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.     

颅内镜像动脉瘤的外科治疗

目的 探讨颅内镜像动脉瘤的临床特点和治疗策略.方法 回顾性研究2007年11月至2012年11月治疗的19例20对颅内镜像动脉瘤患者资料.其中男性6例,女性13例,年龄32～75岁,平均56岁.双侧后交通动脉瘤11例(其中1例伴发双侧脉络膜前动脉瘤),双侧大脑中动脉分叉部动脉瘤4例,双侧床突旁动脉瘤3例,双侧胼周-胼缘动脉瘤1例.根据出血部位、Hunt-Hess临床分级、动脉瘤的部位、大小等制定手术策略.结果 一期同时夹闭两侧动脉瘤4例,二期分次夹闭两侧动脉瘤3例,手术夹闭联合介入栓塞动脉瘤2例,只处理一侧动脉瘤10例.出院时格拉斯哥评分(GOS)5分者15例(15/19),4分(轻残)4例(4/19).术后随访3～ 50个月,平均18.6个月.2例术后出现动眼神经麻痹,随访3个月1例恢复,1例未好转.10例对侧动脉瘤未处理者动脉瘤直径均小于5 mm且形态规则,为未破裂动脉瘤.9例一期或二期处理双侧镜像动脉瘤的患者随访时无动脉瘤残颈或复发.结论 颅内镜像动脉瘤是多发动脉瘤的一种特殊类型,应优先处理责任动脉瘤,对侧未破裂动脉瘤可以采取观察、一期同时处理或二期延期处理等策略.     

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。     

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8～37 d,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.     

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.     

双能量CT血管成像在颅内动脉瘤钛夹夹闭术后随访中的应用

目的探讨双能量CTA(DECTA)在颅内动脉瘤夹闭术后随访中的价值。方法对77例临床确诊为颅内动脉瘤并接受动脉瘤钛夹夹闭术的患者行DECTA检查,将原始数据传至后处理工作站进行图像重组,采用原始轴位图像与重建图像相结合的方式进行综合分析。结果 77例中,DECTA均能清晰显示动脉瘤夹闭情况、动脉瘤钛夹及载瘤动脉与其他颅内主要大血管的通畅情况;共84个动脉瘤接受手术夹闭,其中颅内动脉瘤完全夹闭82个,均未发生移位,动脉瘤颈残留2个;3例动脉瘤夹闭术后其他部位出现新发病灶,1例载瘤动脉血管纤细狭窄。结论 DECTA可作为颅内动脉瘤患者动脉瘤钛夹夹闭术后准确、无创的影像学随访方法。     

前交通动脉瘤的显微手术治疗

目的观察经翼点入路显微外科手术治疗前交通动脉瘤的疗效。方法前交通动脉瘤患者62例,采用翼点入路显微手术夹闭前交通动脉瘤瘤颈。结果显微手术成功夹闭动脉瘤62例,术后GOS评定:恢复良好50例(80.6%),轻度残废8例(12.9%),重度残疾2例(3.2%),死亡2例(3.2%)。38例术中神经电生理监测患者术中SSEPs变化4例,MEPs变化5例,EEG变化2例,术中监测无变化或虽有变化但干预后恢复者术后神经功能良好。术后复查,36例恢复良好,偏瘫2例。术后4例出现神经功能障碍,CT示脑组织挫伤或脑梗死灶。结论翼点入路显微手术治疗前交通动脉瘤安全有效。     

小脑上动脉动脉瘤的治疗体会

目的：探讨小脑上动脉动脉瘤的临床特点及治疗方法和效果。方法回顾性分析5例小脑上动脉囊性动脉瘤患者的临床资料。3例采用血管内介入治疗的患者中,2例使用支架辅助弹簧圈技术栓塞,1例单纯弹簧圈栓塞;2例行开颅夹闭术的患者,其中1例经颞下入路,1例经翼点入路。结果除1例经颞下入路开颅夹闭的患者术后遗留同侧动眼神经麻痹外,其余患者无神经功能障碍,痊愈出院;术后随访3～18个月,未见动脉瘤复发,无再出血病例。结论小脑上动脉动脉瘤发病率较低,临床表现以后循环蛛网膜下腔出血为主,可以根据具体情况采用血管内治疗或开颅手术,血管内治疗具有微创、疗效好和并发症少等特点,可以作为首选治疗方法。     

