皮层电极在颅内动脉瘤术中监测中的应用研究

目的 研究颅内动脉瘤术中应用皮层电极进行皮层脑电图(EEG)和皮层运动诱发电位(MEP)监测的价值和意义.方法 42例颅内动脉瘤患者,翼点开颅夹闭动脉瘤术中常规行头皮EEG、体感诱发电位(SEP)、MEP和皮层EEG、MEP监测,将监测变化结果与术后神经功能做前瞻性研究.结果 36例可诱发出皮层MEP,8例监测出现了变化,其中SEP 4例、皮层EEG 6例、头皮EEG 2例、皮层MEP 7例、头皮MEP 5例.皮层MEP出现变化的6例非大脑前动脉系统动脉瘤中仅3例头皮MEP出现了变化.结论 皮层MEP所需刺激量小,较适合于非大脑前动脉动脉瘤的术中监测,其敏感性高于头皮MEP.皮层EEG监测的敏感性明显高于头皮EEG.     

Effects of intraoperative hypothermia on neuropsychological outcomes after intracranial aneurysm surgery

OBJECTIVE: Subarachnoid hemorrhage and surgical obliteration of ruptured intracranial aneurysms are frequently associated with neurological and neuropsychological abnormalities. We reported that intraoperative cooling did not improve neurological outcome in good-grade surgical subarachnoid hemorrhage patients, as assessed by the Glasgow Outcome Scale score or other neurological and functional measures (National Institutes of Health Stroke Scale, Rankin Disability Scale, Barthel Activities of Daily Living). We now report the results of neuropsychological testing in these patients. METHODS: A total of 1,001 patients who bled < or = 14 days before surgery were randomly assigned to intraoperative hypothermia (t = 33 degrees C) or normothermia (37 degrees C). Outcome was assessed approximately 3 months after surgery. Patients underwent the Benton Visual Retention, Controlled Oral Word Association, Rey-Osterrieth Complex Figure, Grooved Pegboard, and the Trail Making tests. T-scores for each test were calculated from normative data. T-scores were averaged to calculate a Composite Score. A test result (or the Composite Score) was considered "impaired" if the T-score was two or more standard deviations below the norm. A Mini-Mental State Examination was also performed. RESULTS: Neurological outcome data were available in 1,000 patients. Sixty-one patients died. Of the 939 survivors, 873 completed 3 or more tests (exclusive of the Mini-Mental State Examination). Patients with poor neurological outcomes were less likely to complete testing; only 3.9% of Good Outcome (Glasgow Outcome Scale score = 1) patients were untested, compared with 38.6% of patients with Glasgow Outcome Scale scores of 3 and 4. There were no prerandomization demographic differences between the two treatment groups. For hypothermic patients, 16.8% were impaired from their Composite Score versus 20.0% of patients in the normothermic group (p = 0.317). For patients in the hypothermic group, 54.5% were impaired on at least one test, compared with 55.5% of patients in the normothermic group (p = 0.865). Similar results were seen in patients with baseline WFNS scores = I. Mini-Mental State Examination scores in the hypothermic and normothermic groups were 27.4 +/- 3.8 and 26.8 +/- 4.5, respectively. INTERPRETATION: This is the largest prospective evaluation of neuropsychological function after subarachnoid hemorrhage to date. Testing was completed in a high fraction of patients, demonstrating the feasibility of such testing in a large trial. However, the frequent inability to complete testing in poor-outcome patients suggests that testing may be best used to refine outcome assessments in good-grade patients. Many patients showed impairment on at least one test, with global impairment present in 17 to 20% of patients (18-21% of survivors). This was true even among the patients with the best preoperative condition (WFNS = 1). There was no difference in the incidence of impairment between hypothermic and normothermic groups.     

The treatment of raised intracranial pressure following aneurysm surgery

The effect of intravenous mannitol infusion and withdrawal of cerebrospinal fluid on the intracranial pressure and clinical state was studied in 26 patients with raised intracranial pressure after direct surgery for ruptured aneurysm. Each method decreased the mean intracranial pressure by about 60% of the pre-treatment level. The maximal decrease following mannitol occurred after 60-90 minutes and generally lasted between three and four hours. The effects of mannitol did not decrease when repeated infusions were necessary. Rebound increases in the intracranial pressure following infusion were not observed. Withdrawal of cerebrospinal fluid lowered the intracranial pressure immediately and the effect persisted for approximately 60 minutes. This could be repeated as often as necessary and was without systemic disturbance, although a patent intraventricular catheter was necessary. The two methods could be used simultaneously.     

