颅内动脉瘤438例显微手术分析

目的 总结438例患者的508个动脉瘤的显微手术治疗经验.方法 回顾性总结分析438例患者的临床资料,包括围手术期处理、手术时机、术中处理要点、动脉瘤分级.结果 共476个动脉瘤显微手术治疗成功,其中直接瘤颈夹闭450个,包裹14个,孤立8个,切除动脉瘤4个.术中动脉瘤破裂32个(6.72%).术前Hunt-Hess分级与手术死亡率正相关.延期(≥7 d)手术患者病死率(4.28%),明显低于早期手术病死率.结论 正确的显微外科手术入路治疗颅内动脉瘤是一个十分有效的治疗手段.术前Hunt-Hess分级越高,病死率越高.     

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.     

颅内外动脉狭窄合并颅内动脉瘤同期血管内治疗的效果分析

目的探讨同期治疗颅内外动脉狭窄合并颅内动脉瘤的策略及临床效果。方法回顾性分析2013年4月至2018年9月于北京大学第一医院神经外科行同期血管内治疗的15例颅内外动脉狭窄合并颅内动脉瘤患者的临床资料。男性6例,女性9例,年龄(63.9±9.1)岁(范围:43~79岁);动脉狭窄部位共15处,狭窄程度为75%~95%,其中前循环8处,后循环7处;动脉瘤共17个,最大径(5.3±1.2)mm(范围:3~7 mm),其中前循环动脉瘤11个、后循环动脉瘤6个。患者均行同期动脉狭窄支架成形及动脉瘤栓塞术治疗。记录患者围手术期及术后临床症状、影像学资料及并发症情况。结果15处动脉狭窄均成功置入支架(残余狭窄<30%);17个动脉瘤中,10个行单纯弹簧圈栓塞,7个行支架辅助弹簧圈栓塞,均完全栓塞。围手术期1例患者出现轻微脑梗死症状,其余未发生手术相关并发症。术后随访(43.8±8.2)个月(范围:24~85个月),患者术后6~12个月均复查数字减影血管造影,其中2例出现无症状性支架内再狭窄,所有动脉瘤未见复发。截至末次随访时,患者均未出现颅内出血、缺血性卒中等相关症状。结论颅内外动脉狭窄合并颅内动脉瘤应根据血管狭窄的部位、程度及动脉瘤的大小、形态、位置、数量及两者的位置关系等因素综合分析,制定个体化的治疗策略,给予同期血管内治疗可能是一种安全、有效的治疗方法。     

Emergency treatment of cerebral aneurysms with large haematomas

Of 469 patients with subarachnoid haemorrhage (SAH) from ruptured intracranial aneurysms, 31 had large intracerebral haematomas and were treated as emergency cases at the University Central Hospital, Kuopio, Finland during 1979-1985. The haematomas were evacuated and the aneurysms clipped immediately after diagnosis with CT and angiography. The mean diameter of the haematomas was 48 mm. Of the 31 patients 15 died. Mortality was lower for patients with aneurysms of the middle cerebral artery and for those with a better clinical grade (Gr. IV) at the time of the operation (41%); all patients with dilated pupils in grade V died. Five patients returned to work, and 10 are living a useful and independent life at home. Because early CT is increasingly used as the first diagnostic tool in vascular catastrophies, the pressure for early emergency treatment of aneurysmal intracerebral haematoma is increasing. The almost 100% mortality with conservative treatment should be compared to the 41% mortality with selection of the surgical candidates.     

Considerations on surgical treatment for elderly patients with intracranial aneurysms

BACKGROUND: The purpose of this study was to investigate why elderly patients have poorer outcomes and to determine indications for surgery in elderly patients. METHODS: One hundred fifty-four patients with intracranial aneurysms admitted to the Department of Neurosurgery, Showa University School of Medicine, from 1990 through 1996 were reviewed. The patients were classified by age into three groups (young group, middle-aged group, elderly group). RESULTS: Forty-four patients (28.6%) were in the elderly group (mean age, 73 years). No difference in outcome was found between middle-aged and elderly patients if patients were stratified according to clinical grade. In addition, the main factors related to unfavorable outcomes in elderly patients were infection, organ failure, aneurysm rerupture before operation, and delayed ischemic deterioration. Elderly patients were more likely to experience rebleeding and have poor outcomes. CONCLUSIONS: Our results suggest that elderly patients should have early surgery. Furthermore, we found that the presence of hypertension or atherosclerosis had no significant effect on outcome. We conclude that early surgical treatment of aneurysms is indicated for elderly patients with good clinical grades in the absence of organ failure.     

