颅内巨大动脉瘤载瘤动脉球囊闭塞及颅内外血管搭桥术

目的 探讨颅内巨大动脉瘤的治疗方法及疗效，并对球囊闭塞载瘤动脉近段以及联合颅内外血管搭术治疗方法进行评价。方法 对载瘤动脉球囊闭塞术治疗的21例巨大动脉瘤病人的资料进行分析。载瘤动脉闭塞试验(BOD阳性，首先行颅内外血管搭桥，再行血管球囊闭塞。结果 21例巨大动脉瘤病例中，单用球囊闭塞载瘤动脉17例，联合颅内外搭桥4例。术后随访17例，6个月动脉瘤内血栓形成，2例动脉瘤缩小；2例3年后动脉瘤消失，2例颈内外动脉搭桥术随访3～4年，血管造影示吻合口通畅。结论对直接手术和填塞难以治愈的颅内巨大动脉瘤，载瘤动脉球囊闭塞以及联合颅内外搭桥术是一种有效可取的方法。     

颅内外血管重建用于颅内复杂动脉瘤的治疗(附11例分析)

目的探讨应用颅内外血管重建技术治疗颅内复杂动脉瘤的技术要点。方法回顾性分析应用颅内外血管重建技术治疗11例颅内复杂动脉瘤的经验。行颈外动脉-大隐静脉-大脑中动脉搭桥手术5例,颈外动脉-桡动脉-大脑中动脉搭桥手术3例,颞浅动脉-大脑中动脉搭桥手术2例,枕动脉-小脑后下动脉搭桥手术1例。搭桥手术后行动脉瘤孤立术5例,载瘤动脉近心端阻断术6例。结果术后血管造影或3D-CTA显示吻合血管通畅9例,急性闭塞1例,慢性闭塞1例;动脉瘤不显影10例,动脉瘤接受对侧椎动脉供血而需行进一步介入栓塞治疗1例。术后随访6～67个月,平均40.6个月;1例移植血管慢性闭塞病人在术后第50个月死亡,余10例病人临床表现不同程度改善,未发生再出血。结论颅内外血管重建结合载瘤动脉近心端阻断或动脉瘤孤立术是治疗颅内复杂动脉瘤的有效方法。     

血管吻合联合颈内动脉闭塞治疗海绵窦段巨大梭形动脉瘤2例

目的总结颈内动脉海绵窦段巨大梭形动脉瘤的的治疗方法。方法2例颈内动脉海绵窦段巨大梭形动脉瘤术前造影均存在交叉循环不良,行Matas试验均不能耐受,故先行颞浅动脉-大脑中动脉吻合术以增加脑供血。1例术后可以耐受颈内动脉阻断,行球囊闭塞颈内动脉治疗;另1例仍不能耐受Matas试验,采用逐渐阻断夹夹闭颈内动脉的方法治疗。结果2例术后症状消失治愈,随访8个月～1.5年生活良好。结论对海绵窦段巨大动脉瘤,可采取间接手术包括阻断动脉瘤近侧段载瘤动脉,促使动脉瘤内血栓形成以闭塞动脉瘤的方法治疗。若术前交叉循环造影示侧支循环不良,可先行颅内-颅外血管吻合以增加侧支供血,再用球囊或手术将载瘤动脉近段闭塞。     

颅内复杂动脉瘤搭桥孤立术疗效观察

目的 探讨颅内外血管吻合或搭桥联合动脉瘤孤立术治疗颅内巨大型复杂动脉瘤的术式选择及适应证.方法 回顾分析2008年2月-201 1年12月经脑血管造影术明确诊断的12例颅内巨大型动脉瘤患者术前评价方法 及手术治疗经过.结果 12例患者中颈内动脉系统巨大型动脉瘤6例(4例位于颈内动脉海绵窦段或床突段、2例位于颈内动脉交通段),大脑中动脉巨大型动脉瘤3例,后循环动脉瘤3例.其中7例术前MR灌注成像显示载瘤动脉远端组织存在明显缺血.选择行颞浅动脉.大脑中动脉低流量血管吻合术;5例载瘤动脉远端组织供血正常,且搭桥血管长度较长(≥15 cm)、术前球囊闭塞试验呈阴性、患侧压颈脑血管造影侧支循环充盈不良患者,行高流量颅内外血管搭桥术.11例术后神经功能缺损程度评价良好,改良Rankin量表评分0-3分;1例术后4分,3个月后改善至3分.结论 对于无法施行塑形夹闭术的颅内复杂巨大型动脉瘤患者,颅内外血管吻合或搭桥联合动脉瘤孤立术是其可选择的最后方法 ;而MR或CT灌注成像观察载瘤动脉远端组织供血正常与否.是选择不同流量血管吻合或搭桥术的关键.枕动脉、颞浅动脉或桡动脉为常用搭桥血管.     

