存在瘤内血栓的颅内大型动脉瘤的手术治疗

目的探讨伴有瘤内血栓的颅内大型或巨大型动脉瘤的诊断和手术治疗。方法本组瘤内有陈旧性血栓的颅内大型动脉瘤62例,其中行动脉瘤瘤颈夹闭或塑型夹闭47例,动脉瘤孤立术13例,动脉瘤部分切除后缝合瘤壁重建载瘤动脉1例,另1例双侧椎动脉汇合处巨大梭形动脉瘤在深低温、停循环技术辅助下行载瘤动脉重建手术。结果根据GOS评分,病人恢复良好51例(82.3%),中残4例(6.5%),重残2例(3.2%),死亡5例(8.1%)。中、重残病例随访一年以上,中残的4例中3例恢复术前生活能力;重残的2例中,1例因大面积脑梗死、偏瘫仅有部分恢复,另1例深低温、停循环辅助手术病例,手术后2d内意识清楚,但术后13个月因肝功能衰竭死亡。结论颅内血栓性大型或巨大型动脉瘤手术处理困难,致残率及死亡率高于同类型无血栓的颅内动脉瘤。载瘤动脉暂时性阻断、动脉瘤切开血栓清除均有助于瘤颈夹闭。     

Fusiform Aneurysm on the Basilar Artery Trunk Treated with Intra-Aneurysmal Embolization with Parent Vessel Occlusion after Complete Preoperative Occlusion Test

Fusiform aneurysms on the basilar artery (BA) trunk are rare. The microsurgical management of these aneurysms is difficult because of their deep location, dense collection of vital cranial nerves, and perforating arteries to the brain stem. Endovascular treatment is relatively easier and safer compared with microsurgical treatment. Selective occlusion of the aneurysmal sac with preservation of the parent artery is the endovascular treatment of choice. But, some cases, particularly giant or fusiform aneurysms, are unsuitable for selective sac occlusion. Therefore, endovascular coiling of the aneurysm with parent vessel occlusion is an alternative treatment option. In this situation, it is important to determine whether a patient can tolerate parent vessel occlusion without developing neurological deficits. We report a rare case of fusiform aneurysms in the BA trunk. An 18-year-old female suffered a headache for 2 weeks. Computed tomography and magnetic resonance image revealed a fusiform aneurysm of the lower basilar artery trunk. Digital subtraction angiography revealed a 7.1×11.0 mm-sized fusiform aneurysm located between vertebrovasilar junction and the anterior inferior cerebellar arteries. We had good clinical result using endovascular coiling of unruptured fusiform aneurysm on the lower BA trunk with parent vessel occlusion after confirming the tolerance of the patient by balloon test occlusion with induced hypotension and accompanied by neurophysiologic monitoring, transcranial Doppler and single photon emission computed tomography. In this study, we discuss the importance of preoperative meticulous studies for avoidance of delayed neurological deficit in the patient with fusiform aneurysm on lower basilar trunk.     

Neuroendoscopic third ventriculostomy in the management of noncommunicating hydrocephalus secondary to giant basilar artery bifurcation aneurysm - case report and review of literature

Recently neuroendoscopic third ventriculostomy has become a well-established procedure for the treatment of noncommunicating hydrocephalus. However, morphological changes of the third ventricular floor can make endoscopic fenestration technically difficult, and increase the risk of injury to the basilar artery and perforators. The risk is especially high in patients with basilar artery bifurcation aneurysms, in whom aneurysm exclusion should precede treatment of hydrocephalus. If definitive aneurysm treatment is impossible or hazardous, endoscopic septostomy or shunting may be beneficial. However, reduction of intracranial hypertension may induce aneurysmal growth and rupture. We report upon a case of obstructive hydrocephalus produced by a non-ruptured partially thrombosed giant basilar artery bifurcation aneurysm, in which definitive treatment was considered impossible, successfully treated with neuroendoscopic third ventriculostomy. To the authors' knowledge this is the first reported case of its kind. The authors conclude that in similar cases neuroendoscopic ventriculostomy is worth trying if anatomical landmarks are identifiable.     

