前循环动脉瘤破裂并发颅内血肿的超早期显微手术治疗

目的探讨前循环动脉瘤破裂并发颅内血肿的超早期显微手术治疗。方法回顾性分析20例前循环动脉瘤破裂并发颅内血肿患者的临床资料,所有病例术前急诊行脑血管3D-CTA检查,在24小时内行显微外科动脉瘤夹闭手术。结果 20例患者共发现20个破裂动脉瘤,3个未破裂动脉瘤,破裂动脉瘤中前交通动脉瘤6个,颈内后交通动脉瘤8个,大脑中动脉瘤6个,未破裂动脉瘤中颈内后交通动脉瘤1个,脉络膜前动脉瘤1个,前交通动脉瘤1个,直接夹闭破裂动脉瘤和2个未破裂动脉瘤。术后GOS分级5分8例,4分2例,3分3例,2分4例,1分3例。结论前循环动脉瘤破裂并发颅内血肿病情发展迅速,3D-CTA应作为该类患者术前首选检查手段,超早期显微手术清除血肿夹闭动脉瘤能取得较好的效果。     

颅内动脉瘤的显微外科治疗

目的 :总结颅内动脉瘤显微外科治疗经验 ,探讨显微手术技巧。方法 :总结显微外科手术夹闭 2 1例颅内动脉瘤患者的临床资料 ,在气管插管全麻及控制性降压下手术 ,手术采用改良Yasargil入路 ,显微镜下直视操作 ,解剖动脉瘤颈 ,稳妥的夹闭动脉瘤蒂 ,必要时实行瘤体切除及瘤颈加固。结果 :2 1例全部行动脉瘤夹闭术。 2例因瘤体巨大在行瘤颈夹闭后行瘤体切除术。术中动脉瘤破裂 3例 ,死亡 1例。治愈率 95 .2 % ,死亡率 4.7%。结论 :显微外科技术对提高颅内动脉瘤手术成功率至关重要。动脉瘤术中破裂出血是手术失败和致死的重要原因。术中采用有效的控制性降压和临时阻断是处理术中动脉瘤破裂出血的重要应急措施。     

颅内动脉瘤显微夹闭术中并发症的预防及处理

目的 探讨颅内动脉瘤显微夹闭术中并发症的预防及处理措施.方法 在实施颅内动脉瘤显微夹闭术98例中,发生动脉瘤破裂17例,脑血管痉挛21例,对颅内高压者给予静脉滴注甘露醇或腰大池置管引流脑脊液,术中控制血压,在手术显微镜下操作夹闭动脉瘤.结果 术后恢复良好93例,不能生活自理3例,植物生存1例,死亡1例.结论 术中做好对并发症的预防及处理措施对提高效果至关重要.     

前交通动脉瘤的显微外科治疗

目的探讨前交通动脉瘤治疗中影像学检查对显微手术的作用、显微手术技巧、术中动脉瘤破裂的处理。方法总结15例前交通动脉瘤的显微神经外科手术治疗经验，采用Yasargil的经额颞翼点入路，夹闭瘤颈。结果术后愈合优良13例，轻残1例，死亡1例。结论影像学检查和显微外科手术对于成功的夹闭动脉瘤和减少并发症的发生起到相当重要的作用。     

脑动脉瘤破裂并颅内血肿形成的诊断和显微外科治疗

目的 探讨颅内动脉瘤破裂并颅内血肿形成患者的诊断、手术入路、操作技巧和治疗效果.方法 采用显微外科技术对23例Hunt-Hess分级Ⅲ-Ⅴ级的颅内动脉瘤破裂并血肿形成患者实施手术.并对其临床特点、影像学资料等进行回顾性分析.结果 单纯动脉瘤夹闭术4例,动脉瘤夹闭术加去骨瓣减压术18例,动脉瘤栓塞术加去骨瓣减压术1例.术后随访3个月～2年.按Glasgow预后指标分级:其中1级9例,2级8例,3级4例,4级1例,5级1例.结论 此类患者的临床特点、影像学等方面有别于其他类型动脉瘤,采取及时的诊断和恰当的治疗能够取得较好治疗效果.     

