裂，1例经颈动脉修补术后再发血管破裂出血死亡，3例经行颈动脉结扎术后存活。结论：对于肿瘤累及颈动脉的患者术前应作好结扎切除颈动脉的准备；术中若发现肿瘤与血管壁粘连，则应结扎血管连同肿瘤一并切除；一旦术后并发颈动脉破裂，则应结扎之，而不宜行修补术。     

A case of bilateral nontraumatic internal carotid aneurysms presenting with recurrent massive epistaxis]

A case of bilateral nontraumatic internal carotid aneurysms presenting with recurrent massive epistaxis was reported. A 37-year-old female complaining of massive epistaxis from the left nostril was admitted to our hospital. After admission, she experienced recurrent massive epistaxis, but had no cranial nerve palsies. Carotid angiography demonstrated an aneurysm of the cavernous portion of the left internal carotid artery partially protruding into the sphenoid sinus. Neck clipping of the aneurysm was unsuccessful, therefore the left internal carotid ligation in the neck was performed with a Selverstone clamp. After the ligation, no rebleeding and neurological deficits occurred. Postoperative carotid angiography showed an aneurysm of the right internal carotid artery at the same site. The carotid angiography of 3 months later and 1 year and 3 months later revealed that the left aneurysm decreased in size and the right one remained unchanged. Twenty-one cases including ours that presented nontraumatic internal carotid aneurysm of the cavernous portion were reviewed. Twelve cases had no cranial nerve palsies, and 7 cases including ours had no other symptoms than massive epistaxis. Because massiveness of epistaxis from an internal carotid aneurysm often threatens one's life, diagnosis should be made by carotid angiography as soon as possible. There are several surgical procedures for such aneurysms. Clipping is the ideal method which can interrupt the blood flow to the aneurysm completely, but it is very difficult to be performed anatomically. Carotid ligation in the neck with little surgical invasion was an excellent method in 7 cases without rebleeding and neurological deficits. Bilateral intracavernous internal carotid aneurysms were found in our case and another case.(ABSTRACT TRUNCATED AT 250 WORDS)     

颅内段颈内动脉创伤的诊断及血管内治疗

目的 探讨颅内段颈内动脉创伤的诊断和血管内治疗的临床价值.方法 11例颅内段颈内动脉病变的患者应用选择性全脑造影进行诊断,10例行颈内动脉栓塞治疗.所有资料采用回顾性分析.结果 3例颈内动脉假性动脉瘤,4例颈内动脉-海绵窦瘘,1例颈内动脉假性动脉瘤伴颈内动脉-海绵窦瘘及1例巨大蛇形动脉行球囊颈内动脉完全性栓塞,1例颈内动脉-海绵窦瘘行电解可脱式弹簧圈保留颈内动脉栓塞,1例放弃治疗.随访4个月～7年,1 0例颈内动脉病变的患者痊愈.结论 选择性全脑造影是外伤性颈内动脉损伤首选诊断方法,血管内治疗安全有效.     

Contrasting radiological presentation of cervical sympathetic chain schwannoma: Case series of two cases

Splaying of carotid bifurcation on imaging, known as Lyre sign, is seen characteristically in carotid body tumors. Is positive Lyre sign always confirmatory of carotid body tumor? Here we discuss two cases of cervical sympathetic chain schwannoma. The first case presented radiologically as an enhancing lesion with splaying of external carotid artery and internal carotid artery (positive Lyre sign) and misled us to the diagnosis of carotid body tumor. The second case presented as an enhancing lesion causing anterior displacement of external carotid artery and internal carotid artery (negative Lyre sign). Both lesions were confirmed as cervical sympathetic schwannoma. Post-operatively both patients developed Horner's syndrome. Lyre sign is not always confirmatory of carotid body tumor.     

血管结扎术治疗颈部血管破裂

目的探讨恶性肿瘤侵犯颈总动脉、颈内动脉致动脉破裂后紧急行单纯血管结扎术的应用价值及并发症分析。方法回顾分析1989年11月～2004年5月间病例共11例(发生破裂为13例次),其中喉咽癌1例,鼻咽癌1例,食管癌2例,喉癌4例(1例喉癌反复破裂3次),口颊癌1例,甲状腺癌2例;有放疗病史9例,最大剂量130Gy：合并咽瘘7例。颈总动脉破裂10人次,颈内动脉破裂3人次。全部病例均是肿瘤复发患者,为动脉破裂后行紧急结扎止血。4例颈总动脉破裂者行术中残端血管测压。术后随访3个月～3．5年。结果颈总动脉结扎10例次,颈内动脉结扎3例次：其中1例喉癌第1次颈总动脉结扎后无并发症,18天后远心残端破裂行颈内动脉结扎,术后6小时出现轻度偏瘫;其他均无偏瘫、失语、精神障碍、肢体运动障碍等并发症。4例行术中颈动脉残端测压者其残端血压与动脉压之比值均＞50%。结论①恶性肿瘤侵犯颈总动脉、颈内动脉后由于血管长期受压,脑血流代偿多已形成,单纯结扎血管并发症少,是一可行紧急处理方案;②术中残端血管测压对治疗方案的选择及预后有重要价值。     

