多技术联合应用于颅内巨大动脉瘤的显微外科治疗

目的 探讨神经电生理监测、术中超声、术中荧光造影、神经内镜多技术联合应用于颅内巨大动脉瘤的显微外科手术治疗的临床效果。方法 回顾性分析显微手术治疗颅内巨大动脉瘤17例的临床资料。术前采用3D-CTA、MRI和DSA,充分评估动脉瘤的位置、大小和形状。术中应用神经电生理监测评价动脉瘤夹闭前、后的神经功能保留和损害程度;通过微血管多普勒超声的定性和定量分析联合术中荧光造影评定动脉瘤和周围邻近血管的血液流速及通畅度;神经内镜观察动脉瘤区的局部解剖,辨认重要的穿支血管、瘤颈结构和动脉瘤夹情况。手术在手术显微镜下操作,采用载瘤动脉控制性技术、瘤颈成形技术、动脉瘤内减压和切除技术、多瘤夹夹闭技术和血管痉挛保护技术等进行联合治疗。 结果 在多技术联合监测下,显微外科手术成功夹闭巨大动脉瘤17个,术后恢复良好15例,出现轻偏瘫1例,重度偏瘫l例,无死亡病例。DSA复查示瘤颈夹闭完全,载瘤动脉通畅。远期随访仍在进行中。 结论 多技术联合显微手术技术,能有效提高颅内巨大动脉瘤的手术疗效。     

眶上锁孔入路显微手术治疗前循环动脉瘤

目的 探讨眶上锁孔人路、神经内镜辅助显微手术治疗前循环动脉瘤的手术方法。方法 对12例前循环动脉瘤患者,依据手术前诊断性影像资料,制订个体化手术计划;手术行眉部皮肤切口,于眶上作直径2cm左右骨窗开颅,采用内镜辅助的显微外科技术夹闭动脉瘤。结果 12例5种不同类型动脉瘤患者经该方法治愈,其中1例患者术中动脉瘤破裂,经阻断载瘤动脉12min,妥善分离动脉瘤后,在内镜辅助下准确夹闭瘤颈,术后对侧肢体有暂时性轻瘫,经治疗1周后肌力恢复正常。本组病例均未出现与手术人路相关的并发症。结论 采用眶上锁孔入路、内镜辅助的显微外科技术治疗前循环动脉瘤,是一种安全、微侵袭和有效的途径。     

脑血管

重组腺病毒载体介导外源基因转移至痉挛脑血管的研究；中低温停循环技术在复杂头颈部血管病变中的脑保护作用；去骨瓣减压术治疗大面积脑梗死100例；影响破裂大脑中动脉瘤手术预后因素的分析；以动静脉瘘为主的脑动静脉畸形的栓塞治疗；内镜辅助下经外侧裂手术治疗基底节区高血压性脑出血的临床疗效观察；神经内镜辅助下显微神经外科“锁孔”手术治疗前循环动脉瘤(综述)；颅内动脉瘤术后低血压反应的危险因素分析；3D-CTA在颅内动脉瘤诊治中的应用；创伤性颈动脉海绵窦瘘介入治疗的临床效果影响因素分析；锁孔手术治疗基底节区脑出血的术式评价；血管内栓塞辅助显微手术治疗复杂难治性脑动静脉畸形。     

神经内镜辅助显微手术治疗颅内动脉瘤疗效分析

目的探讨神经内镜动脉瘤显微外科手术的适应证、应用方法、操作技巧及注意事项,进一步提高动脉瘤手术的疗效,减少手术并发症,降低病死率和致残率。方法选取2011-06—2014-10间住院的90例颅内动脉瘤患者并随机分成观察组和对照组,每组45例。观察组行神经内镜辅助显微外科手术夹闭动脉瘤,对照组单纯应用显微外科手术治疗,收集2组相关指标,进行比较分析,探讨内镜辅助显微神经外科手术治疗颅内动脉瘤的适应证、技术要点及优势。结果观察组患者的并发症发生率、临床预后及生存质量明显优于对照组,2组比较,差异有统计学意义(P<0.05)。结论应用神经内镜辅助显微神经外科手术治疗颅内动脉瘤,可显著改善手术靶区的可视范围,并发症少,疗效满意。     