颅内多发动脉瘤的手术治疗

目的 探讨颅内多发动脉瘤的手术策略并分析临床疗效.方法 回顾性分析2009年1月至2013年12月手术治疗49例颅内多发动脉瘤患者的临床资料.49例患者中,男性12例,女性37例;平均年龄(49±11)岁;35例动脉瘤破裂,14例未破裂;治疗策略有一期手术(一侧入路夹闭所有动脉瘤),二期治疗(分期处理所有动脉瘤)和部分治疗(只处理责任动脉瘤).随访中复查脑CT血管造影(CTA)或数字减影血管造影(DSA),用格拉斯哥预后量表(GOS)评估预后.结果 一期手术32例(65.3％),二期治疗9例(18.4％),部分治疗8例(16.3％).47例随访4 ～ 49个月,平均(22 ±7)个月.术后CTA或DSA均未见动脉瘤复发.根据GOS评分,患者预后良好(4～5分)41例(83.7％),残疾(2～3分)6例(12.2％),死亡(1分)2例(4.1％).结论 在具有娴熟手术技术的前提下选择合适的患者,根据动脉瘤和患者的特征制定个性化的手术策略,能提高颅内多发动脉瘤的手术疗效.     

基底动脉分叉部动脉瘤夹闭的手术体会

目的分析两种不同的手术入路行夹闭基底动脉分叉部动脉瘤,探讨该手术入路方式、规范和改进手术操作等措施,提高手术成功率和改善患者预后。方法回顾性分析10例基底动脉分叉部动脉瘤在显微镜下经两种不同手术入路夹闭治疗的临床资料。结果 10例患者术后存活9例,1例患者术前患合并多种并发疾病,全身状况差,术后1个月因多器官功能衰竭死亡。结论根据基底动脉分叉部动脉瘤的形态、位置采用不同的手术入路进行规范夹闭术操作,能提高手术成功率,改善患者预后。     

Surgical treatment of bilateral multiple intracranial aneurysms. Review of a personal experience in 69 cases

AIM: There has been much controversy concerning the surgical treatment of bilateral multiple intracranial aneurysms. Some authors advocate the use of two-stage surgery by bilateral pterional craniotomies and others advocate the one stage complete repair of all lesions using the contralateral approach. We analyze the surgical experience of one neurosurgeon using both approaches. METHODS: Sixty nine patients operated on for bilateral multiple intracranial aneurysms were divided in three groups: group A comprised 43 patients (62.3%) in whom all bilateral aneurysms were treated by one stage operation; group B comprised 9 patients (13.0%) in whom the clipping of the contralateral aneurysm it was not possible through the same approach, needing a second operation; group C comprised 17 patients (24.7%) in whom all bilateral multiple intracranial aneurysms were treated by two stage operations. RESULTS: According to the Glasgow Outcome Scale 61 cases (88.4%) had excellent or good results (GOS V, IV), 2 cases (2.9%) had fair results (GOS III) and 6 patients have died (GOS I). The results of group A were significantly better than in-group B (p<0,05 Fisher test), but they were not different in relation to the group C (p=0,439 Fisher test). Among the six deaths, only one was related to the surgical procedure. CONCLUSIONS: Under favorable clinical situations, as patients in H&H I to III, good brain conditions during the surgical procedure and aneurysms smaller than 1,5 cm, the contralateral surgical approach for the treatment of patients with bilateral multiple intracranial aneurysms can be used with advantages over the two stage approach.     

Surgical management of an internal carotid lesion by contralateral pterional approach in bilateral intracranial aneurysms: report of two cases

Two cases of bilateral carotid aneurysms are reported in which the neck of remaining aneurysm was successfully clipped by way of a contralateral pterional approach. The authors emphasized that in some cases of bilateral intracranial aneurysms (e.g. Aneurysms of the unilateral circle of Willis' and ipsilateral middle cerebral aneurysm plus contralateral internal carotid aneurysm), this is the preferred approach.     

Results of the surgical treatment of multiple aneurysms--review of 372 cases

The authors review the surgical results in 372 cases of multiple intracranial aneurysms during this 25-year period in which one of the authors (JS) performed 2,000 direct operations for aneurysms. All patients were classified into four groups according to the location of aneurysms as follows: Group 1: multiple aneurysms including anterior communicating artery aneurysm (157 cases); Group 2: multiple aneurysms of unilateral anterior circulation (72 cases); Group 3: multiple aneurysms of bilateral anterior circulation (110 cases); Group 4: multiple aneurysms including vertebrobasilar artery aneurysms (33 cases). In multiple aneurysm cases, their policy has been to treat all aneurysms, ruptured and unruptured, in a one-stage operation whenever possible. About 90% of patients in both Group 1 and Group 2 were treated by one-stage operations, while 60% of patients in Group 3 and 42% of in Group 4 were operated on in the same manner. Excellent and good results in from 73% to 81% of cases was obtained in patients of Group 1, Group 2 and Group 3. Morbidity was 14-19% and mortality was 6-8%. These results were almost equal to the results with a single aneurysm of the anterior circulation. On the other hand, the surgical results in Group 4 were poor with a mortality of 27%. Poor results were attributable to the postoperative rebleeding from the untreated vertebro-basilar aneurysms, which were thought to be unruptured aneurysms preoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral abducens nerve palsies in treated cases of subarachnoid hemorrhage