显微手术治疗破裂颅内动脉瘤155例

目的 通过总结颅内动脉瘤破裂的显微手术治疗,探讨颅内动脉瘤破裂的手术时机、手术技巧对术后疗效的影响.方法 系统总结2004年10月至2007年10月经手术治疗的155例破裂颅内动脉瘤的临床情况,以GOS计分评价患者出院时转归,比较不同手术时机对预后的影响.结果 155例中发现162个动脉瘤,单纯夹闭149个,夹闭加包裹4个,包裹6个.手术时间在发病72 h之内(包括72 h)79例,3～14 d(包括14 d)65例,14 d以上11例.术后恢复良好140例(90.3%),一般11例(7.1%),植物生存3例(1.94%),死亡1例(0.65%).不同手术时期患者出院时GOS评分差异无统计学意义(P＞0.05).结论 显微手术治疗破裂的颅内动脉瘤可取得满意疗效.     

颅内前循环动脉瘤的显微外科手术治疗

目的 探讨颅内前循环动脉瘤显微外科手术治疗方法,总结前循环动脉瘤治疗的相关经验.方法 回顾性分析近2年来显微外科治疗Ⅰ～Ⅳ级颅内前循环动脉瘤171例(共174个动脉瘤)的临床资料,以及不同部位动脉瘤的手术技巧及治疗经验.结果 Ⅰ～Ⅳ级颅内前循环动脉瘤171例,其中后交通动脉瘤67例,前交通动脉瘤56例,大脑中动脉瘤32例,颈内动脉分叉部动脉瘤10例,眼动脉瘤6例,多发动脉瘤3例.均成功进行了手术夹闭,术后GOS评分预后分级Ⅰ级3例,Ⅲ级6例,Ⅳ级14例,Ⅴ级148例.结论 良好的显露及显微外科技术是成功夹闭动脉瘤的关键;术中预判、动脉瘤夹合理的选择、载瘤动脉的正确阻断是值得重视的影响手术成败的因素.     

显微手术中亚低温对颅内破裂动脉瘤预后的影响

目的 观察颅内破裂动脉瘤行显微手术夹闭过程中应用亚低温处理对预后的影响.方法 回顾性对比分析2006年9月-2010年12月颅内破裂动脉瘤施行显微手术40例的临床资料,其中亚低温处理20例,常温处理20例.亚低温处理于麻醉诱导后开始,在打开硬脑膜前达到中心体温33℃～35℃,并持续至关闭硬脑膜后复温.常温处理除了不进行亚低温治疗外其余治疗方法与亚低温相同.观察记录患者术后1周内颅内血肿、颅内水肿、症状性脑血管痉挛、心衰、肺部感染、上消化道出血等并发症发生率、术后1周及随访3个月的GOS评分.结果 术后1周内复查头颅CT:常温处理组出现术后再出血1例,脑水肿2例,症状性脑血管痉挛9例,其中肺部感染2例,平均住院时间为(26.10±11.09)d.亚低温处理组出现脑水肿1例,症状性脑血管痉挛3例,其中肺部感染2例,平均住院时间为( 18.85±10.84)d.根据GOS评分:术后1周时预后良好率常温处理的为65.0％,亚低温处理的为90.0％;术后随访3个月,常温处理的预后良好率为85％,亚低温处理的为95％.结论 术中33℃～35℃亚低温处理可显著改善颅内破裂动脉瘤显微手术后1周的GOS预后评分,治疗效果较好.     

颅脑损伤合并颅内动脉瘤破裂出血10例

目的探讨颅脑损伤合并颅内动脉瘤破裂出血的临床特点及诊治。方法对本院6年收治的10例颅脑损伤合并颅内动脉瘤破裂患者的临床资料进行回顾性分析,总结临床特征及治疗。结果颅内动脉瘤破裂出血10例均行颅脑CTA证实。大脑中动脉瘤8例,后交通动脉瘤2例。恢复良好8例,轻度残疾1例,重度残疾1例。结论颅脑损伤应注意并发颅内动脉瘤破裂出血可能,颅脑CTA是早期诊断颅内动脉瘤的有效方法,熟练的颅内动脉瘤夹闭术能显著提高预后。     

颅内动脉瘤显微外科手术86例分析

目的 总结用显微外科治疗颅内动脉瘤的经验。方法 回顾分析近3年来显微外科手术夹闭的86例颅内动脉瘤患者的临床资料、手术方法及预后。结果 患者术后恢复良好69例,轻残10例,重残2例,死亡5例（5.8%)。结论 颅内动脉瘤一旦诊断明确,应积极手术以防再次出血。正确预防和处理动脉瘤术中破裂是手术成功的关键。多发动脉瘤应争取1次手术治疗。动脉瘤术后长期血管造影随访,可早期发现新生的动脉瘤。     

Dissection from Fundus to Neck for Ruptured Anterior and Middle Cerebral Artery Aneurysms at the Acute Surgery