载瘤动脉闭塞术治疗颅内巨大动脉瘤的探讨

目的总结和探讨脑血管造影和载瘤动脉闭塞在治疗颅内巨大动脉瘤上的作用及特点。方法60例颅内巨大动脉瘤患者,根据其脑血管造影的特点采取血管内介入方法[可脱式球囊和(或)弹簧圈]闭塞载瘤动脉近端53例、闭塞载瘤动脉两端后孤立动脉瘤7例;其中23例闭塞前先行颅内-外血管搭桥术。结果出院时Rankin评分分级:单纯血管内介入治疗组37例中轻残3例,合并颅内-外血管搭桥术组23例中死亡1例、重残2例。1-6年的影像学随访动脉瘤无复发。结论血管内介入结合颅内-外血管搭桥术闭塞载瘤动脉是治疗颅内巨大动脉瘤的方法之一。     

"双保险"颅内外血管搭桥术在巨大颈内动脉海绵窦段动脉瘤术中的应用

目的 探讨巨大颈内动脉海绵窦段动脉瘤治疗中,"双保险"颅内外血管搭桥术的适应证、手术技巧和疗效.方法 对5例巨大颈内动脉海绵窦段动脉瘤采用"双保险"颅内外血管搭桥(颞浅动脉-大脑中动脉;颈外动脉-桡动脉-大脑中动脉)、颈内动脉阻断术治疗,分析其治疗效果.结果 术后血管造影显示,4例吻合血管通畅,1例颞浅动脉-大脑中动脉吻合口狭窄.5例动脉瘤均不显影.随访3-24个月,临床症状均有好转,无动脉瘤复发或破裂.结论 "双保险"颅内外血管搭桥能有效防治术中、术后脑缺血,提高手术安全性,是治疗巨大颈内动脉海绵窦段动脉瘤有效、安全的方法.     

颅内外血管搭桥术对颅内动脉瘤的临床诊疗实效性评价

目的探究颅内外血管搭桥术对颅内动脉瘤的临床诊疗实效性。方法回顾性分析2013-10-2015-05在我院进行治疗的颅内动脉瘤18例患者的临床资料、手术方式、复查与随访结果,观察颅内外血管搭桥术的临床效果。结果 2例术后2h发生偏瘫,经检查其大隐静脉内有血栓出现,立即手术取栓,1个月后患者完全康复。2例行夹闭载瘤动脉时发生出血情况。余14例术后经过均顺利。随访中8例手术6个月后行血管超声复查,搭桥血管通畅。4例巨大动脉瘤患者术后2a复查发现动脉瘤明显减小。2例患者双侧颈内动脉海绵窦段巨大动脉瘤先行右侧颞浅动脉大脑中动脉搭桥并右侧颈内动脉球囊闭塞,在手术5a后进行复查,可见其主要通过搭桥血管进行供血。结论在对颅内动脉瘤患者进行治疗时,颅内外血管搭桥术效果良好,应在临床中推广使用。     

颅内外血管搭桥术治疗颅内巨大型动脉瘤

目的 报告采用动脉瘤夹闭联合颅内外血管搭桥术治疗6例颅内巨大型动脉瘤患者的临床经过,探讨手术适应证及治疗效果.方法 回顾分析6例颅内巨大型动脉瘤患者颅内外血管搭桥术前血流动力学状态、搭桥方式,以及临床和影像学转归.结果 6例患者中3例施行动脉瘤夹闭、切除(或载瘤动脉重建)联合颞浅动脉.大脑中动脉搭桥术,3例行动脉瘤夹闭、切除(或孤立)联合高流量搭桥术(颈外动脉.桡动脉,大隐静脉.大脑中动脉搭桥术).手术后平均随访17个月,近远期脑血管造影和CT血管造影检查显示,搭桥血管及吻合口血流通畅;临床症状与体征得到不同程度改善,随访期间无急性出血性或缺血性脑血管事件发生.3例行联合低流量搭桥术患者远期改良Rankin量表评分2例0分、1例2分;3例联合高流量搭桥术患者远期改良Rankin量表评分1例0分、2例1分.结论 对于脑血管重建术可能牺牲载瘤动脉或远端大脑中动脉血流的颅内复杂动脉瘤患者,可根据具体情况联合各种颅内外血管搭桥术使血流得到有效代偿.脑血管造影联合CT灌注成像对颅内巨大型动脉瘤远端组织灌注状态及侧支循环评价具有一定参考价值.     