Surgical indications to maintain quality of life in elderly patients with ruptured intracranial aneurysms

OBJECTIVE: We performed a retrospective study to assess long-term outcomes in very old patients with ruptured intracranial aneurysms. The aim of the study was to develop guidelines for choosing surgical or conservative treatment with the goal of maintaining patients' quality of life. METHODS: Between 1996 and 1999, 76 consecutive patients, aged 80 to 89 years, with ruptured intracranial aneurysms were treated at 18 participating centers. They were divided retrospectively into operated and nonoperated groups, and their preoperative characteristics and treatment outcomes were analyzed. Their Glasgow Outcome Scale and Barthel Index scores at least 2 years after the insult were recorded and analyzed from the perspective of their admission Hunt and Hess grade. RESULTS: Our retrospective review encompassed 5.9 years. Of the original 76 patients, 54 (71.1%) died, 13 (17.1%) had a good outcome (Barthel Index >or=60), and 9 (11.8%) had a poor outcome (Barthel Index <60). All patients with Hunt and Hess grades of III or higher at admission had poor outcomes irrespective of treatment. Of 32 patients with an initial Hunt and Hess grade of I or II, 19 (59.4%) underwent surgery; 9 of these patients (47.4%) had good outcomes. Conversely, of 13 nonoperated patients (40.6%), only 2 (15.4%) experienced good outcomes. In seven of the nine operated patients with good outcomes, the aneurysm was small (<12 mm) and located at the internal carotid artery-posterior communicating artery junction. CONCLUSION: Our results suggest that patients in the 9th decade of life with ruptured intracranial aneurysms can be considered for surgical treatment if they have a Hunt and Hess grade of I or II. The highest rate of favorable results was achieved in patients with small internal carotid artery-posterior communicating artery aneurysms.     

Pure surgical treatment of 109 aneurysms

AIM: Target of this study was to investigate outcomes after pure surgical treatment of intracranial aneurysms. METHODS: Patients with intracranial supratentorial circle aneurysms were retrospectively reviewed between July 1994 and October 1998. Studied cases were admitted at the Department of Neurosurgery of S. Maria-Hospital, Terni, a Government supported General Hospital. One hundred and nine Hunt and Hess Grade 0 to III patients with supratentorial circle aneurysms was studied in order to determine whether advances in the surgical management of intracranial aneurysms have improved surgical outcomes and which factors may predict outcome. All patients were managed only with standard neurosurgical aneurysms clipping procedures. Outcomes evaluation was made at patients' discharge and classified on the base of the Glasgow Outcome Scale (GOS). Surgical timing, SAH grading, pre and post surgical symptomatic vasospasm, temporary clipping, and intraoperative aneurysm rupture were correlated with outcomes. RESULTS: Surgical results showed a 75% excellent outcome. Mortality rate was 3%. Hunt and Hess grade 0 highly influenced outcome. Differences in outcomes among grades I to III were not significant. No differences in outcomes related to temporary clipping were noted. A low rate of intraoperative aneurysm rupture is reported: 5 out of 109 cases. In all these cases outcome was good, with neither mortality or morbidity. CONCLUSIONS: Results indicate a progressive improvement in surgical outcomes, suggesting that there still exist margins for improvements in pure surgical management of intracranial aneurysms.     

Total morbidity and mortality rates of patients with surgically treated intracranial aneurysms.

The authors report their recent experience in treating 80 patients with intracranial aneurysms. A total of 83 surgical procedures were performed with a surgical mortality of 4.8%. Fifty-six patients had suffered a subarachnoid hemorrhage. Total mortality for this group was 14.2% regardless of clinical grade. Early surgical intervention, meticulous preoperative monitoring, and control of circulatory dynamics were used to improve the perioperative morbidity and mortality rates. We believe that any major improvements in the outcome of patients with aneurysms will come from advances in perioperative management.     

Virtual endoscope-assisted intracranial aneurysm surgery: evaluation of fifty-eight surgical cases.