Cerebral aneurysms causing visual symptoms: their features and surgical outcome

Cerebral aneurysms causing visual symptoms before surgery are relatively rare. We have experience with 17 cases of such aneurysms and report their clinical features and surgical outcome. The locations of aneurysms presenting with visual dysfunction in our series are as follows: internal carotid (IC)-cavernous aneurysms in six of 29 total cases, 21%; IC-ophthalmic aneurysms in nine of 36 total cases, 25%; and anterior communicating artery (A com A) aneurysms in two of 217 total cases, 1%. The size of the aneurysms, the period between the onset of symptoms and surgical treatment, the pre- and post-operative visual function, and the surgical methods used to treat the aneurysm were analyzed. All the visually symptomatic cases featured large (15–24 mm) or giant (>25 mm) aneurysms. Visual symptoms occurred before aneurysmal rupture in all cases but one. The type of visual field defect and the degree of reduced visual acuity were highly variable, without a typical clinical presentation. Five out of six IC-cavernous aneurysms were treated surgically with common carotid artery (CC) ligation or IC ligation with superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis. Three of these cases showed improvement of visual symptoms after surgery. Six out of nine IC-ophthalmic aneurysms were treated surgically (CC ligation or direct clipping), with four cases showing improvement of visual symptoms after surgery. One case of an A com A aneurysm featured a ruptured aneurysm that had physically penetrated the optic chiasm, while the other case was a giant unruptured aneurysm. The interval between the onset of symptoms and surgical treatment was the only factor identified which affected the clinical outcome of the aneurysms presenting with visual dysfunction. All cases that were determined to show improvement of visual function were treated surgically within 3 months of the onset of symptoms. Cerebral aneurysms presenting with visual dysfunction before surgery are most commonly large or giant, and unruptured. Recovery of visual function can most often be expected when surgical treatment is performed expeditiously, before the visual dysfunction becomes irreversible.     

Surgical management of aneurysms of the bifurcation of the internal carotid artery

Internal carotid artery (ICA) bifurcation aneurysms are rare and easily bleed in younger patients, but are difficult to treat surgically, due to perforators surrounding and adherent to the aneurysm. A series of 25 patients treated by clipping under the operating microscope are analyzed and compared with previous cases. Twenty-five patients, 11 men and 14 women (mean age 51 years), were treated by the same neurosurgeon. Seventeen patients presented with subarachnoid hemorrhage (Hunt & Kosnik Grade I in three, II in five, III in two, IV in seven), five with unruptured ICA bifurcation aneurysms, and three with unruptured ICA bifurcation aneurysms but another ruptured aneurysm. There were 23 small, one large, and one giant ICA bifurcation aneurysms. The projection was superior in 12, anterior in seven, and posterior in six cases. Pterional approach was employed for all cases. Outcomes were evaluated at discharge with the Glasgow Outcome Scale. Favorable outcomes (good recovery (GR) and moderate disability (MD)) were obtained in ten of 17 patients with ruptured ICA bifurcation aneurysm. Favorable outcomes were significantly greater in Grades I and II (three in I, four in II) than in Grades III and IV (one in III, two in IV; P=0.0498). Seven of eight patients with unruptured ICA bifurcation aneurysm had favorable outcomes. Temporary clipping and projection of the aneurysm did not affect the outcome. Causative factors of unfavorable outcomes were primary brain damage in cases of small and large aneurysms and perforator damage in the case of giant aneurysm. Poor clinical grade and vasospasm are the causative factors of poor outcome in patients with ruptured ICA bifurcation aneurysm. Preservation of perforators is crucial in cases of giant aneurysm. Clipping of unruptured ICA bifurcation aneurysms is recommended since they tend to bleed at a lower age than other aneurysms.     

