一次性开颅手术治疗颅内多发动脉瘤

报道７例颅内多发动脉瘤。每例均有２个动脉瘤，其中１３个为囊性，１个为梭形。有１例为双侧脉络膜前动脉对称性囊性动脉瘤。经单侧额颞开颅，翼点入路将全部囊性动脉瘤一次性夹闭。经术中瘤囊穿刺及术后动脉造影证实动脉瘤被完金夹闭。梭形动脉瘤仅用肌肉包裹。术后病人均恢复良好，无手术死亡和重残。结合我们的病例，本文对颅内多发性动脉瘤的识别、手术时机及手术方法进行了讨论，强调有条件时，对颅内多发性动脉瘤应及时一次性手术治疗。     

Prevalence of intracranial saccular aneurysms in a Japanese community based on a consecutive autopsy series during a 30-year observation period. The Hisayama study.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage is a life-threatening disease that occurs mostly because of the rupture of intracranial saccular aneurysms. However, little is known about the prevalence of ruptured and unruptured aneurysms in the general population. The aim of the present study was to examine the prevalence of intracranial aneurysms on the basis of a consecutive autopsy series over a 30-year observation period in a general Japanese population in Hisayama. METHODS: We evaluated 1230 consecutive autopsy cases with craniotomy among the total deaths of Hisayama residents during 1962 through 1991 (overall autopsy rate, 80.1%). RESULTS: A total of 73 intracranial saccular aneurysms were found in 57 cases (4.6%). The prevalence of aneurysms for women was 2.4 times higher than that for men (7.1% versus 2.9%). Among men, the prevalence of aneurysms remained unchanged across the range of age groups. In contrast, there were 2 peaks in the prevalence of aneurysms for women falling in the 40- to 49-year (14.3%) and 60- to 69-year age groups (14.5%). The most common site of the aneurysms was the middle cerebral artery (31.5%), followed by the anterior communicating artery (30.1%), anterior cerebral artery (15.1%), vertebrobasilar artery (12.3%), and internal carotid artery (11.0%). Among these 73 aneurysms, 29 (39.7%) were ruptured. Ruptured aneurysms were common in subjects <80 years of age, whereas unruptured aneurysms were prevalent in those >/=80 years of age. The frequency of ruptured aneurysms was highest in the vertebrobasilar system (66.7%) and lowest in the middle cerebral artery (13.0%). CONCLUSIONS: Our data suggest that intracranial aneurysms are more frequent in women in the general Japanese population. Aneurysms are more prevalent in the middle cerebral artery, but the risk of rupture is highest in the vertebrobasilar system.     

Expressions of PDGF-B and collagen type III in the remodeling of experimental saccular aneurysm in rats

The essential etiologic factors of intracranial berry aneurysm may be the hemodynamic stress on the arterial wall. Vascular remodeling triggered by abnormal hemodynamic stress on the blood vessels may play an important role in the formation, development and rupture of intracranial aneurysms. However, the specific causative mechanisms associated with this remain elusive. In this study, we look for the possible mechanism of platelet-derived growth factor B (PDGF-B) on the pathogenesis of saccular aneurysms in rats. Direct microsurgical destruction of the arterial intima and internal elastic lamina at the bifurcation of the carotid artery was performed in 30 rats to induce saccular aneurysms and the contralateral carotid arteries were ligated in half of them. After 4-5 months, the size of the aneurysms was determined. The expressions of PDGF-B and collagen type III on the walls of the normal carotid arteries and the saccular aneurysms were determined by in situ hybridization and immunohistochemistry. Saccular aneurysms could be induced immediately by destroying the intima and internal elastic lamina at the bifurcation of the carotid artery in rats. Saccular aneurysms grew significantly due to the hemodynamic stress in 4-5 months, and much bigger after the ligation of the contralateral carotid artery which enhanced the hemodynamic stress. There was no PDGF-B expression on the walls of the normal carotid arteries in rats, but it was expressed on the aneurysmal walls and more distinctly with the growth of the saccular aneurysms. However, there was collagen type III expression on the media of the normal carotid artery, but its expression decreased on the aneurysmal walls and further reduced with the growth of the saccular aneurysms. So, PDGF-B may induce the expression of MMP for the degradation of collagen type III on the wall of the saccular aneurysms. This may be one of the important mechanisms on the pathogenesis of the saccular aneurysm.     

Type III collagen deficiency in saccular intracranial aneurysms. Defect in gene regulation?