术中超声导航辅助切除脑动静脉畸形

目的探讨术中实时超声导航在脑动静脉畸形(AVM)外科治疗中的应用价值。方法26例脑AVM显微手术切除术中,使用Aloka SSD 4000型超声检查仪扫描,进行AVM定位、辨别供血动脉和引流静脉;确定血肿与AVM的关系以及血流动力学监测。病变切除后重复超声检查AVM残留与否,并与术后脑血管造影结果对比。结果26例畸形血管团均住实时超声下清晰显示并获得全切除。血肿区为高同声无血流信号;供血动脉与正常血管在血流动力学上有差别;术中超声影像所示的病变全切除为术后血管造影所证实。结论术中实时超声能够对脑AVM进行准确定位,指导皮质切口的设计,并可判定病灶是否全切除.对于术前的MRI、DSA检查起到很有价值的补充作用。     

颅内胶质瘤术中超声的临床应用

目的 探讨颅内胶质瘤术中超声的使用方法及其价值。方法 将2011年2月至2013年2月收治的72例颅内胶质瘤手术患者分为超声组（33例,使用术中超声）和对照组（39例,未使用术中超声）。超声组使用术中超声对肿瘤进行定位,引导术者选择合适的手术入路,并对切除后的瘤腔进行探查,实现最大程度地安全切除肿瘤。对比分析两组患者肿瘤的定位率和全切率以及手术时间。结果 超声组肿瘤定位准确率（100%）显著高于对照组（82.1%,32/39;PP<0.05）,超声组手术时间[（85.7±31.1）min]明显少于对照组[（117.4±40.8）min;>P<0.05]。低级别和高级别胶质瘤在超声图像上有不同的特征性表现。>结论 术中超声具有低成本、准备时间短、方便快捷、实时监测、可重复和无辐射等优点,是胶质瘤手术重要的辅助工具,在胶质瘤定位和实时监测残余肿瘤方面具有重要价值。     

An approach to intraoperative neurophysiologic monitoring of thoracoabdominal aneurysm surgery.

Thoracoabdominal aneurysm surgery carries an approximate 10% risk of intraoperative paraplegia. Abrupt cord ischemia and the confounding effects of systemic alterations and limb or cerebral ischemia challenges neurophysiologic spinal cord monitoring. This investigation sought a rapid differential monitoring approach to predict or help prevent paraplegia. Thirty-one patients were monitored with motor evoked potentials (MEPs) and median and tibial somatosensory evoked potentials (SSEPs). MEPs involved single-pulse transcranial electrical stimulation with D wave recording (n = 16), arm and leg muscle MEPs following multiple-pulse transcranial electrical stimulation (n = 12), or both (n = 3). D wave recordings required averaging, invasive epidural electrode insertion, and produced both false positives and false negatives. Muscle MEPs were instantaneous and reliably sensitive and specific for cord ischemia. Cortical and peripheral nerve SSEPs provided rapid detection of systemic alterations and cerebral or limb ischemia. Cord and subcortical SSEPs required excessive averaging time. In conclusion, bilateral arm and leg muscle MEPs with median and tibial peripheral nerve and cortical SSEPs provide sufficiently rapid detection and differentiation of cord ischemia from confounding factors. There were two predicted intraoperative spinal cord infarctions (6.5%) and nine circumstantial examples of possible contributions to deficit prevention.     

术中超声引导下显微手术切除颅内深部病灶

目的探讨术中超声对显微手术治疗颅内深部病灶（病灶中心距脑表面〉2 cm）的应用价值。方法2009年3月至2012年12月术中超声引导下显微手术切除颅内深部病灶112例（超声组）,同期未使用术中超声显微手术切除颅内深部病灶110例（对照组）。结果超声组所有病灶均在超声引导下精确定位,均一次探查到病灶;对照组15例经2次、2例经3次才探查到病灶。超声组病灶全切除率（90.19%）、术后并发症发生率（14.29%）和手术时间（246.2±48.1）min均明显优于对照组[分别为65.45%、28.13%和（380.6±62.2）min;P〈0.05]。结论术中超声可准确定位颅内深部病变,同时指导术中病变的完整切除,保护周围正常神经结构。     