大脑中动脉动脉瘤的显微手术治疗

目的总结显微外科手术处理大脑中动脉动脉瘤的经验。方法1998年1月～2006年1月共手术治疗大脑中动脉动脉瘤36例，男19例，女17例。年龄12～65岁（平均41岁）。36例共计38个大脑中动脉动脉瘤，动脉瘤大小3～60mm，其中3～7mm9个，8～14mm17个，15～24mm7个，≥25mm5个。术前破裂出血30例，其中14例形成脑内血肿；6例因其它疾病或体检时偶然发现。所有病例经DSA检查，部分病人同时行MRA或CTA检查，其中2例病人DSA检查未发现动脉瘤，而CTA则清楚显示动脉瘤。4例病人合并有其它部位动脉瘤，2例为双侧镜影动脉瘤。动脉瘤位于大脑中动脉分叉部30个，分叉部近端7个、远端1个。采用翼点入路，显微镜下打开侧裂，依动脉瘤部位，逆行或顺行沿大脑中动脉主干（支）寻找分离动脉瘤，并夹闭之。结果全部38个动脉瘤均用一个或多个动脉瘤夹夹闭，其中8个大或巨大动脉瘤同时摘除血栓并切除大部瘤体以解除其占位效应。术后恢复良好28例，发生偏瘫失语7例（因局部脑梗塞所致），死亡1例。结论显微手术治疗大脑中动脉动脉瘤可以获得满意疗效，术中应尽量避免损伤大脑中动脉的分支，防止术后发生脑梗塞造成患者神经功能障碍。     

前循环巨大动脉瘤的手术治疗

目的探讨手术治疗脑前循环巨大动脉瘤的方法，设计个体化治疗方案。方法回顾分析2001年1月至2005年3月间手术治疗的38例脑巨大动脉瘤方法和效果。分别采用：直接夹闭瘤颈12例；动脉瘤切除加脑血管重建5例；动脉瘤孤立术4例；颅内外动脉吻合伴或不伴血管内介入治疗14例；包裹1例；载瘤动脉阻断2例。结果术后恢复优良32例，重度病残4例，死亡2例。结论术前应充分评价脑血流动力学和侧支循环，个性化设计治疗方案，采用不同手术术式可取得良好预后；同时颅内外血管吻合术可有效改善颅内供血，确保动脉瘤的后续治疗；手术和血管内介入治疗的结合是今后巨大型动脉瘤治疗的一个方向。     

Spontaneous thrombosis in giant intracranial aneurysms.

Twelve patients in a series of 22 with giant intracranial aneurysms demonstrated neuroradiological features of partial or total spontaneous intra-aneurysmal thrombosis. The presence of this intra-aneurysmal clot significantly altered the computed tomographic appearance of the giant aneurysm. Massive intra-aneurysmal thrombosis did not protect against subarachnoid haemorrhage and the likelihood of rupture of a clot containing giant aneurysm was not significantly different from that of a non-thrombosed giant aneurysm. Although parent artery occlusion from a thrombosed giant aneurysm, and massive aneurysmal thrombosis leading to the formation of giant serpentine aneurysm were documented, these are rare epiphenomena. The risk of embolisation from a partially thrombosed giant aneurysm, which was documented in one case, would appear to be greater than that from a non-thrombosed giant aneurysm. The findings in this series, and a review of literature, suggest that the presence of intra-aneurysmal clot in giant intracranial aneurysms has little prognostic significance and does not alter the management or outcome after treatment.     