血管内治疗颅内巨大动脉瘤(附40例报告)

目的探讨颅内巨大动脉瘤的血管内治疗方法，并对疗效进行评价。方法对40例颅内巨大动脉瘤行血管内治疗，其中33例行载瘤动脉闭塞术．5例行动脉瘤栓塞术，2例行颞浅-大脑中动脉搭桥术后闭塞载瘤动脉。结果载瘤动脉闭塞术后死亡3例，动脉瘤栓塞术后死亡1例．其余病人临床状况良好。临床随访28例，状况均良好；CT随访18例，示8例动脉瘤缩小或消失；造影随访15例．示9例动脉瘤不显影．3例瘤体缩小，2例载瘤动脉再通，1例栓塞后动脉瘤复发。结论对于手术罔难的颅内巨大动脉瘤，血管内治疗是一种安全、有效的方法。     

颅内外血管搭桥术在颅内动脉瘤治疗中的应用

颅内动脉瘤的治疗从创始至今已经有一百七十余年的历史,其方法主要是开颅夹闭术和血管内介入栓塞术.然而,对于复杂的动脉瘤如巨大动脉瘤、宽颈动脉瘤、蛇形动脉瘤,或存在动脉分支融合进瘤壁的动脉瘤等,难以通过单纯手术夹闭或介入栓塞的方法进行治疗,而需行颅内外动脉搭桥合并动脉瘤孤立手术来治疗.但颅内外动脉搭桥术治疗颅内动脉瘤由于技术复杂、容易出现并发症,因此行动脉搭桥术的医生必须对动脉搭桥术治疗动脉瘤的历史、手术指征和搭桥方法有明确的了解,才能更好地运用这一技术治疗复杂动脉瘤.故本文对颅内外血管搭桥术治疗动脉瘤的发展历史、手术指征和搭桥方法进行综述.     

Result of Extracranial-Intracranial Bypass Surgery in the Treatment of Complex Intracranial Aneurysms : Outcomes in 15 Cases

Objective

The standard treatment strategy of intracranial aneurysms includes either endovascular coiling or microsurgical clipping. In certain situations such as in giant or dissecting aneurysms, bypass surgery followed by proximal occlusion or trapping of parent artery is required.

Methods

The authors assessed the result of extracranial-intracranial (EC-IC) bypass surgery in the treatment of complex intracranial aneurysms in one institute between 2003 and 2007 retrospectively to propose its role as treatment modality. The outcomes of 15 patients with complex aneurysms treated during the last 5 years were reviewed. Six male and 9 female patients, aged 14 to 76 years, presented with symptoms related to hemorrhage in 6 cases, transient ischemic attack (TIA) in 2 unruptured cases, and permanent infarction in one, and compressive symptoms in 3 cases. Aneurysms were mainly in the internal carotid artery (ICA) in 11 cases, middle cerebral artery (MCA) in 2, posterior cerebral artery (PCA) in one and posterior inferior cerebellar artery (PICA) in one case.

Results

The types of aneurysms were 8 cases of large to giant size aneurysms, 5 cases of ICA blood blister-like aneurysms, one dissecting aneurysm, and one pseudoaneurysm related to trauma. High-flow bypass surgery was done in 6 cases with radial artery graft (RAG) in five and saphenous vein graft (SVG) in one. Low-flow bypass was done in nine cases using superficial temporal artery (STA) in eight and occipital artery (OA) in one case. Parent artery occlusion was performed with clipping in 9 patients, with coiling in 4, and with balloon plus coil in 1. Direct aneurysm clip was done in one case. The follow up period ranged from 2 to 48 months (mean 15.0 months). There was no mortality case. The long-term clinical outcome measured by Glasgow outcome scale (GOS) showed good or excellent outcome in 13/15. The overall surgery related morbidity was 20% (3/15) including 2 emergency bypass surgeries due to unexpected parent artery occlusion during direct clipping procedure. The short-term postoperative bypass graft patency rates were 100% but the long-term bypass patency rates were 86.7% (13/15). Nonetheless, there was no bypass surgery related morbidity due to occlusion of the graft.