额外侧锁孔入路的显微与神经内镜解剖

目的对比研究前颅底的显微解剖与神经内镜解剖，为额外侧锁孔手术入路处理前颅底、鞍区病变提供解剖基础。方法经额外侧锁孔手术入路对15具成人尸头进行显微解剖和神经内镜下解剖，比较两种解剖所暴露的范围。结果显微解剖在嗅沟、鞍区和外侧裂存在一定范围的视野盲区；内镜有充足的照明，可将手术视野放大，无视野盲区，清楚地显示周围的解剖结构，而且看得更远。但内镜的图像为二维图像，缺乏景深。神经内镜辅助显微手术可以互补各自不足。结论额外侧锁孔入路在神经内镜的辅助下显微手术切除前颅底和鞍区的病变安全、微创。     

眶上与翼点"锁孔"入路显微手术治疗颅内动脉瘤的比较研究

目的 报道经眶上“锁孔”入路和经翼点“锁孔”入路显微手术治疗颅内动脉瘤的临床疗效。方法 回顾分析165例颅内动脉瘤“锁孔”手术临床资料，其中采用眶上“锁孔”入路106例共108个动脉瘤，翼点“锁孔”入路59例，共62个动脉瘤。结果 眶上“锁孔”组有103个动脉瘤夹闭成功，行包裹术1例，孤立术2例，孤立加切除术2例。翼点“锁孔”组61个动脉瘤一次夹闭成功，行孤立术1例。根据GOS评估标准，眶上“锁孔”组恢复良好98例，轻残2例，死亡6例，翼点“锁孔”组恢复良好53例，轻残5例，死亡1例。结论 眶上与翼点“锁孔”入路疗效相近，均可适用于颈内动脉、眼动脉、大脑前动脉水平段、前交通动脉、大脑前动脉垂直段近端、基底动脉分又部及大脑后动脉前段动脉瘤手术夹闭，欲行对侧眼动脉、大脑前动脉水平段、垂直段近端及颈内动脉动脉瘤手术，以选择眶上“锁孔”入路更合适。本方法具有手术创伤小、疗效佳、并发症少、外观影响少和费用节省等优点，是颅内动脉瘤显微手术有效和理想的入路。     

神经内镜在颅内动脉瘤外科的应用

颅内动脉瘤外科手术中应用神经内镜 ,可增强光照并放大动脉瘤周围图像 ,属微创神经外科 (minimallyinvasiveneuro surgery)重要技术之一。一、神经内镜在动脉瘤外科中应用价值颅内动脉瘤外科最大的问题是手术空间小 ,容易造成神经和血管的损伤。 2 0世纪 90年代神经内镜用于动脉瘤手术 ,与手术显微镜相比 ,内镜有 3个优势 :(1)有角度的内镜显示一些手术显微镜所无法达到空间的解剖结构 ;(2 )增加局部照明 ;(3 )放大图像 ,对病变进行“特写” ,尤其是在狭小间隙内进行深部病变操作 (如基底动脉瘤 )十分有帮助。Kalavakoid等认为使用内镜 ,可…     

神经内镜辅助锁孔显微外科治疗颅内胆质瘤

目的 探讨神经内镜辅助锁孔显微神经外科治疗颅内胆质瘤的方法和意义。方法 应用神经内镜辅助锁孔显微神经外科技术治疗颅内胆质瘤16例。以MRI显示的肿瘤核心部位选择锁孔入路，在手术显微镜下尽可能切除可见的肿瘤部分，再辅助使用神经内镜寻找残余的肿瘤并切除。结果 在常规显微神经外科切除肿瘤后，应用神经内镜探查，13例仍能发现残余肿瘤，在内镜下进一步切除；3例无残余肿瘤；肿瘤全切除14例，次全切除2例。15例手术后2周内原有症状明显缓解或恢复，1例发生了无菌性脑膜炎，经治疗2周后痊愈。无术后脑积水及继发性颅内出血。术后3～12个月随访10例，9例痊愈，1例存在三叉神经痛，需药物治疗。结论 神经内镜辅助锁孔显微神经外科治疗颅内胆质瘤，尤其是生长广泛的巨大胆质瘤，有助于提高颅内肿瘤全切率，减少手术创伤，降低术后并发症。     