Summary  It is generally believed that a ruptured aneurysm should be dissected from its neck to its fundus or that only the neck should be dissected. This study was conducted to clarify whether, during the acute stage, intra-operative bleeding occurs at the same site as the initial rupture point when aneurysms are dissected completely without clipping.  The subjects were 170 patients with ruptured anterior or middle cerebral artery aneurysms who were surgically treated by day 7. These aneurysms were operated on through an interhemispheric or a pterional route, respectively. Most of the aneurysms were dissected from the fundus to the neck. Complete exposure of entire aneurysms without temporary clipping was performed in 118 of 170 patients (69%). Intra-operative aneurysmal rupture occurred during 16 (9%) operative procedures. There were no significant correlations between the rate of intra-operative aneurysmal rupture occurrence and the timing of the operation, pre-operative grade or location of ruptured aneurysms. Intra-operative aneurysmal rupture occurred during dissection of the aneurysm itself in 8 patients, during dissection of the artery adhering to the aneurysm in 5 and during clip application in 3. In all the patients whose aneurysms ruptured during aneurysmal dissection, the rupture was caused by injury to the aneurysm and was not directly related to complete exposure of the aneurysm.  Intra-operative bleeding did not occur at the same site as the initial rupture point even when the entire aneurysmal complex was dissected from the fundus to the neck without clipping.     

Size and location of ruptured cerebral aneurysms diagnosed by three dimensional computed tomographic angiography

The purpose of this study is to confirm the correct size and the location of ruptured cerebral aneurysms diagnosed and measured using three dimensional computed tomographic angiography. The size and the location were investigated in 136 ruptured cerebral aneurysms encountered in our hospital during 3 years and 10 months. As regards the location of 136 ruptured cerebral aneurysms, 40 were anterior communicating artery aneurysms, 35 were middle cerebral artery aneurysms, 33 were internal carotid artery aneurysms, 12 were distal anterior cerebral artery aneurysms and 16 were posterior circulatory aneurysms. Twenty-seven aneurysms (19.9%) were smaller than 3.0 mm, and 74 aneurysms (54.4%) were less than 5.0 mm in maximum diameter. The maximum diameter of aneurysms located on the anterior communicating artery was 4.8 mm. On the middle cerebral artery it was 6.7 mm, and on the internal carotid artery it was 7.4 mm. We concluded that the rate of small aneurysmal rupture was comparatively more frequent than is reported. The results led to the speculation that the aneurysmal rupture occurred more often in smaller size, and the rate of occurrence may be also related to the aneurysmal location.     

Study of multiple cerebral aneurysms comprised of both ruptured and unruptured aneurysm--an analysis of incidence rate with respect to site and size

The purpose of this investigation was to study the incidence rate of rupture with respect to the site and size of multiple cerebral aneurysms that include both ruptured and unruptured aneurysms. Site and size were investigated in 58 cases of this type of multiple cerebral aneurysm. All cerebral aneurysms were examined with MR angiography, 3D-CT angiography and digital subtraction angiography, as well as seeing measured using 3D-CT or digital subtraction angiography. As regards the site of the 58 ruptured cerebral aneurysms under study, 18 were internal carotid aneurysms (C2 or C3: 4 cases, IC-PC: 12 cases, IC-ancho.: 1 case, IC terminal: 1 case), 25 were anterior communicating aneurysms, 10 were middle cerebral aneurysms, 4 were anterior cerebral aneurysms and 1 case was a VA-PICA aneurysm. The ruptured internal carotid aneurysms were 4.0-21.0 mm in size, the anterior communicating aneurysms were 1.8-13 mm, the middle cerebral aneurysms were 2.0-21.3 mm, the anterior cerebral aneurysms were 3.2-9.1 mm, and the VA-PICA aneurysm was 4.4 mm. The sites of the 89 unruptured cerebral aneurysms break down as follows: 29 were internal carotid aneurysms (C2 or C3: 4 cases, IC-PC: 10 cases, IC-ancho.: 10 cases, IC terminal: 5 cases), 18 were anterior communicating aneurysms, 34 were middle cerebral aneurysms, and there were 5 cases of posterior circulation aneurysm. In size, the unruptured internal carotid aneurysms were 1.0-18.3 mm, the anterior communicating aneurysms were 1.0-6.5 mm, the middle cerebral aneurysms were 1.0-10.3 mm, the anterior cerebral aneurysms were 1.0-3.3 mm, and the posterior circulation aneurysms were 2.2-17.3 mm. Out of 58 ruptured cerebral aneurysms, 44 were of the largest size category, and 53 (91.4%) were in the largest size category and/or anterior communicating aneurysms. The accumulated incidence rate of rupture of anterior communicating aneurysms rose suddenly upon reaching 2 mm in size, and after reaching 3 mm, these aneurysms accounted for a nearly uniform 55%-60% of the incidence rate of rupture. The accumulated incidence rate of rupture of IC-PC aneurysms rose drastically at 4 mm in size with the data describing a parabolic slope when graphed. IC-PC aneurysms represented a uniform 55% of the incidence rate of rupture after reaching 8 mm in size. The accumulated incidence rate of rupture of middle cerebral aneurysms rose in a gently sloping parabola beginning at 4 mm, and stabilized at 20% upon reaching 10 mm. These results suggest that each site is associated with a characteristic size and rate of aneurismal rupture. Special attention should thus be paid to large and anterior communicating aneurysms when operating on multiple cerebral aneurysms.     