Conclusion

Revascularization technique is a pivotal armament in managing complex aneurysms and scrupulous prior planning is essential to successful outcomes.     

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。     

Saphenous vein graft bypass in the treatment of giant cavernous sinus aneurysms: report of two cases

Two cases of giant intracavernous aneurysms treated by high flow bypass with saphenous vein graft between the external carotid artery (ECA) and branches of the middle cerebral artery (MCA) are presented. Very often these aneurysms are unclippable because they are fusiform or have a large neck. Occlusion of the internal carotid artery (ICA) is the treatment of choice in many cases. This procedure has however a high risk of brain infarction. Revascularization of the brain by extra-intracranial anastomosis between the superficial temporal artery (STA) and branches of the MCA is frequently performed. This procedure provides however a low flow bypass and brain infarction may occur. We report two cases of giant cavernous sinus aneurysms treated by high flow bypass and endovascular balloon occlusion of the ICA. Immediate high flow revascularization of MCA branches was achieved and the patients showed no ischemic events. Follow-up of 8 and 14 months after operation shows patency of the venous graft and no neurological deficits. Angiographic control examination showed complete aneurysm occlusion in both cases.     

Diagnostic and therapeutical considerations in the treatment of giant aneurysms

The treatment of giant aneurysms requires a thorough surgical and endovascular planning as this entity is accompanied by complex vascular and blood flow particularities. Even in experienced neurovascular centers the clinical outcome varies considerably. Within a series of 1386 aneurysm patients 72 (5%) giant (>25 mm) aneurysms were treated in our institution. Their age ranged between 26 and 81 years (medium age 52 years). 22 patients were suffering of a subarachnoid hemorrhage (SAH). Additionally there were 50 patients with nerve palsies or unspecific symptoms due to unruptured giant aneurysms (UGA). Treatment modalities included surgical clipping (n = 35), balloon occlusion of the ICA (n = 12), endovascular coiling (n = 7) or a combined regimen of balloon occlusion, surgical clipping and EC-IC bypass (n = 8). 10 patients could not be treated on due to their high age or minor clinical status (H&H IV and V). 6 of 15 (40%) SAH-patients were discharged without any complaints compared to 26% (12 of 47 patients) in the group of unruptured aneurysms. 1 SAH-patients (7%) versus 13 UGA (28%) patients suffered persisting nerve palsies or minor neurological disorders. 32% (n = 15) of the UGA-patients were suffering of major neurological deficits and required further professional help. 5 patients remained in a vegetative state, 3 of these had been admitted with an incidental finding of an UGA. 6 of 15 (40%) SAH-patients died, 5 of them admitted with H&H grade IV or V. However only 3 of 47 (6%) UGA patients died. 2 of these had a fatal SAH before treatment, 1 underwent EC-IC bypass surgery with insufficient hemispheric vascularization followed by gross infarction. The clinical status and age of the patient are significant factors influencing treatment associated morbidity and mortality. The individual vascular situation may lead to a complex therapeutical regimen thereby predisposes higher complication rates. We believe that surgical clipping is the first choice of treatment allowing temporarily clipping and reconstruction of the normal anatomy by shrinking or/and reconstructive clipping while reducing the mass effect. Whereas endovascular coiling alone is less favorable due to the packing of the coils a combined endovascular and surgical approach have to be considered in selected cases.     