显微手术治疗颅内复杂动脉瘤16例

目的 探讨颅内复杂动脉瘤的显微手术治疗方法及临床疗效. 方法 回顾性分析16例26个颅内复杂动脉瘤显微外科手术治疗患者的临床资料.16例复杂动脉瘤均使用64排螺旋CT血管造影(CTA)检查确诊,其中巨大动脉瘤3例,位置深在、难于暴露且周围有重要神经、血管的动脉瘤5例,一次开颅同时处理多个病变的多发动脉瘤8例.根据动脉瘤的所在部位和动脉瘤体积采取相应的外科手术入路,主要有翼点入路、扩大的额颞入路、眶-颧-颞-翼点入路和枕下极外侧入路.对多发动脉瘤的处理原则是先处理破裂动脉瘤,再处理末破裂动脉瘤.动脉瘤直接夹闭14个,孤立1个,包裹1个. 结果 依据GOS判断:良好11例,中残1例,重残1例.结论 显微外科手术治疗颅内复杂动脉瘤效果显著,术中需采取充分的显露、血管临时阻断、脑保护技术、瘤颈缩窄、瘤体成形等综合措施,方能达到满意的手术效果.     

锁孔入路手术治疗颅内前循环动脉瘤患者围术期护理

对85例颅内前循环动脉瘤患者采用锁孔入路（74例经翼点锁孔入路，11例经眉弓锁孔入路）手术治疗。结果85例患者显微镜下手术成功夹闭动脉瘤，翼点入路术中动脉瘤破裂1例，眉弓入路术中动脉瘤破裂1例，术后出现急性硬膜下血肿1例；患者住院8～37d，术后1～3个月复诊。恢复良好82例（96．5％），轻度残疾3例（3.5％）。提出术前避免颅内动脉瘤破裂再出血诱因和脑血管痉挛的护理是重点，术后注重病情监护、并发症的观察和护理、加强功能锻炼、做好出院指导，是促进患者早日康复,提高其生存质量的重要措施。     

Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients.

OBJECT: To enhance visual confirmation of regional anatomy, endoscopy was introduced during microsurgery for cerebral aneurysms. The risks and benefits are analyzed in the present study. METHODS: The endoscopic technique was used during microsurgery for 54 aneurysms in 48 patients. Forty-three aneurysms were located in the anterior circulation and 11 were in the posterior circulation. Thirty-eight aneurysms (70.4%) had not ruptured. All ruptured aneurysms in the present series produced Hunt and Hess Grade I or II subarachnoid hemorrhage. After initial exposure achieved with the aid of a microscope, the rigid endoscope was introduced to confirm the regional anatomy, including the aneurysm neck and adjacent structures. The necks of 43 aneurysms were clipped using microscopic control or simultaneous microscopic/endoscopic control. After clipping, the positions of the clip and nearby structures were inspected using the endoscope. Use of the neuroendoscope provided useful information that further clarified the regional anatomy in 44 cases (81.5%) either before or after neck clipping. In nine cases (16.7%), these details were available only with the use of the endoscope. In five cases (9.3%), the surgeons reapplied the clip on the basis of endoscopic information obtained after the initial clipping. There were two cases in which surgical complications were possibly related to the endoscopic procedures (one patient with asymptomatic cerebral contusion and another with transient oculomotor palsy). CONCLUSIONS: It is the authors' impression that the use of the endoscope in the microsurgical management of cerebral aneurysms enhanced the safety and reliability of the surgery. However, there is a prerequisite for the surgeon to be familiar with this instrumentation and fully prepared for the risks and inconveniences of endoscopic procedures.     

Neuroendoscope-assisted minimally invasive microsurgery for clipping intracranial aneurysms.

OBJECTIVE: The aim of this study was to evaluate the efficacy of intracranial aneurysm treatment with the help of the neuroendoscope. METHODS: Eighty-eight patients were treated from February 2000 to November 2003 for intracranial aneurysms of which 89 lesions were clipped with the help of neuroendoscope, including 82 anterior circulation aneurysms (in 81 cases) and 7 posterior circulation aneurysms. The diameters of the aneurysms were between 5 and 40 mm with mean value of 12.5 mm. In the Hunt and Hess preoperative classification, 10 cases were grade 0, 37 cases were grade I, 36 cases were grade II, and 5 cases were grade III. RESULTS: Postoperative complications were observed in 7 cases (7.9%), including hemiplegia in 5 cases (1 case with combination of aphasia), pseudomembranous enteritis in 1 case and optic blur in 1 case. We did not observe any neuroendoscope-related complications and had no postoperative deaths. CONCLUSIONS: The operative efficacy in aneurysm neurosurgery can be improved by the use of the neuroendoscope, especially for minimally invasive microsurgery operation. The neurosurgeon should pay more attention to the training of the endoscope procedure and master more knowledge about endoscopic anatomy.     

Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note

A modification of the supraorbital keyhole approach, the eyebrow incision-minisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 cm, that incorporates the orbital rim and roof and the frontal process of the zygomatic bone through an eyebrow incision. The orbital osteotomy facilitates view of the anterior and middle cranial fossa through the operating microscope, as well as the maneuverability of instruments through a small craniotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used successfully in elective surgery of 10 aneurysms of the anterior circulation. The mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tissue, reduced frontal lobe retraction, and an excellent postoperative cosmetic result. The approach is performed quickly by virtue of a limited skin incision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contraindications include the presence of a large frontal sinus, severe brain edema, and recent subarachnoid hemorrhage. In addition, this approach has not been used for the treatment of giant intracranial aneurysms.     

翼点锁孔入路鞍区显微解剖及神经内镜下的应用解剖

目的 研究翼点锁孔入路鞍区各间隙的神经内镜解剖,为内镜辅助下该入路进行显微手术提供解剖学依据.方法 在15例湿头标本上选择翼点人路开30 mm×25 mm锁孔.使用显微镜和神经内镜模拟手术过程对鞍区Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ间隙进行解剖结构观察,并作比较. 结果 应用锁孔概念,确定内镜下的解剖学"路标",可以显示间隙Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ及Willis环等显微结构.利用神经内镜比显微镜可以更广泛清晰地显示鞍区不同间隙内的解剖结构,尤其是对一些重要的细微结构.利用成角内镜可"绕过"神经、血管观察其背后的结构,是显微手术中重要的辅助方法. 结论 运用神经内镜按解剖"路标"进行,可以消除翼点锁孔人路鞍区显微手术的显微外科解剖的死角,减少术中脑组织及重要颅底血管、神经的牵拉,减少并发症的发生,从而提高鞍区手术的疗效.     

锁孔微创入路手术治疗颅内动脉瘤的风险因素及对策分析

目的 探讨颅内动脉瘤在锁孔手术中破裂的风险因素、适应证选择、手术难点、预防动脉瘤破裂的方法及应急处理措施.方法 回顾性分析1999年至2005年115例动脉瘤患者的临床资料.将动脉瘤破裂风险较低的43例患者通过锁孔微创入路手术治疗（锁孔组）,其余72例患者采用常规开颅手术治疗（常规组）.锁孔组43例患者手术中翼点锁孔入路20例,眶上锁孔入路18例,纵裂锁孔入路5例.常规组72例患者风险高而采用常规翼点开颅31例,额下开颅11例,纵裂开颅7例,翼点-额下联合10例,翼点-纵裂联合6例,额下-纵裂联合4例,翼点-额下-纵裂联合3例.结果 锁孔组术中动脉瘤渗漏6例,破裂出血3例,发生率为7%,无手术死亡.2例在锁孔手术中无法夹闭动脉瘤而改为常规开颅.常规组术中发生动脉瘤渗漏18例,破裂出血9例,发生率为13%,手术后死亡2例.结论 尽管锁孔手术有微创、伤口美观、术后恢复快等优点,但在风险低的患者中动脉瘤渗漏和破裂的风险仍然不能忽视.     

How useful is the 3-dimensional,surgeon’s perspective-adjusted visualisation of the vessel anatomy during aneurysm surgery? A prospective clinical trial

We hypothesized that neuronavigational 3-dimensional display of vessel and aneurysm anatomy, which is adjusted to the actual surgeon’s view, could be helpful during the critical steps of aneurysm treatment. A total number of 32 patients with 42 aneurysms entered this prospective clinical trial. With a neuronavigational system, a 3-dimensional image of the arterial vascular anatomy was generated by autosegmentation of a computerized tomography (CT) angiographic data set. The 3-dimensional image was then adjusted to the surgeon’s perspective by rotation. The neurosurgeon linked the 3-dimensional image information with the vascular structures in his surgical field by a neuronavigational pointer. He had the opportunity to further rotate the image with the displayed pointer for visualization of hidden structures. After operation, the neurosurgeon had to define with which expectations neuronavigation was applied and to evaluate if these expectations were fulfilled. The expectations with which the neurosurgeon used neuronavigation were to localize the aneurysm (n = 24), to understand the branching anatomy (n = 18), to visualize hidden structures (n = 8), to evaluate the projection of the aneurysm dome (n = 5) and to tailor the approach (n = 2). In 5 of the 42 aneurysms that were either very small or located in close vicinity to the skull base, the neurosurgeon’s expectations were not fulfilled. A favorable outcome was achieved in 29 of the 32 patients (91%). Neuronavigational 3-dimensional display of the vessel anatomy was considered useful by the vascular neurosurgeon. Possibly, this technique has the potential to improve operative results by reduction of the surgical trauma and avoidance of intraoperative complications.     