The role of intraoperative flowmetry in surgery of cerebral aneurysms

Aim of the study was to assess the capabilities of intraoperative ultrasonic flowmetry in cerebral aneurysm surgery for prevention and immediate correction of cerebral ischemia. Ultrasonic flowmeter (Model HT313/323, "ransonic Systems Inc.", USA) was used during surgery in patients with complicated, large and giant aneurysms for evaluation of cerebral blood flow in main arteries (internal carotid, anterior and middle cerebral) and their branches (branches of M2-M3 and A2 segments). The series included 20 adult patients (13 male and 7 female) operated in Burdenko Moscow Neurosurgery Institute during 2008-2011 years. Mean age was 47.4 +/- 8.6 years. Giant aneurysms (> 2.5 cm) were present in 12 (60%) patients, large (1.5-2.5 cm)--in 5 (25%). Aneurysms of internal carotid artery were found in 8 cases. 1 female patient was operated on giant aneurysm of anterior cerebral--anterior communicating artery. In 4 (20%) cases significant alterations of blood flow were registered after clipping (> 25% according to initial), the changes were not visible. This allowed to correct the position of clips. In 2 surgeries ('low' paraclinoid aneurysms) the collateral flow was sufficient during temporary clipping, this allowed trapping of aneurysms with good neurological outcome. In 3 cases flowmeter was used to evaluate blood flow after extracranial-intracranial bypass. Ultrasonic flowmetry is a simple, reproducible and safe technique for intraoperative assessment of blood flow. Despite visual sufficiency of arteries flowmetry allows detection of surgically significant alterations of blood flow after clipping.     

微血管多普勒超声在颅内动脉瘤手术中的应用

目的探讨微血管多普勒(microvascular Doppler,MVD)在颅内动脉瘤手术中的作用。方法应用MVD对20例颅内动脉瘤患者(共计21个动脉瘤)进行动脉瘤夹闭前后监测,记录动脉瘤、载瘤动脉及分支的血流速度和频谱,根据MVD检查结果重新调整瘤夹。结果所有动脉瘤患者均探及瘤体内呈毛刺样、涡流样杂音频谱。15例动脉瘤夹闭的患者中,3例因载瘤动脉或分支血管狭窄而调整动脉瘤夹位置;动脉瘤夹闭术后,瘤体内均未探及血流信号,无音频和频谱显示,证实已被完全夹闭,而载瘤动脉及分支血流频谱波动性良好;8例动脉瘤患者术中运用MVD协助区分巨大动脉瘤和载瘤动脉走行。结论动脉瘤夹闭术中运用MVD同步进行动脉瘤及载瘤动脉血流动力学监测,可根据检查结果调整动脉瘤夹位置,具有无创、简单易行,安全的特点。建议MVD作为颅内动脉瘤手术的常规监测方法,尤其对瘤颈粗、甚至无明显瘤颈的巨大动脉瘤手术具有指导意义。     

Nationwide co-operative study of intracranial aneurysm surgery in Japan

A cooperative study was made of 4750 intracranial aneurysm cases collected from 133 neurosurgical clinics in Japan by letter inquiry for the period of 2 years from January 1974 to December 1975. Among them, 4124 cases (87%) had a single aneurysm, and 626 cases (13%) had multiple ones. Direct radical surgery was done in 78% of all cases, carotid ligation in 2% and non-surgical treatment in 17%. Direct surgery in a mortality rate of 15% for ruptured aneurysm cases and 7% for nonruptured cases. Radical surgery within 24 hours after rupture had a mortality of 51%, while those within 1 week and 2 weeks were 39% and 30% respectively; grade I or II patients, however, showed much better surgical results even in early operations. The neurosurgical clinics included in this study were spread throughout most of Japan. Micro-surgical technic was already in use of aneurysm surgery at the time of this study in Japan.     

Iatrogenic false aneurysm caused by surgery of a traumatic intracranial false aneurysm

A superficial temporal artery (STA) false aneurysm caused by surgery of a traumatic intracranial false aneurysm is reported. A 28-year-old man underwent craniotomy for aneurysm clipping 20 days after traumatic head injury. At surgery the aneurysm was a false aneurysm due to its avulsion from the parent artery without a real neck. A "clip wrapping" technique was used to repair the deficit on the parent artery. On postoperative Day 25, repeat digital subtraction angiogram (DSA) revealed a new right STA aneurysm, which was not apparent in the preoperative DSA. We feel that this aneurysm might have probably resulted from the iatrogenic injury to the STA during the initial surgery as the location of aneurysm was at the initial craniotomy site. The pathophysiology, etiology, surgical treatment and preventive measures of false aneurysms have been discussed.     