Isolated abducens nerve palsies associated with the rupture of intracranial aneurysms have rarely been reported. We report two cases of isolated bilateral abducens nerve palsies occurring after subarachnoid hemorrhage due to the rupture of an intracranial aneurysm. Case 1: A 49-year-old woman had bilateral abducens nerve palsies following subarachnoid hemorrhage due to the rupture of the left vertebral artery-posterior inferior cerebellar artery aneurysm. Case 2: A 55-year-old man had bilateral abducens nerve palsies following subarachnoid hemorrhage due to dissecting aneurysm of the right vertebral artery. Case 1 and 2 were treated with surgical clipping of the aneurysm and internal occlusion of the parent artery. In both cases, bilateral abducens nerve palsies achieved almost full recovery several months after treatment. It is speculated that the main causes of palsies are compression and stretching of the bilateral abducens nerves by a thick clot in the prepontine cistern. Although most of the abducens palsies may be reversible and have good prognosis, it is important that they are kept in mind as isolated symptoms of subarachnoid hemorrhage.     

Surgical treatment of multiple aneurysms

Summary We review the surgical results in 372 cases of multiple intracranial aneurysms over a 25-year period in which one of us (JS) performed 2,000 direct operations for aneurysms. All patients were classified into four groups according to the location of the aneurysm: Group 1: multiple aneurysms including anterior communicating artery aneurysm (157 cases); Group 2: multiple aneurysms of unilateral anterior circulation (72 cases); Group 3: multiple aneurysms of bilateral anterior circulation (110 cases); Group 4: multiple aneurysms including vertebro-basilar artery aneurysms (33 cases).In multiple aneurysm cases, our policy has been to treat all aneurysms, ruptured and unruptured, in a one-stage operation whenever possible. About 90% of patients in both Group 1 and 2 were treated by one-stage operations, while 60% of patients in Group 3 and 42% of patients in Group 4 were operated on in the same manner.Excellent and good results in from 73% to 81% of cases were obtained in patients in Group 1, Group 2 and Group 3. Morbidity was 14–19% and mortality was 6–8%. These results were comparable to the results with a single aneurysm of the anterior circulation. On the other hand, the surgical results in Group 4 were poor with a mortality of 27%. Poor results were attributable to the postoperative rebleeding from the untreated vertebro-basilar aneurysms, which were thought to be unruptured aneurysms preoperatively.Furthermore, it was clarified that the results of early one-stage operations (within one week from onset) in patients with multiple aneurysms were satisfactory. In this group, there was good recovery in 84% of patients, 7% were disabled and 9% died. The morbidity was notably lower in patients operated on within one week than in those operated on after 8 days. Based on these results, the one-stage operation in the acute period is recommended for patients with multiple aneurysms.     

Contralateral approach to bilateral and ophthalmic aneurysms

In a previous survey, we found a high incidence of fatal rupture of an unclipped aneurysm in patients with multiple aneurysms. To deal with this problem, we introduced a more vigorous technique that accesses aneurysms previously considered unapproachable during one operating session. Attempts were made to clip middle cerebral and ophthalmic aneurysms contralateral to the operative exposure. We have successfully clipped contralateral aneurysms of the posterior communicating artery when bilateral aneurysms were present. We have also used this contralateral approach successfully with single ophthalmic and proximal carotid aneurysms that pointed medially. We review the cases of 39 patients with 43 intracranial aneurysms operated from the contralateral side and present the surgical technique in relation to the angiographic findings.     

