大脑中动脉动脉瘤的显微手术治疗

目的 总结大脑中动脉动脉瘤(MCAA)显微手术技术、手术效果和预后.方法 对55例MCAA病例进行前瞻性分析,总结其临床特点,包括部位、大小、术前主要临床表现、Hunt & Hess分级等.术前Hunt & Hess分级:0级9例,Ⅰ级12例,Ⅱ级23例,Ⅲ级8例,Ⅳ级2例,Ⅴ级1例.主要表现包括头痛42例,呕吐22例,偏瘫11例.本组全部采用翼点开颅.经侧裂近端-远端入路23例,经侧裂远端-近端入路27例,经血肿入路5例.行动脉瘤瘤颈夹闭术45例(夹闭切除术6例),血管重建7例,肌肉包裹加固3例.采用相应的手术入路,并用格拉斯哥预后评分(GOS)对手术效果进行评价.结果 中动脉分叉部动脉瘤37例(67.2%),近端部13例(23.6%),远端部5例(9.1%).动脉瘤体最大径3～70 min,平均15.5 mm.远期主要术后并发症包括偏瘫12例,失语3例,癫痫2例.随访11～39个月(平均23个月).GOS评分:恢复良好(5级)45例,中度残疾(4级)5例,重度残疾(3级)5例,无植物生存和死亡.影像学随访无一例复发.结论 结合现代影像技术,通过充分手术计划,适宜的手术入路,细致的显微手术技术等,大脑中动脉动脉瘤的手术治疗能够获得满意的疗效.

Microsurgical techniques of middle cerebral artery aneurysms

Objective To summarize the experience in surgical treatment for middle cerebral aneurysm (MCAA), and results and prognosis thereof. Methods The clinical data, including location, size, main presentations, and Hunt & Hess grade, of 55 consecutive MCAA patients were prospectively analyzed. The surgical outcome was evaluated by Glasgow Outcome Scale (GOS). Follow-up was conducted for 23 (11-19) months. Results According to the Hunt & Hess classification, there were 9 cases in grade 0, 12 cases in grade Ⅰ , 23 cases in grade Ⅱ, 8 cases in grade Ⅲ, 2 cases in grade Ⅳ, and 1 case in grade Ⅴ at admission. Headache (42 cases), vomiting (22 cases), and hemiplegia (11 cases) were the top 3 common presentations. Pterional craniotomy was adopted in all cases. Proximal to distal lateral fissure approach was used in 23 cases, distal to proximal approach in 27 cases, and trans-hematoma approach in 5 cases. There were 45 cases treated by direct neck-clipping (clipping and resetting in 6 cases) , 7 cases by parent artery reconstruction, and 3 cases by wrapping by muscle. The location of MCAA was at the bifurcation in 37 cases (37.2%), at proximal middle cerebral artery (MCA) in 13 cases (23.6%), and at distal MCA in 5 cases (9.1%). The largest diameter was 15.5 (3-70) mm. The main postoperative complications included hemiplegia (12 cases), aphasia (3 cases), and seizure (2 cases). Follow-up showed good recovery in 45 cases, moderate disability in 5, and severe disability in 5 according to GOS. There was no vegetative state, death, and recurrence. Conclusion With modern imaging techniques, perfect surgical plan, appropriate surgical approach, and careful microsurgical techniques, treatment of MCAA can be perfected and achieve satisfying outcome.