颅内多发动脉瘤患者的显微外科手术治疗策略

目的 探讨颅内多发动脉瘤患者的显微手术治疗策略.方法 回顾性分析新乡医学院第一附属医院神经外科在2008年2月至2010年10月期间收治24例颅内多发动脉瘤.所有病例均以自发性蛛网膜下腔出血起病而就诊,经CT血管成像（CTA）或者（脑血管造影）DSA确诊为颅内多发动脉瘤.入院时患者的Hunt-Hess分级如下：1级3例,2级10例,3级8例,4级3例.本组24例患者中20例有2个动脉瘤,4例有3个动脉瘤,共有52个动脉瘤.动脉瘤均为囊状,瘤体直径2 ~19 mm,颈宽2～8 mm.2例患者在等待和保守治疗中二次破裂出血末及时手术治疗而死亡,1例因家属放弃治疗而出院,其余的21例均采用开颅显微手术夹闭动脉瘤.在所有的手术治疗病例中,手术时机选择如下：4例1~3级患者采用超早期手术,8例1~3级患者采用早期手术,10例1～3级患者采用巾期手术,2例4级患者采用延期手术.结果 21例经过开颅显微手术治疗的46个动脉瘤均被成功夹闭.术后患者恢复良好（无明显神经功能障碍,能完全恢复正常生活和工作）14例,轻度残疾（轻偏瘫和颅神经功能障碍,日常生活能自理）4例,重度残疾（完全偏瘫、失语和思维障碍,日常生活不能自理需要别人照顾）2例,植物生存（昏迷超过1个月）1例,无死亡病例.所有病例在术后进行了DSA或CTA复查,显示动脉瘤被完全夹闭,不再显影.结论 颅内多发动脉瘤手术治疗复杂,需要结合每个患者的具体特点制定个体化的手术治疗方案,提倡在首先处理责任动脉瘤的前提下,尽早、尽量通过一期或者分期手术将所有动脉瘤处理,可取得较好的临床治疗效果.

The microsurgical strategies for treatment of intracranial multiple aneurysms

Objective To explore the mierosurgical strategies for treatment of intracranial multiple aneurysms. Methods The 24 cases with intracranial multiple aneurysms treated in the First Affiliated Hospital of Xinxiang Medical University from February of 2008 to October of 2010 were retrospectively reviewed. All the cases began with the symptoms of subarachnoid hemorrhage and the diagnosis of intracranial multiple aneurysms were confirmed by CT angiography （ CTA ） or digital subtraction angiography （ DSA ）. According to the Hunt and Hess grade scale, 3, 10, 8 and 3 cases were at grade 1, 2, 3 and 4 respectively. In this study, 20 cases had 2 aneurysms and 4 cases had 3 aneurysms, and thus there were 52 aneurysms in total. All the aneurysms were saccular with the neck of 2-8 mm in diameter and the body of 2-19 mm in diameter. Of the 24 cases, 2 cases died of second rupture when waiting for endovascular treatment and 1 case refused treatment and discharged. All the other cases received microsurgical clipping by craniotomy. The surgical timing was as following： 4 cases, 8 cases, 10 cases at grade 1-3 and 2 cases at grade 4 received super-early operation, early operation, middle term operation and delayed operation respectively. Results Forty six aneurysms of 21 cases were successfully clipped. One month after operation, 14, 4, 2, and 1 case were at normal health, mild disabled, moderate disabled, severe disabled and persistent vegetative status respectively, without dead case. All the cases were followed by CTA or DSA and the results showed that the aneurysms were clipped completely. Conclusions The treatment of intracranial muhiple aneurysms is relatively complex and the treatment should be individualized. The aneurysms are suggested to be clipped as early as possible by one term or multiple term operation at the basis that the primary goal of operation is to deal with the responsible aneurvsms, thus a better clinical outcome could be achieved.