Unruptured intracranial aneurysms in elderly patients.

A total of 556 patients with 769 intracranial aneurysms, of which 256 were unruptured and 513 were ruptured, were included in the present study. The patients were divided into three age groups: those aged 59 years or younger, those aged 60 to 69 years, and those aged 70 years or older. Small aneurysms of 4 mm or less in diameter were more common in the series of unruptured aneurysms than in the ruptured aneurysms. The rupture rate in anterior communicating artery aneurysms was the highest, and it increased with age. A follow-up study was performed on 47 patients with 55 unruptured aneurysms, and only one giant basilar artery aneurysm ruptured during the average follow-up period of 5.2 years. Direct operation was performed on 52 patients with unruptured aneurysms. While the surgical mortality rate was 0%, the morbidity rate was 6% (three of 52 cases), which was not directly related to the patients' age. When considering surgery for unruptured aneurysms, rupture rate of aneurysms at each site is one of the most important factors, especially in elderly patients.     

A case of ruptured internal carotid artery "kissing aneurysms": case report and review of the literature

OBJECTIVE: A rare case of ruptured kissing aneurysms on the right internal carotid-posterior communicating artery (ICPCA) and -anterior choroidal artery (ICAchA) is reported. CASE: A 47-year-old female was transferred to our hospital because of subarachnoid hemorrhage (SAH). Cerebral angiography revealed two aneurysms on the right ICPCA and ICAchA. Right frontotemporal craniotomy was performed to obliterate them on the day of admission. Despite the presence of angiographical cleavage, these two aneurysms were attached to each other tightly, and it was extremely difficult to dissect the space between them and premature rupture occurred. A Sugita long straight clip was inserted parallel to internal carotid artery to obliterate the body of ICAchA aneurysm and the neck of ICPCA aneurysm. Another straight clip was applied to the neck of the former aneurysm. Both PCA and AchA could be secured successfully. Postoperatively, although she developed symptomatic vasospasm on the 10th day, she discharged without any neurological deficits 40 days later. CONCLUSIONS: Because of the difficulty in dissection of aneurysms, the operation for kissing aneurysms has been recognized as hazardous and challenging since Jefferson. We emphasize that a clipping technique described above should be kept in mind as a safe value, though meticulous dissection of each aneurysmal neck followed by independent neck clipping is reasonable.     

颅内动脉瘤栓塞术围手术期护理策略及术中瘤体破裂的护理配合

目的探讨颅内动脉瘤行MicroPlex弹簧圈系统(MCS)栓塞术的围手术期护理策略及术中瘤体破裂的护理配合。方法回顾分析行MCS栓塞术的64例颅内动脉瘤患者临床资料(其中4例患者术中发生瘤体破裂),动脉瘤位于前交通动脉23例,后交通动脉17例,大脑前动脉14例,大脑中动脉9例,左颈内动脉1例。结果术中瘤体破裂4例,仍继续施行MCS栓塞术,其中3例获得治愈,1例因术后并发脑梗塞死亡。治愈63例,均获随访,平均6(3~24)月,均未见并发症发生。结论术前健康宣教,术中积极配合,术后密切观察病情,对减少颅内动脉瘤并发症的发生以及帮助病人顺利度过围手术期均具有十分重要的作用。     

