椎基底动脉瘤的手术治疗

目的 探讨手术治疗椎基底动脉瘤的方法.方法 26例28个椎基底动脉瘤患者.动脉瘤破裂出血9例;16例基底动脉瘤,10例椎动脉瘤.5例基底动脉顶部动脉瘤经翼点入路,5例基底动脉顶部和2例基底动脉上段动脉瘤用额颞颧(切断颧弓、扩大中颅窝底)入路,4例基底动脉中段动脉瘤采用乙状窦前(岩骨)和远外侧联合入路.10例椎动脉瘤中,4例椎动脉瘤采用乙状窦前(岩骨)和岩骨联合入路,6例取用远外侧-枕骨髁联合入路.11例术中临时阻断血管时间延长或可能影响开通血管患者行血管搭桥术,其中颈内动脉大脑后动脉P2段移植搭桥2例,颈外动脉与大脑后动脉P2段移植搭桥4例,椎动脉移植搭桥2例,枕动脉与小脑后下动脉搭桥3例.结果 术后恢复正常工作,无神经功能障碍者:基底动脉顶端动脉瘤9例,基底动脉干动脉瘤5例,椎动脉瘤10例,良好率为92%.1例基底动脉顶端动脉瘤患者术后有严重神经功能缺失,生活不能自理;1例基底动脉主干动脉瘤术后穿通动脉闭塞引起中脑缺血,术后20 d死亡.结论 选择适合的颅底手术入路有利于术中获得充分的手术操作空间.对于单纯手术夹闭困难的动脉瘤,用血管移植搭桥的方法,可以避免因夹闭动脉瘤和临时阻断载瘤动脉出现术后脑缺血.

Surgical clipping of vertebral and basilar artery aneurysms

Objective To study an effective method for clipping vertebral and basilar artery aneurysms. Method There were 26 patients with 28 aneurysms of vertebral and basilar arteries. Aneurysms ruptured in 9 patients,the aneurysms in 16 patients were located in basilar artery including two aneurysms in one patient,and 10 aneurysms were located in vertebral artery including bilateral vertebral artery aneurysms in one patient and vertebral AVMs in one patient. Pterional approach underwent in 5 patients with basilar tip aneurysms,orhitozygomatic approach in 5 patients with basilar tip aneurysms and 2 patients with the upper basilar aneurysms, combination of presigmoid with far-lateral approach in 4 patients with mid basilar aneurysms. Of 10 patients with aneurysms of vertebral arteries, combination of far lateral with transpetrosal approaches were performed in 4 patients and combination of far lateral with condylar approaches in 6 patients. In 11 patients with bypass grafts because of the likehood of prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice, the internal carotid artery to P2 segment of posterior cerebral artery bypass were performed in 2 patients, the external carotid artery to P2 segment of posterior cerebral artery bypass were performed in 4 patients, cervical vertebral to cranial vertebral artery bypass in 2 patients,and occipital to PICA bypass in 3 patients. Results There were back to normal life without neurological deficits after surgery in 9 patients with basilar tip aneurysms, 5 patients with basilar trunk aneurysms,and 10 patients with vertebral artery aneurysms. Total good outcome reached 24 (92%) patients after surgery. One patient need assistant for his daily life related to severe neurological deficits after surgery, one patient with basilar trunk aneurysm die of brain stem ischemia from the perforating arteries occlusion 20 days after surgery. Conclusions The selection of proper cranial base approaches should be benefit to obtain an adequate operative space for clipping of vertebrobasilar aneurysms. The adjunctive use of graft bypass may be till required to avoid parent and major branch occlusion during protracted temporary clipping of the parent artery and the sacrifice of either the parent vessel or one of the major branches for management of a complex intracranial aneurysm.