BACKGROUND AND PURPOSE: We sought to determine whether there are mutations in the COL3A1 gene in patients with saccular intracranial aneurysms with a type III collagen deficiency and whether there is an association between a marker in the COL3A1 gene and saccular intracranial aneurysms. One of the heritable factors possibly involved in the pathogenesis of saccular intracranial aneurysms is a reduced production of type III collagen, demonstrated earlier by protein studies. METHODS: We analyzed the type III collagen gene in a group of 41 consecutive patients with an intracranial aneurysm, of whom 6 patients had shown a reduced production of type III collagen in cultured diploid fibroblasts from a skin biopsy. RESULTS: No mutations could be demonstrated in the COL3A1 gene, especially not in the globular N- and C-terminal regions. A null allele was excluded in 25 patients, including 1 patient with a decreased type III collagen production. No differences were found between 41 patients and 41 controls in allele frequencies of a DNA tandem repeat polymorphism located in the COL3A1 gene. CONCLUSIONS: It is concluded that the COL3A1 gene is not directly involved in the pathogenesis of most of intracranial aneurysms. The reduced type III collagen production in cultured fibroblasts found in some patients with an intracranial aneurysm is not explained by the present study and needs further exploration.     

iNOS在颅内囊性动脉瘤瘤壁中的表达及意义

目的探讨诱导性一氧化氮合酶（iNOs）在颅内囊性动脉瘤瘤壁中的表达及其意义。方法应用免疫组化染色和原位杂交染色技术检测iNOS在颅内囊性动脉瘤和正常动脉血管壁组织中的表达。结果所有脑动脉瘤标本中均可见iNOS表达，而正常脑动脉标本中则未见其表达：iNOS阳性表达部位主要在动脉瘤壁外膜和中膜的炎症浸润区的炎症细胞（如淋巴细胞、单核巨噬细胞）的胞浆内。结论动脉瘤的发生可能与局部iNOS过度表达，继而合成大量的NO有关。     

Effect of intermittent blood pressure elevation on the growth of experimental saccular aneurysms in the rat.

In this study we applied the technique described in the previous paper (see pp. 103-106 of previous issue (1991); 13(2)) to rats with experimental saccular aneurysms. We found that the mean sizes and some growth ratios of experimental aneurysms were significantly larger in the intermittent blood pressure elevation groups than in the control groups. The increase of growth ratios was proportional to the number of transient blood pressure elevations. The morphological structure of these saccular aneurysms showed that the regenerative processes in the aneurysm wall had obviously been interfered with in animals with intermittent blood pressure elevation. The effective mechanism of this influential factor is discussed.     

微弹簧圈血管内栓塞治疗205例颅内囊状动脉瘤

目的：介绍微弹簧圈血管内栓塞治疗２０５例颅内囊状动脉瘤。方法：用微弹簧圈经血管内栓塞治疗颅内囊状动脉瘤２０５例。使用国产和进口的普通微弹簧圈和机械性可脱性微弹簧圈，大多数病例在局部麻醉下施术。２４例蛛网膜下腔出血（ＳＡＨ）急性期治疗请麻醉师协助。结果：本组２０５例中无死亡率，手术当时完全闭塞动脉瘤１８３例，不完全闭塞２２例。１２６例经１～３年随访无一例再出现ＳＡＨ。结论：微弹簧圈血管内栓塞治疗颅内囊状动脉瘤是可行的治疗方法，特别是窄颈动脉瘤。其效果确实，创伤小，病人恢复快。但是动脉瘤栓塞治疗的远期效果还有待进一步大宗病例的血管造影随访观察。     

The relationship of blunt head trauma, subarachnoid hemorrhage, and rupture of pre-existing intracranial saccular aneurysms

Patients with a history of closed head trauma and subarachnoid hemorrhage are uncommonly diagnosed with an intracranial saccular aneurysm. This study presents a group of patients in whom a pre-existing aneurysm was discovered during work-up for traumatic subarachnoid hemorrhage. Without an accurate pre-trauma clinical history, it is difficult to define the relationship between trauma and the rupture of a pre-existing intracranial saccular aneurysm. We retrospectively reviewed 130 patients who presented to Detroit Receiving Hospital between 1993 and 1997 with a diagnosis of subarachnoid hemorrhage (SAH). Of these 130 patients, 70 were spontaneous, and 60 had a history of trauma. Mechanisms of trauma include motor vehicle accident, assault, or fall from a height. Of the 60 patients with subarachnoid hemorrhage and a history of trauma, 51 (86%) did not undergo conventional four-vessel angiography, and had no further neurological sequelae. Nine patients (14%) had a suspicious quantity of blood within the basal cisterns or Sylvian fissure and had a four-vessel angiogram. Five patients (8%) were diagnosed with a saccular intracranial aneurysm, and all underwent surgical clipping of the aneurysm. We conclude that the majority of patients (92%), with post-traumatic SAH do not harbor intracranial aneurysms. However, during initial evaluation, a high level of suspicion must be entertained when post-traumatic subarachnoid hemorrhage is encountered in the basal cisterns or Sylvian fissure, as 8% of our population were diagnosed with aneurysms.     