Ruptured intracranial aneurysms: an autopsy study of 133 patients

The autopsy findings of 133 patients with ruptured intracranial aneurysms were reviewed: 24 (18%) had multiple aneurysms. Intraventricular hemorrhage was seen in 53 patients (40%), and intracerebral hematoma was seen in 52 (39%). Intraventricular hemorrhage was seen most frequently in patients with anterior communicating artery aneurysms [21 of 40 (53%)]. Intracerebral hematoma occurred most frequently in patients with middle cerebral artery aneurysms [11 of 28 (39%)]. Hemorrhages arising from anterior communicating artery aneurysms had two types of penetration routes into the lateral ventricle. The first was through the inferomedial portion of the frontal lobe, and the second was through the corpus callosum. The second type was poorly visualized in horizontal sections of the brain. Of 40 patients with anterior communicating artery aneurysms, the first type of penetration route was observed in 15, and the second type was found in 3. The second type is rare, and if the hemorrhage is not massive, it may be overlooked in axial computed tomography scans. Of the 109 ruptured aneurysms, 18 (17%) were 4 mm or less in diameter, 50 (46%) were 5-9 mm in diameter, and 41 (38%) were 10 mm or larger in diameter. In the 21 patients with multiple aneurysms, unruptured aneurysms were smaller than ruptured aneurysms in 17 of 27 (63%), equal size in 9 (33%), and larger in 1 (4%). Regarding rerupture, the larger the ruptured aneurysms were, the higher the percentage of rerupture, that is, 11% of 18 ruptured aneurysms of 4 mm or less in diameter, 32% of 50 of 5-9 mm in diameter, and 37% of 41 of 10 mm or larger in diameter had reruptured. It seems that the larger the size of the aneurysm, the higher the risk of rerupture as well as of initial rupture.     

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.     

Surgical management of unruptured aneurysms: prognostic indicators

BACKGROUND: The treatment of unruptured aneurysms (UA) remains controversial. Therefore, it has become necessary to define various prognostic indicators in the surgical treatment of unruptured aneurysms not associated with previously ruptured aneurysms. METHODS: During a 6-year period, 78 unruptured aneurysms were managed. The results of management were retrospectively reviewed to define the prognostic indicators. RESULTS: There were 104 patients with unruptured aneurysms who underwent surgical treatment. Seventy-five patients without previous subarachnoid hemorrhage (SAH) were selected for data analysis. Eighty-seven percent of the aneurysms were on the anterior circulation. The most common location was the middle cerebral artery (MCA) followed by the posterior communicating artery (PCom), ophthalmic artery, and anterior communicating artery (ACom). Six percent were found on the basilar artery. The mean size of aneurysms was 12.5 mm (range = 3-30 mm, SD = 7.4). At surgery, rupture of the aneurysm was encountered in eight cases with temporary control of the parent vessel being required in 31 procedures. In four cases, intraoperative angiography warranted clip reapplication. The Glasgow Outcome Scale (GOS) was used as an outcome measure. Surgical treatment resulted in good outcome (GOS 1) in 87% and 10.7% had fair outcome; 2.3% were in GOS 3 (severe disability) at 6 month follow-up. There was no mortality. Logistic regression identified significant relationships between GOS and intraoperative rupture (p < 0.0002), rupture and size (p < 0.003), and size and age (p < 0.01). CONCLUSIONS: Large size aneurysms were associated with intraoperative rupture, which had a strong correlation with poor outcome. Increased age showed a linear relationship with the size of the aneurysm. Overall results of treatment for UA are gratifying. There was no mortality. Early diagnosis and surgical extirpation of UA may reduce both intraoperative difficulties as well as poor outcome probability.     

A review of size and location of ruptured intracranial aneurysms

OBJECTIVE: To review our experience and examine the size at which aneurysms ruptured in our patient population. METHODS: Patient charts and angiograms for all patients admitted with a diagnosis of subarachnoid hemorrhage to the Thomas Jefferson/Wills Eye Hospital between April 1996 and March 2000 were reviewed. RESULTS: Of the 362 cases reviewed, definite measurements of the ruptured aneurysm were obtained in 245. The data clearly showed that most ruptured aneurysms presenting to our institution were less than 10 mm in diameter. We found that, regardless of location on the circle of Willis, 85.6% of all aneurysms presenting with rupture were less than 10 mm. Review by location shows that aneurysms of the anterior communicating artery most often presented with rupture at sizes less than 10 mm (94.4%). A large number of ruptured posterior communicating artery aneurysms also presented at sizes less than 10 mm (87.5%). This trend continued for all aneurysm sites in our review. The incidence of subarachnoid hemorrhage in Western countries is estimated at 10 per 100,000 people per year. Recent reports have indicated that aneurysms less than 10 mm in size are unlikely to rupture. CONCLUSION: We argue that the risk of small aneurysms rupturing is not insignificant, especially those of the anterior communicating artery. Our findings indicate that surgery on unruptured aneurysms should not be predicated on aneurysm size alone.