显微手术治疗大脑中动脉分叉部动脉瘤

目的 探讨大脑中动脉(MCA)分叉部动脉瘤的解剖特点、临床特征、影像学表现、显微手术技巧及临床疗效.方法 回顾分析41 例MCA 分叉部动脉瘤显微外科治疗患者的临床资料,39 例有动脉瘤破裂出血的临床表现,按Hunt-Hess 分级:0～Ⅰ级5 例,Ⅱ级15 例,Ⅲ级11 例,Ⅳ级9 例,Ⅴ级1 例.64 排螺旋CT 血管造影(CTA)确诊.41 例均行显微手术治疗,手术入路为翼点入路或扩大翼点入路.对多发动脉瘤采取早期与择期、一期与分期相结合的方法处理动脉瘤,原则是先处理破裂动脉瘤,再处理未破裂动脉瘤.结果 动脉瘤夹闭38 例,动脉瘤夹闭+包裹2 例,夹闭一侧动脉瘤,另一侧动脉瘤未处理1 例.依据GOS 判断:优良31 例,轻残6 例,重残2 例,死亡2 例.结论 显微外科手术治疗MCA 分叉部动脉瘤效果显著.熟悉MCA 分叉部动脉瘤的解剖特征有助于减少术中血管损伤和术后神经功能障碍;对合并脑内血肿的MCA 分叉部动脉瘤,应急诊手术清除血肿并夹闭动脉瘤.     

Surgery of intracranial aneurysms previously treated endovascularly

OBJECTIVE: To perform a retrospective study on the patients who underwent aneurysmal surgery following endovascular treatment. PATIENTS AND METHODS: We performed a retrospective study on eight patients who underwent aneurysmal surgery following endovascular treatment (-attempts) with gugliemi detachable coils (GDCs). The indications for surgery, surgical techniques and clinical outcomes were analyzed. RESULTS: The indications for surgical treatment after GDC coiling of aneurysm were classified into three groups. First group: surgery of incompletely coiled aneurysms (n=4). Second group: surgery of mass effect on the neural structures due to coil compaction or rebleeding (n=2). Third group: surgery of vascular complications after endovascular procedure due to parent artery occlusion or thrombus propagation from aneurysm (n=2). Aneurysm obliterations could be performed in all cases confirmed by postoperative angiography. Six patients had an excellent outcome and returned to their profession. Patient's visual acuity was improved. One individual experienced right hemiparesis (grade IV/V) and hemihypesthesia. CONCLUSIONS: Microsurgical clipping is rarely necessary for previously coiled aneurysms. Surgical treatment is uncommonly required when an acute complication arises during endovascular treatment, or when there is a dynamic change of a residual aneurysm configuration over time that is considered to be insecure.     

颅内动脉瘤手术中破裂的处理(附89例报告)

目的探讨破裂颅内动脉瘤术中再破裂的预防与处理方法。方法回顾性分析2006年1月至2009年12月经显微手术治疗的89例破裂颅内动脉瘤病人的临床资料。这89例病人中,17例术中发生动脉瘤再破裂,均经采用控制性低血压、沾生物胶的明胶海绵压迫、小功率双极电凝器电灼破裂口和暂时阻断载瘤动脉等方法控制出血后,夹闭瘤颈。结果出院时良好78例,轻残6例,重残3例,死亡2例。其中17例动脉瘤术中再破裂出血均得以有效控制,术后患者恢复优良者15例,轻残1例,死亡1例。结论术前认真细致阅读患者的影像学资料并制订相应的手术策略和应急预案,采用个体化手术入路,以及良好的术中操作技巧可减少颅内动脉瘤的术中再破裂;而术者沉着冷静地采用相应措施,可有效地控制出血,从容夹闭瘤颈。     

Clinical and radiological findings and surgical management of ruptured aneurysms at the non-branching sites of the internal carotid artery

Ruptured aneurysms located at the non-branching sites of the internal carotid artery, including blister-like aneurysms, possess unique clinical and technical features. This report presents nine consecutively managed patients with these types of aneurysm, detailing the clinical and radiological characteristics and surgical outcomes. The initial angiography identified aneurysmal lesions in six of the nine patients with two of these patients requiring additional three-dimensional (3D) angiography. In three patients the aneurysm was only diagnosed on second or third angiograms. Six patients had blister-like aneurysms, and two had saccular-shaped aneurysms diagnosed on the basis of intraoperative findings. One patient with a saccular aneurysm died without surgery. Eight patients underwent a microsurgical procedure: clipping in five, clipping on wrapping with suturing in two and trapping in one. Three of these eight patients had an intraoperative rupture. A favorable outcome was obtained in seven patients. Advances in microsurgical techniques to prevent premature rupture and 3D radiological diagnosis with careful pre-operative consideration of the surgical strategies will be required for a further improvement of the clinical outcome.     