Transient focal cerebral ischemia as a presenting manifestation of unruptured cerebral aneurysms

Few reports have described an association between cerebral transient ischemic attacks (TIAs) and unruptured cerebral aneurysms. This study presents seven patients with TIA who had aneurysms in a vascular distribution appropriate to their clinical symptoms. In three patients, angiographic evidence of embolization was present distal to the aneurysm without another apparent cardiac or extracranial arterial source for the emboli. The most reasonable pathogenesis for TIA in a patient with an associated saccular aneurysm would be thrombosis of the aneurysmal sac with subsequent embolization. However, subarachnoid blood can cause permanent focal intracranial narrowing, and this appeared to be a factor in at least one patient. The results imply that patients with symptoms of TIA should have their intracranial arterial circulation visualized as part of the diagnostic evaluation.     

Effect of contralateral carotid ligation on experimental carotid artery aneurysm in the rat.

Haemodynamic factors in the formation and development of saccular aneurysms have been widely studied. Saccular aneurysms could appear and grow at the side of the increased blood flow. The effects of contralateral carotid ligation on the formation and growth of our experimental saccular aneurysms were studied. Measurement and pathological examination showed that the haemodynamic changes could facilitate the development of saccular aneurysms, but by itself could not bring about their formation.     

颅内囊性动脉瘤VEGF表达与瘤壁超微结构变化

目的　探讨颅内囊性动脉瘤(ISA)血管内皮细胞生长因子(VEGF)的表达及瘤壁超微结构特征。方法　采用免疫组化方法检测正常脑组织血管和ISA中VEGF的表达情况;透射电镜观察动脉瘤壁超微结构变化。结果　ISA组VEGF表达较正常对照组显著增高(P <0 0 5) ,免疫阳性产物主要分布于动脉瘤壁的中膜层;ISA的内皮细胞变性脱落,胞浆内出现肿胀的线粒体和大小不等的空泡,瘤壁可见形态异常的平滑肌细胞和成纤维细胞,增多的胶原纤维排列紊乱。结论　VEGF表达可能与ISA的血管退行性变以及瘤体的形成、扩大和破裂有重要关系。     

电解可脱性弹簧圈超早期栓塞颅内破裂囊性动脉瘤

目的 总结２２例电解可脱性弹簧圈（Ｇｕｇｌｉｅｌｍｉ ｄｅｔａｃｈａｂｌｅ ｃｏｉｌ,ＧＤＣ）超早期栓塞颅内破裂囊性动脉瘤的经验。方法 女１４例,男８例,年龄４０￣８５岁,平均６２岁。均以自发性蛛网膜下腔出血急诊入院手术,按ＨＥＳＳ－ＨＵＮＴ分级Ⅲ级９例,Ⅳ级１３例。基底动脉顶端动脉瘤８例,前交通动脉动脉瘤５例,颈内动脉－后交通动脉动脉瘤５例,海绵窦部动脉瘤２例,大脑中动脉分叉部动脉瘤２例。６例行     

Aneurysm of pericallosal artery]

The authors describe 3 cases of saccular aneurysms of the pericallosal artery. They accounted for 3.36% of all intracranial aneurysms in the material of the authors. Difficulties in management of pericallosal artery aneurysms are discussed. All patients with aneurysms in this area were operated upon from an approach through the interhemispheric fissure and the results were good.     

A method for temporary and repeated increase of blood pressure in the rat, using intraperitoneal adrenaline injections.

In experimental studies, permanent hypertension has been considered to be an important factor in aneurysm formation and growth. However, in clinical studies it has been found that saccular aneurysms often develop and rupture in some patients without persistent hypertension. Environmental events that temporarily and repeatedly increase blood pressure do not take an equivalent length of time in vivo but have been noted as factors in the growth or rupture of saccular aneurysms. In order to test the effect of intermittent blood pressure elevations on saccular aneurysm formation and growth, a reliable method for temporarily and repeatedly increasing blood pressure should be developed first and in this paper, such a model is described. It is based on the intraperitoneal injections of adrenaline in rats, a route which does not seem to have been used so far.     