颅内动脉瘤手术技巧与术中破裂的预见及处理

目的探讨颅内动脉瘤夹闭术的手术技巧、术中可能发生破裂出血的相关影像学改变、针对可能发生破裂出血的预案制定以及处理方法。方法本组42例颅内动脉瘤,其中男18例,女24例,平均年龄47岁。41例采用翼点入路行前循环动脉瘤显微直视夹闭手术,另1例大脑后动脉P2段巨大动脉瘤采用颞下入路行夹闭切除术。结果术后痊愈39例,偏瘫2例;术中动脉瘤破裂7例(占16.7%),破裂出血动脉瘤成功夹闭后,6例恢复良好,1例因发生全脑多发性梗塞而死亡。结论显微镜下充分显露载瘤动脉后夹闭动脉瘤是预防并成功处理术中动脉瘤破裂出血的关键;对于DSA/3D-DSA呈葫芦状、宽颈及瘤体另有囊泡(子囊)形成的动脉瘤,应警惕术中发生动脉瘤破裂出血的可能。     

吲哚菁绿造影在巨大动脉瘤手术中的应用

目的 探讨吲哚菁绿造影(ICGA)在颅内巨大动脉瘤(GIA)手术中的作用.方法 首都医科大学附属北京天坛医院神经外科自2007年3月至2009年10月行瘤体夹闭和(或)切除术治疗GIA患者57例(61个动脉瘤),术中瘤体夹闭前、后分别进行ICGA并做比较,术后行DSA或CTA检查观察有无瘤体残留,载瘤动脉是否畅通,并与术中瘤体夹闭后ICGA结果对比分析.结果 57例患者共行ICGA 128次,夹闭切除动脉瘤61个,ICGA可实时显示术野内血流循环,清晰显示动脉瘤、载瘤动脉和穿支血管.通过对比夹闭前、后的ICGA影像,4例患者追加或调整瘤夹后,ICGA显示无瘤体残留,无载瘤动脉和穿支血管闭塞,术后DSA与夹闭后ICGA显示一致.结论 ICGA做为术中血管成像技术的一种,对术中确认GIA与周围血管的关系、监测瘤颈是否残留和载瘤动脉及穿支动脉是否畅通具有重要意义.     

颅内动脉瘤术中临时阻断载瘤动脉的临床研究

目的探讨颅内动脉瘤手术中载瘤动脉临时阻断后继发脑缺血性脑功能损伤的相关因素。方法128例患者的130个动脉瘤临时阻断载瘤动脉,术后根据相应部位有无脑功能障碍,CT检查阻断血管供应区有无新鲜梗塞灶为标准判断是否造成缺血性脑损伤,并将性别、年龄、有无蛛网膜下腔出血、Hunt-Hess分级、动脉瘤的大小、部位、手术时机、阻断部位、时间、次数、方式、术中破裂、有无高血压、高血糖、载瘤动脉硬化斑块等14种因素进行单因素分析、探讨动脉阻断后可能导致缺血性损伤的原因。结果在130个动脉瘤中,共临时阻断166次,平均每个动脉瘤阻断1.28次,阻断时间为3～45min,平均每个动脉瘤阻断时间约为（9.8±7.8）min,有18例术后出现与载瘤动脉阻断有关新的脑缺血灶（14.06%）,单因素分析显示年龄≥60岁、蛛网膜下腔出血、阻断时间≥20min和动脉硬化斑块对术后发生脑缺血具有较高危险性（均P〈0.05）。结论载瘤动脉临时阻断继发缺血性脑损伤与阻断部位、阻断时间、阻断方式、侧支循环的个体差异、病人术前状况等因素有关。阻断时间〈20min,临时载瘤动脉阻断是安全的。     

颅内动脉瘤支架置入术后发生盐酸替罗非班相关血小板减少症的危险因素分析

目的 分析颅内动脉瘤支架置入术后发生盐酸替罗非班相关血小板减少症的危险因素.方法 选择2016年2月至2020年1月在我院行颅内动脉瘤支架置入术后发生盐酸替罗非班相关血小板减少症的102例患者为病例组,以性别、年龄(±5)进行1:1配对选择同期行颅内动脉瘤支架置入术后未发生盐酸替罗非班相关血小板减少症的102例患者为对...     

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。     

64层螺旋CT对颅内小动脉瘤的诊断及术中应用

目的 探讨64层螺旋CT血管成像(CTA)技术对颅内小动脉瘤的诊断及术中应用价值.方法 经CTA检查发现动脉瘤性蛛网膜下腔出血患者60例,采用最大强度投影(MP)和容积成像显示(VR)技术进行三维重建,分析小动脉瘤的影像特征并与DSA或手术结果比较.部分病例术后行CTA或DSA复诊.结果 60例患者CTA所示的小动脉瘤的大小、形态、瘤顶指向、起源、与载瘤动脉及周围骨性结构的关系等方面均与DSA或手术所见相符.结论 64层CTA能准确检测颅内小动脉瘤及其特征,有助于选择治疗策略.