颈内动脉颅内段创伤性假性动脉瘤的诊断与治疗

目的 探讨颈内动脉颅内段创伤性假性动脉瘤的诊断与治疗。方法17例鼻腔大出血患者，男11例，女6例；平均年龄39岁。其中10例为颅脑创伤后6d-3个月突发鼻腔大出血；余7例均为经鼻-蝶窦入路手术后鼻腔大出血，6例发生于经鼻-蝶窦入路垂体瘤切除手术后1周左右，1例出现于脑脊液鼻漏修补手术后3d。17例均经股动脉穿刺置管行双侧选择性颈内和颈外动脉血管造影诊断为颈内动脉颅内段创伤性假性动脉瘤。其中14例经8F导引管置入Magic-BD导管，采用可脱式球囊闭塞颈内动脉破口及颈内动脉，或经5F造影导管送入金属弹簧圈闭塞同侧颈内动脉。1例脑脊液鼻漏患者，应用可脱性弹簧圈直接栓塞动脉瘤。余2例全脑血管造影检查显示健侧颈内动脉完全闭塞，大脑前动脉、大脑中动脉供血区由患侧颈内动脉供血代偿，而椎-基底动脉系供血不能代偿。全身麻醉经翼点入路于显微镜下行颈内动脉假性动脉瘤切除及颈内动脉破口修补手术。结果15例行血管内栓塞治疗者，均一次性闭塞颈内动脉破口及颈内动脉，全脑血管造影显示动脉瘤消失，双侧大脑半球供血代偿良好。2例经显微外科手术切除动脉瘤并修补颈内动脉者，手术后1周全脑血管造影可见颈内动脉假性动脉瘤消失，患侧颈内动脉通畅良好。6个月随访期间，均未再发生鼻腔大出血，无一例出现永久性并发症。结论全脑血管造影检查是诊断颈内动脉颅内段创伤性假性动脉瘤出血的首选方法。血管内治疗技术可直接栓塞动脉瘤或闭塞载瘤动脉，达到止血目的，是一种较为理想的治疗方法。对于对侧颈内动脉已经完全闭塞，椎-基底动脉代偿不完全者，应选择显微外科手术修补颈内动脉。

Diagnosis and treatment of traumatic pseudoaneurysm in intracranial segment of internal carotid artery

Objective To study the diagnosis and treatment of traumatic pseudoaneurysm in intracranial segment of internal carotid artery. Methods Seventeen patients with nasal hematorrhea (male 11, female 6, average age 39) were enrolled in this study. Among them 10 cases were sudden attack of nasal hematorrhea in 6 d-3 mon after craniocerebral injury and 7 cases were nasal hematorrhea after operation via naso-sphenoid sinus including 6 cases occurred about 1 week after resection of pituitary tumor and 1 case occurred in 3 d after repair of cerebrospinal rhinorrhea. All of the 17 patients were diagnosed as traumatic pseudoaneurysm in intracranial segment of internal carotid artery by selective bilateral digital subtraction angiography of internal or external carotid artery via femoral artery approach. In 14 patients the homolateral internal carotid arteries were occluded by positioning Magic-BD catheter and ballon to the arterial rupture site or transplanting metallic spring coil via 5F catheter. One patient with cerebrospinal rhinorrhea, the aneurysm was embolized by GDC. In another 2 patients the cerebral angiography showed that the contralateral internal carotid artery occluded completely, and the blood supply area of anterior cerebral artery and middle cerebral artery were compensated by the injured internal carotid artery but the blood supply area of vertebrobasilar artery system was not compensated. Thus the resection of pseudoaneurysm in internal carotid artery and repair of ruptured internal carotid artery were performed via pterion approach under general anesthesia and microscope. Results In 15 patients treated with endovascular embolization their rupture in internal artery was successfully occluded by one treatment. Their aneuryms disappeared and well compensated blood supply in bilateral cerebral hemisphere were found in cerebral angiography. In 2 patients treatead with resection of aneurysm and repair of internal artery rupture, the 1 week postoperational cerebral angiography showed the pseudoaneurysm in internal carotid artery was disappeared and its circulation was free. In 6 months following up the nasal hematorrhea and severe complication were not found in all 17 patients. Conclusion It is demonstrated that the cerebral angiography is the first choice measure for diagnosis of internal carotid artery pseudoaneurysm of intracranial segment bleeding. The endovascular therapeutic technique can directly embolize the aneurysm or occlude the aneurysm carrying artery and successfully achieve hemostasis, thus it is a better therapeutic approach. The microsurgical repair of internal carotid artery should be performed for those patients with complete occluding contralateral internal carotid artery and uncomplete compensation of vertebrobasilar artery.