Radiation-induced petrous internal carotid artery aneurysm

Iatrogenic internal carotid artery aneurysm is a rare complication of irradiation. There are few reported cases in the literature. A case of radiation-induced petrous internal carotid artery aneurysm in a patient with nasopharyngeal cancer treated with radiotherapy is reported. The approach to managing such an aneurysm is discussed.     

恶性肿瘤累及颈动脉的外科处理

为探讨头颈部恶性肿瘤侵犯颈动脉的外科治疗，对５例喉癌或下咽癌颈淋巴结转移累及一侧颈动脉病人，术前经ＣＴ或Ｂ超检查，３例经术前体外颈动脉压迫训练合格后手术切除受累段颈总动脉，２例系术中损伤颈总动脉后紧急切除受轻动脉。其中１例即刻行断端吻合，５例术中，术后均无明显脑缺血表现，３例术后随访２年以上健在，２例尚在随访中。     

Angiography of the carotid artery in centro-lateral skull base fractures?

BACKGROUND: In latero-basal, central or spheno-fronto-orbital skull base fractures the internal carotid artery is more frequently involved in severe lesions than expected. PATIENTS AND METHODS: Between 1996 and 2003 we examined 684 patients with Glasgow Coma Scales (GCS) between 2 and 15, median 7.2, using computed tomography (CT). In suspicion of a latero-basal, central or spheno-fronto-orbital fractur they got an additional high resolution skull base CT. If the bony canal of the internal carotid artery (ICA) was involved the patient underwent digital subtraction angiography (DSA). The ICA lesion was treated either interventional neuroradiologically, by surgery or only conservatively. RESULTS: Of the 684 patients 33 (4.8 %) had fractures of the ICA bony canal and therefore underwent DSA. Among them were 25 men and 8 women (mean age 35.3 years). Lesions of the ICA were seen in 1.9 % of the patients. A traumatic cavernous-carotid fistula was found in 7 patients (1 %) and in 6 patients (0.9 %) a dissection and/or an aneurysm of the ICA was diagnosed. Six of the patients had clinical symptoms. The lesions were treated primarily interventional neuroradiologically (n = 5) as well as surgically in two cases by clipping the aneurysm and closing the sphenoid sinus, respectively. CONCLUSIONS: Vessel lesions of the ICA in skull base fractures and involvement of the bony carotid canal are more frequent than mentioned in current literature. A solid diagnosis can only be achieved by DSA. Early diagnosis and treatment is important for improving the prognosis of these often multiply injured patients.     

Aneurysm of the extracranial carotid artery

Aneurysms of the extracranial carotid artery are rare vascular lesions. These aneurysms usually present to the otolaryngologist or vascular surgeon as a cervical or parapharyngeal pulsatile mass. Rupture and hemorrhage are unusual complications. Central nervous system symptoms secondary to embolism or thrombosis, however, are relatively common. Because of these serious complications, surgical resection of the aneurysm with restoration of arterial continuity is the treatment of choice. We describe herein three cases of the extracranial carotid aneurysm treated at the Mie University Hospital, Tsu, Japan, in the past two years. Surgical treatments include end-to-end anastomosis, saphenous vein autograft replacement, and direct closure utilizing an internal shunt, respectively, after resection of the aneurysm. In all patients, the postoperative course was uneventful, and angiography six weeks after the operation demonstrated good blood flow through the repaired artery.     

Intratemporal carotid artery bypass in resection of a base of skull tumor

Tumors of the skull base with carotid artery involvement have heretofore required carotid ligation or been deemed inoperable. Two case reports are presented in which en bloc resection of malignant base of skull tumors included removal of a portion of the internal carotid artery. In the first case, the tumor was primarily in the parapharyngeal space and extended to the base of skull. Partial temporal bone resection was carried out to obtain exposure for carotid reconstruction. The second case involved an en bloc temporal bone resection for a recurrent, malignant, mixed tumor that had invaded the carotid canal. Revascularization was achieved in both cases by an autogenous, saphenous vein graft. The patients suffered no postoperative ischemic neurologic sequelae. These are the first known cases of a carotid bypass with distal anastomosis to the intratemporal portion of the internal carotid artery for a malignant base of skull neoplasm. The authors propose this procedure as an alternative to carotid ligation during surgery of tumors of the skull base requiring carotid resection.