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。

Surgical strategy for large and giant internal carotid artery aneurysms

Objective To study clinical features and operative techniques of large and giant internal carotid artery aneurysm. Methods Surgical experiences from 48 patients with large and giant carotid artery aneurysms were retrospectively analyzed. Pterional approaches were taken in all the cases. The cervical internal artery was exposured and blocked transiently. The anterior clinoid process and roof and lateral crista of optic canal were drilled off intradurally to display proximal angle of the aneurysm in the cases of paraclinoid aneurysms. Retrograde suction was applied for decompression of aneurysm, if there was thrombus in aneurysm, CUSA was used to remove it, so that the aneurysm can be clipped satisfactorily and the optic nerve decompressed. Intraoperative EEG and SEP monitorings were applied to check the brain function. Ultrasonic Doppler was used to check the blood flow before and after the aneurysm was clipped. Results The aneurysms were clipped directly in 46 cases, aneurysm trapping with bypass of superficial temporal artery to MCA and external carotid artery to MCA with great saphenous vein graft in the 2 cavernous aneurysms. Postoperative angiography was taken in 43 cases, showing that most of aneurysms were clipped satisfactorily. According to GOS, good outcome occurred in 41 cases (85.4%) in the early stage, poor in 5 cases, and 2 died. Conclusion Sufficient exposure, rational temporary occlusion of parent artery, effective methods for the collapse of aneurysm, intraoperative EEG and SEP monitorings, and the use of ultrasonic Doppler make aneurysms be clipped satisfactorily.