Growth of basilar artery aneurysm after ventriculo-peritoneal shunt

We report upon two cases of obstructive hydrocephalus produced by giant basilar artery aneurysms. They initially presented with symptoms of increased intracranial pressure, and were managed by a ventriculo-peritoneal (VP) shunt with good symptomatic improvement. With time, however, both showed a gradual deterioration of clinical symptoms due to increased aneurysm size. One, with a basilar tip aneurysm was treated by direct neck-clipping of the aneurysm, and was able to return to work. In the other patient, with a basilar trunk aneurysm, endovascular occlusion of one vertebral artery was attempted in an effort to decrease the aneurysm size, but the aneurysm enlarged precipitating brain stem failure. In conclusion, these cases reveal the risk of the VP shunt, which may induce aneurysmal growth, leading to clinical devastation, and emphasize the importance of definitive treatment for giant cerebral aneurysms whenever possible.     

儿童颅内动脉瘤的临床特征及治疗

目的 探讨儿童颅内动脉瘤的发病特点、影像学特征及其治疗策略.方法 对宣武医院神经外科及神经介入中心1985年10月至2008年5月共23例14岁以下(含14岁)儿童的24个颅内动脉瘤的发病方式、部位、大小等影像学特点、治疗方式及其结果进行回顾性分析.结果 儿童颅内动脉瘤占所有年龄组颅内动脉瘤的1.3%,男:女=1.56:1;24个动脉瘤中,16个位于前循环,8个位于后循环;14个属于复杂动脉瘤;以蛛网膜下腔出血为表现者11例;14例采用神经介入治疗,4例采用显微手术治疗,5例未行外科治疗,其中2例在随访过程中动脉瘤及载瘤动脉自行闭塞而自愈;1例死亡,1例因术前动脉瘤再破裂导致中度致残,其余21例结果良好.结论 (1)儿童颅内动脉瘤较为罕见,发病率男性高于女性;(2)颈内动脉及大脑中动脉是儿童颅内动脉瘤的好发部位;(3)与成人相比,巨大动脉瘤、夹层动脉瘤及后循环动脉瘤、感染或外伤性动脉瘤比例较高;(4)神经介入及显微手术都是治疗儿童颅内动脉瘤的有效方法,但对于复杂动脉瘤首选神经介入治疗,相当一部分动脉瘤甚至不得不采用载瘤动脉闭塞的方法治疗.     

Microvascular and transcranial Doppler sonographic evaluation of cerebral aneurysm flow pattern

Ninety percent of cerebral aneurysms were diagnosed after their first rupture with consecutive subarachnoid haemorrhage. In order to detect the aneurysms before rupture investigation by transcranial Doppler sonography was used on the basis of intra-operative evaluation of the normal aneurysmal flow pattern. In 34 patients the directly registered aneurysmal flow pattern was characterized by mean velocities slower than in parent arteries, by low diastolic flow velocities and by additional peaks superimposed on the normal pulse curve. The transcranial investigation with a large sample volume which includes aneurysm and parent artery was not able to distinguish this aneurysmal flow pattern from the normal one. Only in large to giant aneurysms a pathological flow pattern could be recorded transcranially.     

Stroke in patients with fusiform vertebrobasilar aneurysms

We studied seven patients with brainstem infarction and large fusiform vertebrobasilar (VB) aneurysms to clarify the clinical, radiologic, and pathologic features. All presented with pontine infarcts; one also had a cerebellar infarct. VB TIAs preceded brainstem infarction in four patients. Angiography and CT documented VB fusiform aneurysmal dilatation. Four had intraluminal thrombi and one had severe basilar artery stenosis. Two distinct clinical pictures emerged: unilateral pontine infarcts with favorable outcome, presumably related to obstruction of a pontine penetrating artery at its origin from the posterior wall of the aneurysmal basilar artery, and major fatal bilateral pontine infarcts from basilar artery occlusion. Two patients came to autopsy. One had thrombus in the dilated basilar artery and a posterior cerebral artery branch embolus with hemorrhagic occipital infarction; the other had basilar artery thrombus with aneurysmal rupture and subarachnoid hemorrhage. Fusiform VB aneurysms caused brainstem stroke by intraluminal thrombus, local embolism, atherostenosis, and obstruction of paramedian penetrating arteries. Subarachnoid hemorrhage is an uncommon complication.     