Risk of subarachnoid hemorrhage after surgical treatment of unruptured cerebral aneurysms.

BACKGROUND AND PURPOSE: Recent progress in noninvasive imaging techniques has resulted in increased detection of unruptured aneurysms. Although many neurosurgeons advocate surgical intervention for such unruptured aneurysms, the long-term results of surgery for unruptured aneurysms have not been carefully investigated. METHODS: We analyzed 173 consecutive patients who had unruptured intracranial saccular aneurysm(s) detected by angiography that was performed for reasons other than subarachnoid hemorrhage (SAH). Of those, 115 cases were surgically treated and studied. All patients were followed up for either SAH, repeat treatment of aneurysms, or death. The median follow-up period was 8.8 years. RESULTS: Four of the 115 patients suffered SAH either from a de novo aneurysm (2) or from regrowth of clipped aneurysm (1), or from regrowth after wrapping (1). Additionally, 1 patient also suffered SAH from an unstudied basilar aneurysm. One patient was incidentally found to have de novo aneurysm and underwent reoperation 14 years after the first operation. The cumulative risk for SAH for the 114 cases excluding the basilar aneurysm case was 1.4% in 10 years and 12.4% in 20 years. CONCLUSIONS: Although this study confirmed the long-term efficacy of clipping unruptured aneurysms, the risk of SAH was high compared with that in the general population, even after treatment. Considering the high mortality rate of SAH, long-term follow-up by angiography may be warranted for patients with surgically treated unruptured aneurysms.     

Totally thrombosed giant P2 aneurysm: a case report and review of literature.

The diagnosis and treatment of intracranial saccular giant aneurysms is still difficult despite developments in neuroradiology, neuroanesthesiology and micro-neurosurgery. These aneurysms are usually located on major intracranial arteries and are rarely on distal branches of these arteries. An extra-axial 4 x 5 cm mass lesion in the left mediobasal temporal region was detected on the CT and MRI examinations of a 37 year old male patient who was admitted to our institution with headache and slight right-sided hemiparesis lasting for 2 months. The lesion was avascular on angiography. Surgery proved that the lesion was a totally thrombosed giant aneurysm of the P2 segment of posterior cerebral artery (PCA). The P2 segment was clipped proximal to the aneurysm with pterional-transsylvian approach and the aneurysm was totally excised. Giant aneurysms of the P2 segment are rare and 15 cases have been reported in the literature. This report presents a rarely seen totally thrombosed giant P2 aneurysms and discusses the difficulties in diagnosis and treatment.     

颅内囊性动脉瘤破裂形态学的危险因素分析

目的研究颅内囊性动脉瘤破裂的形态学危险因素。方法回顾性分析551例（共611个）颅内囊性动脉瘤的病例资料,以动脉瘤破裂作为最后评定指标,分为破裂组（341个动脉瘤）和未破裂组（270个动脉瘤）,使用SPSS17.0统计软件包分析数据。结果两组之间动脉瘤长、瘤颈宽、载瘤动脉平均直径、载瘤动脉近端与动脉瘤长轴夹角（IA）、瘤体长与瘤颈宽之比（AR）、瘤体最大径与载瘤动脉平均直径之比（SR）、动脉瘤面积与瘤颈处动脉面积之比（S1/S2）、存在子瘤有显著差异（P〈0.05）。多因素Logistic回归分析显示：瘤颈宽〈1.7 mm（OR=2.318,95%CI=1.381-3.893,P=0.001）、存在子瘤（OR=12.512,95%CI=7.827-20.002,P〈0.001）、S1/S2〉2.1（OR=2.460,95%CI=1.408-4.300,P=0.002）为颅内囊性动脉瘤破裂的独立危险因素。结论动脉瘤长、瘤颈宽、载瘤动脉平均直径、IA、AR、SR、S1/S2、存在子瘤是动脉瘤破裂的形态学危险因素。     

Pathological changes in experimental saccular aneurysms in the carotid artery of the rat.

Although the reason for development of saccular aneurysms in humans has still not been elucidated, the process might be observed and explained using a reproducible aneurysm model in vivo. In this paper, a sequential pathological study of the experimental saccular aneurysms was made. No additional influential factors were applied. At all stages of the development between the induction and 6 months, the histology of the aneurysm wall was similar to that of human aneurysms. The imbalance of the degeneration and regeneration processes during the development of these experimental aneurysms is discussed according to the pathological findings in different periods. Haemodynamic stress and different regenerative speeds in different arterial tissues must be responsible for the saccular aneurysm formation and growth.