Design and microsurgical anatomy of the retrosigmoid-retrocondylar keyhole approach without occipital condyle removal.

OBJECTIVE: The goal of this study was to design a new retrosigmoid-retrocondylar keyhole approach based on the minimally invasive keyhole idea and to explore its feasibility and indications, which can be regarded as the base of this keyhole approach in clinical use. METHODS: 8 adult cadaveric heads fixed in formalin and with intracranial vessels perfused by colored latex were used in this study. To search for the most suitable length and shape of the skin incision, we examined two kinds of incision (a longitudinal "S" shape and a straight one) and two lengths (5 cm and 7 cm, respectively). Due to the complexity and thickness of the suboccipital muscles, two ways of muscle dissection were compared: 1) the muscles were incised perpendicularly in layers; 2) the muscles were detached and reflected in layers. A 3-cm diameter retrosigmoid-retrocondylar bone flap was made with a craniotome. Many anatomic structures could be observed under the microscope when the cerebellar hemisphere was retracted. After comparing and balancing the above steps in all specimens, a feasible, duplicable retrosigmoid-retrocondylar keyhole approach was devised. RESULTS: The proper incision of the retrosigmoid-retrocondylar keyhole approach was a longitudinal "S" shaped skin incision about 7 cm in length with its superior border 2 cm behind the middle point of mastoid and inferior margin at the level of C-2. The method of detachment and reflection of occipital muscles was superior to the method of cutting them perpendicularly. By means of adjusting the head position and the angle of microscope, the ipsilateral vertebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery, VII, VIII, IX, X, XI, XII cranial nerves and the ventral lateral aspect of medulla oblongata were exposed via this keyhole approach. CONCLUSIONS: The novel retrosigmoid-retrocondylar keyhole approach has practical value for clinical applications. With the techniques of modern microsurgery, several diseases such as an aneurysm situated at the vertebral artery or the posterior inferior cerebellar artery, a small hypoglossal neurinoma and tumor located at the ventral lateral aspect of the medulla oblongata, may be operated via this retrosigmoid-retrocondylar keyhole approach without drilling the occipital condyle.     

How useful is the 3-dimensional, surgeon's perspective-adjusted visualisation of the vessel anatomy during aneurysm surgery? A prospective clinical trial

We hypothesized that neuronavigational 3-dimensional display of vessel and aneurysm anatomy, which is adjusted to the actual surgeon's view, could be helpful during the critical steps of aneurysm treatment. A total number of 32 patients with 42 aneurysms entered this prospective clinical trial. With a neuronavigational system, a 3-dimensional image of the arterial vascular anatomy was generated by autosegmentation of a computerized tomography (CT) angiographic data set. The 3-dimensional image was then adjusted to the surgeon's perspective by rotation. The neurosurgeon linked the 3-dimensional image information with the vascular structures in his surgical field by a neuronavigational pointer. He had the opportunity to further rotate the image with the displayed pointer for visualization of hidden structures. After operation, the neurosurgeon had to define with which expectations neuronavigation was applied and to evaluate if these expectations were fulfilled. The expectations with which the neurosurgeon used neuronavigation were to localize the aneurysm (n = 24), to understand the branching anatomy (n = 18), to visualize hidden structures (n = 8), to evaluate the projection of the aneurysm dome (n = 5) and to tailor the approach (n = 2). In 5 of the 42 aneurysms that were either very small or located in close vicinity to the skull base, the neurosurgeon's expectations were not fulfilled. A favorable outcome was achieved in 29 of the 32 patients (91%). Neuronavigational 3-dimensional display of the vessel anatomy was considered useful by the vascular neurosurgeon. Possibly, this technique has the potential to improve operative results by reduction of the surgical trauma and avoidance of intraoperative complications.