Intracranical aneurysm and cerebral embolism.

Embolism from the aneurysmal sac is a rare but possible manifestation of intracranial aneurysm; thrombus formation is probably related to the combined action of turbulent flow and a 'stagnant zone'. Three cases are presented: 2 with giant aneurysms (1 internal carotid and 1 sylvian) and 1 with a large aneurysm of the middle cerebral artery. In the latter, surgical treatment was performed, while in the others a conservative therapy was preferred. No ischemic manifestations were observed in the follow-up.     

Distal posterior cerebral artery aneurysm associated with multiple aneurysms

True congenital peripheral aneurysms of the cerebral arteries are rare and may constitute a special entity. We report a rare case of nonmycotic peripheral aneurysm of the posterior cerebral artery (PCA) found in association with aneurysms of distal middle cerebral artery (MCA), junction between basilar artery (BA) and superior cerebellar artery (SCA) and MCA trunk. Our present case was a 37-year-old man with a history of abrupt loss of consciousness. Cerebral angiography revealed a right PCA aneurysm originating at the junction between the trunk of the PCA and the posterior temporal branch, and also aneurysms of the right distal MCA, at the right BA–SCA junction and at the trunk of right MCA just distal to the anterior temporal artery. Distal PCA aneurysm causing subarachnoid hemorrhage was successfully clipped and all the other aneurysms were treated in a one-stage procedure. Pathological examination of the surgically excised distal PCA aneurysmal sac demonstrated no infectious etiology. There have not been any similar cases showing an association of vascular anomalies with distal PCA aneurysm. This is the only reported case with the association of nonmycotic peripheral aneurysms involving the MCA and PCA.     

Microvascular and transcranial Doppler sonographic evaluation of cerebral aneurysm flow pattern

Abstract

Ninety percent of cerebral aneurysms were diagnosed after their first rupture with consecutive subarachnoid haemorrhage. In order to detect the aneurysms before rupture investigation by transcranial Doppler sonography was used on the basis of intra-operative evaluation of the normal aneurysmal flow pattern. In 34 patients the directly registered aneurysmal flow pattern was characterized by mean velocities slower than in parent arteries, by low diastolic flow velocities and by additional peaks superimposed on the normal pulse curve. The transcranial investigation with a large sample volume which includes aneurysm and parent artery was not able to distinguish this aneurysmal flow pattern from the normal one. Only in large to giant aneurysms a pathological flow pattern could be recorded transcranially.     

73例颅内动脉瘤术中破裂的处理体会

目的　探讨动脉瘤术中破裂的对应措施。方法　在控制性低血压下按动脉瘤的解剖特点游离动脉瘤。一旦破裂出血 ,可临时夹闭载瘤动脉 ,或在破裂口处压以涂上医用生物胶的一小块明胶海绵封闭破裂口 ,出血控制后稳妥地夹闭瘤颈。结果　 73例中 6 8例行动脉瘤颈夹闭术。其余 5例 ,分别行囊壁切除动脉修补术、瘤体切除术及颈内动脉血管重建术。治愈率为 93.2 % ,病死率 6 .8%。结论　按动脉瘤的解剖特点游离动脉瘤是控制动脉瘤术中破裂出血的前提 ;有预见性地采用控制性低血压和暂时阻断载瘤动脉或用涂以医用生物胶的小块明胶海绵封闭破裂口是术中控制动脉瘤破裂出血的重要应急措施。