破裂颅内动脉瘤早期夹闭术中脑减压处理策略

目的探讨破裂颅内动脉瘤早期夹闭术中的脑减压处理方法及其有效性和可行性。方法介绍71例破裂颅内动脉瘤早期夹闭术中采用综合性的脑减压处理方法及其实施要点。其中术前HH分级Ⅳ21例,Ⅴ级8例;头部CT Fisher's分级Ⅲ级25例,Ⅳ级15例。评价脑表面与内板间距、术后颅内压(ICP)和脑水肿程度以判断术源性脑牵拉性损害程度。结果所有患者均得到了有效的术中显露和动脉瘤颈夹闭,夹闭术后术路同侧脑表面塌陷与颅骨内板的间距约10～25 mm,平均13.5mm;96.7%(68/71)的病例术后3 d ICP维持在正常范围(200 mmH2O)内,术路同侧早期局灶性脑水肿发生率为12.7%(9/71),表明手术对脑组织的牵拉性损害不严重。本组无因脑牵拉性损伤或关颅前的高颅压而行去骨瓣减压术。结论在破裂动脉瘤早期急诊夹闭术围手术期综合性脑减压措施处理下,可为急诊动脉瘤夹闭术提供足够的显露路径和暴露空间,减轻脑牵拉性损伤和由此引起的不良反应。

Cerebral decompression in early-stage clipping for ruptured intracranial aneurysms

Objective To discuss the effect and feasibility of brain decompression methods during early clipping of ruptured aneurysms.Methods The methods of brain decompression and the key points of management in 71 cases of ruptured aneurysms were discussed.All the cases included 21 cases of grade IV and 8 cases of grade V in H H scale;according to CT Fisher＇s scale,there were 25 cases of grade III and 15 cases of grade IV.The brain retracting damage was evaluated by the distances between brain surface and inner plate of skull,post-operative ICP and degree of brain edema.Results All patients had achieved effective operative exposure and aneurysm clipping.The distances between brain surface and inner plane of skull were about 10~25 mm（mean,13.5 mm）;intracranial pressure（ICP） maintained under normal range（200 mm H2O） in 68 cases（96.7%） at 3 d post-operation.The incidence of early local edema in operated side was 12.7%（9/71）,which indicated the surgical retracting damages to brain was not severe.No case was performed the decompressive cranioectomy due to the retracting damages or increased ICP.Conclusion The combined measurements of decompression during early clipping of ruptured aneurysms can provide enough approaches and exposure,which reduce the retracting damages and the related side effect.