Internal carotid artery bifurcation aneurysms: surgical experience

Internal carotid artery (ICA) bifurcation aneurysms are relatively uncommon and frequently rupture at a younger age compared to other intracranial aneurysms. We have treated a total of 999 patients for intracranial aneurysms, of whom 89 (8.9%) had ICA bifurcation aneurysms, and 42 of the 89 patients were 30 years of age or younger. The present study analyzed the clinical records of 70 patients with ICA bifurcation aneurysms treated from mid 1997 to mid 2003. Multiple aneurysms were present in 15 patients. Digital subtraction angiography films were studied in 55 patients to identify vasospasm and aneurysm projection. The aneurysm projected superiorly in most of these patients (37/55, 67.3%). We preferred to minimize frontal lobe retraction, so widely opened the sylvian fissure to approach the ICA bifurcation and aneurysm neck. Elective temporary clipping was employed before the final dissection and permanent clip application. Vasospasm was present in 24 (43.6%) of 55 patients. Forty-eight (68.6%) of the 70 patients had good outcome, 14 (20%) had poor outcome, and eight (11.4%) died. Patients with ICA bifurcation aneurysms tend to bleed at a much younger age compared to those with other intracranial aneurysms. Wide opening of the sylvian fissure and elective temporary clipping of the ICA reduces the risk of intraoperative rupture and perforator injury. Mortality was mainly due to poor clinical grade and intraoperative premature aneurysm rupture.     

Surgery of incidental intracranial aneurysms

A series of nine patients with an unruptured asymptomatic aneurysm not associated with a ruptured aneurysm is discussed. Three had giant aneurysms. Two patients had bilateral aneurysms of the middle cerebral artery. Five had solitary aneurysms of the middle cerebral artery. One had an aneurysm of the anterior communicating artery. One had an ophthalmic aneurysm. All aneurysms were clipped. Two operations were necessary in the two patients with bilateral aneurysms. There was no mortality and no significant morbidity. Clipping of the aneurysm is recommended for those patients who have no other serious illness that significantly increases the surgical risk. If a combination of pituitary tumor and aneurysm is found, a subfrontal instead of transsphenoidal approach should be considered so as to treat both the tumor and aneurysm at the same operation.     

Direct surgery for carotid bifurcation artery aneurysms

Eighteen patients with bifurcation of internal carotid artery aneurysms were treated with direct surgery. In all cases the pterional approach was used. The strategy used in dissecting the aneurysm depends on the size of the aneurysm and the length of the intracranial internal carotid artery. When the aneurysm is small, the bifurcation of the internal carotid artery can be exposed by dissecting along the internal carotid artery from a proximal-to-distal direction. The aneurysm and the perforating vessels adjacent to it are identified before the aneurysm is clipped. When the aneurysm is not small or if the intracranial segment of the internal carotid artery is long, the sylvian fissure has to be dissected open before dissection of the aneurysm and perforators is undertaken. Using this dissection strategy, 18 bifurcations of internal carotid artery aneurysms were clipped with 16 excellent, one good, and one fair result. There was no mortality.     

Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy

OBJECTIVE: With the increased use of endovascular therapy, an increasing number of patients with incompletely treated intracranial aneurysms are presenting for further surgical management. This study reviews our experiences with such patients. METHODS: During a 7-year period, 38 patients with 40 intracranial aneurysms who were initially treated with endovascular therapy underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry, and their clinical data and imaging studies were analyzed retrospectively. RESULTS: Twenty-six anterior and 14 posterior circulation aneurysms were treated. Four aneurysms were on the cavernous internal carotid artery, 13 were on the distal internal carotid artery, 6 were on the anterior communicating artery complex, 2 were on the middle cerebral artery, 3 were on the posteroinferior cerebellar artery, 1 was at the vertebrobasilar junction, 3 were on the superior cerebellar artery, 4 were at the basilar apex, 2 were on the posterior cerebral artery, and 1 was on the distal vertebral artery. Two pseudoaneurysms-one on the petrocavernous segment of the internal carotid artery and one on the distal VA-also were treated. The median time until recurrence was 6 months. Thirty-one aneurysms were clip-ligated, and six were treated with trapping. Three extracranial-intracranial bypasses were performed. One aneurysm was treated with muslin wrapping. Two aneurysms required the use of surgical approaches that involved hypothermic circulatory arrest. Nine aneurysms required coil mass extraction and/or complex vascular reconstruction to complete lesion obliteration. All aneurysms except the single wrapped aneurysm were successfully excluded from the intracranial circulation. Two deaths occurred as a result of the operative procedures, and another patient died as a result of subarachnoid hemorrhage-induced massive myocardial infarction. Ultimately, 86.8% of patients achieved an excellent or good recovery. CONCLUSION: With endovascular therapy assuming an increasing role in the treatment of patients with intracranial aneurysms, more lesions that are refractory to initial treatment will require surgical management. Our experience indicates that good results are attainable, although technical challenges are frequently encountered.