头颅CT灌注成像在球囊闭塞试验中的辅助作用

目的探讨头颅CT灌注成像（CTP）在球囊闭塞试验（BOT）中的辅助判断作用。方法 20例经DSA确诊的颈内动脉巨大动脉瘤患者,临床判断为BOT阴性的同时行头颅CTP,通过比较双侧半球的脑血流量（CBF）、脑血容量（CBV）及达峰时间（TTP）对脑血流动力学进行评估。结果 20例患者均在BOT过程中完成CTP且无任何脑缺血症状,17例（85.0%）灌注对称,判断为耐受性良好,16例行永久性颈内动脉球囊闭塞术（其中4例联合动脉瘤部分栓塞术）,1例行颈内动脉慢性阻断术;3例（15.0%）灌注不对称,主要为阻断侧TTP延长,CBV正常或轻度升高,而CBF基本正常,即存在早期的脑血流动力学损害,认为其无法耐受颈内动脉的永久闭塞,其中2例行颅内外动脉搭桥联合动脉瘤孤立术,1例行支架辅助的动脉瘤致密栓塞术,载瘤动脉保留完整。所有患者随访15～32个月,均无远期缺血并发症。结论 CTP能检出BOT阴性者潜在的脑血流动力学损害,可以更客观地评估其对颈内动脉永久闭塞的耐受力,是BOT的重要补充。     

颈内动脉球囊闭塞术后产生对侧新生动脉瘤

目的 在国内献中首次报道1例床突旁动脉瘤(AN)病人在行载瘤动脉球囊闭塞术后5年出现对侧后交通AN并破裂。方法 行急诊手术夹闭该新生动脉瘤。结果 病人仍死于严重的颅内高压。回顾献共发现29例35个因颈动脉闭塞术后出现的新生AN，主要位于前、后交通动脉。结论 颈动脉闭塞后对侧血流代偿性增加可能是导致AN的原因，对大型AN应尽量采用保留载瘤动脉的方法；如闭塞载瘤动脉，应进行长期的影像学随访。     

Multimodal Treatment for Complex Intracranial Aneurysms: Clinical Research

Objective

For patients with giant or dissecting aneurysm, multimodal treatment consisting extracranial-intracranial bypass surgery plus clip or coil for parent artery occlusion may be necessary. In this study, the safety and efficacy of multimodal treatment in 15 patients with complex aneurysms were evaluated retrospectively.

Methods

From January 1995 to June 2007, the authors treated 15 complex aneurysms that were unable to be clipped or coiled. Among them, nine patitents had unruptured aneurysms and 6 had ruptured aneurysms. Aneurysms were located in the internal cerebral artery (ICA) in 11 patients (4 in the dorsal wall, 4 in the terminal ICA, 1 in the paraclinoid, and 2 in the cavernous ICA), in the middle cerebral artery (MCA) in 2, and in the posterior circulation in two patients

Results

Fifteen patients with complex aneurysms were treated with bypass surgery previously. Thirteen patients were treated with external carotid middle cerebral artery (ECA-MCA) anastomosis, and one patient with superficial temporal to posterior cerebral artery (STA-PCA) and another patient with occipital artery to posterior inferior cerebellar artery (OA-PICA) anastomosis. Parent artery occlusion was then performed with a clip in 9 patients, with a coil in 4, with balloon plus coil in one patient. All 15 aneurysms were successfully treated with clip or coil combined with bypass surgery. Follow-up angiograms showed good patency of anastomotic site in 10 out of 11 patients, and perfusion study showed sufficient perfusion in 6 out of 9 patients.

Conclusion

These findings indicate that for patients with complex aneurysms, clip or coil for parent vessel occlusion with additive bypass surgery can successfully exclude the aneurysm from the neurovascular circulatory system.     

应用高顺应性球囊辅助弹簧圈技术治疗颅内宽颈动脉瘤

目地探讨应用高顺应性球囊辅助弹簧圈治疗颅内宽颈动脉瘤。方法回顾分析33例颅内宽颈动脉瘤,颈/体≥0.7或瘤颈宽≥4mm,6例动脉分叉部动脉瘤应用高顺应性HyperForm球囊辅助弹簧圈技术治疗,其他27例宽颈动脉瘤应用HyperGlide球囊辅助弹簧圈技术治疗。结果33例应用高顺应性球囊辅助弹簧圈技术治疗的颅内宽颈动脉瘤的病例,25例完全填塞,5例次全填塞(≥90%),3例不全填塞(<90%);1例术中动脉瘤破裂,2例术中血管痉挛,23例影像随访6-12个月,无动脉瘤复发,载瘤动脉保持通畅其他10例临床随访,9例症状好转,1例死亡。结论在填塞颅内宽颈动脉瘤时选择合适的高顺应性球囊,可使部分颅内宽颈动脉瘤得到致密稳定的填塞。