OBJECTIVE: Better visualization of the intracranial aneurysm may improve surgical outcomes. To this aim, we evaluated the effectiveness of using virtual endoscopy (VE) during intracranial aneurysm surgery. METHODS: Fifty-eight patients with 63 intracranial aneurysms were enrolled in this study. Every patient was examined by digital subtraction angiography (DSA) and a randomly selected twenty-six cases were also examined by computed tomography (CT). CT angiography data were linked via imaging software for reconstruction of VE images. All patients were operated on using standard microsurgical procedures. Among these cases, randomly selected cohorts of twenty-six patients with 28 intracranial aneurysms were operated on also using VE-assisted surgical procedures. The surgical results of both groups were compared to determine the efficacy of the VE-assisted surgical procedure. RESULTS: Aneurysm locations, surgical timing and Hunt-Hess grade distribution were not statistically significant between both groups (p=0.948). However, significantly reduced complication rates and increased post-operative Glasgow outcome scores were observed in the VE group (p<0.05) compared to control. CONCLUSION: Aneurysms and surrounding anatomic structures were well depicted by VE in three dimensions with interactive fly-through views. This method improved our surgical results by improving visualization of the aneurysm and increasing surgical orientation. We report that this method can be very helpful to surgeons during intracranial aneurysm surgery and may reduce post-surgical complications.     

Pipeline血流导向装置治疗颅内复杂动脉瘤的效果

目的观察Pipeline血流导向装置(PED)治疗颅内复杂动脉瘤的有效性及安全性。方法回顾性分析接受PED治疗的11例颅内复杂动脉瘤患者的临床资料。结果11例患者共12个动脉瘤,植入12枚PED,其中10例植入1枚PED、1例2枚,3个动脉瘤单纯植入PED、9个植入PED联合弹簧圈栓塞;术后立即造影示动脉瘤内对比剂滞留,PED贴壁良好,完全覆盖瘤颈,载瘤动脉通畅。术后1例发生局部急性脑梗死,经治疗后康复。术后随访6~9个月,中位随访时间7.5个月,患者症状均明显缓解或消失,未发现严重并发症,动脉瘤闭塞率75.00%(6/9)。根据O'Kelly-Marotta(OKM)分级:A级0个动脉瘤,B级1个,C级2个,D级9个。改良Rankin评分(mRS):0分10例,1分1例。结论PED治疗颅内复杂动脉瘤的效果及安全性均较好。     

Management of elderly patients with aneurysmal subarachnoid hemorrhage]

Clinical features of 61 elderly patients aged over 70 years with ruptured intracranial aneurysms were compared with those of 328 younger patients aged under 70 years. According to a policy of early operation, elderly patients with Hunt and Kosnik's grade I, II and younger patients with grade I, II, III were operated on in the acute stage. In elderly patients with grade III, IV and younger patients with grade IV, the indication for surgery was determined case by case. Surgery was performed on 29 patients (48%) in the elderly group and 277 patients (86%) in the younger group. Our conclusions are as follows: 1. Regarding cases of grade I, II and III of Hunt and Kosnik's classification, the rate of good outcome in the elderly group was similar to that in the younger group, following early surgery and meticulous post-operative care. 2. In the elderly group, no patient in cases of grade IV obtained good surgical outcome. 3. Symptomatic vasospasm was less frequent in elderly patients (18.8%) than in younger cases (37%). 4. Delayed operation was planned for some patients in the elderly group, but none of them underwent surgery because of rerupture of aneurysms and deterioration of general condition.     

Results of early and delayed operations for ruptured intracranial aneurysms in two series of 100 consecutive patients

This report compares the results of early and delayed operations for ruptured intracranial aneurysms in two groups of 100 consecutive patients managed at Downstate Medical Center, Brooklyn, N.Y. In the first group, operation was postponed for a minimum of 1 week after subarachnoid hemorrhage, and aneurysmal clipping was carried out only on patients classified as grade I or Ia in whom intracranial pressure was normal, and in whom serial angiograms demonstrated absence or resolution of vasospasm. According to this policy, 35 patients came to operation with no operative deaths (0%) and four permanent neurological deficits (11%). Sixty-five patients died prior to operation from a variety of causes including aneurysmal rebleeding, cerebral vasospasm, and systemic complications. Of 81 patients admitted in grades I-III, the survival rate was 43% (35/81). In the second group, aneurysmal clipping was carried out as soon as possible after admission on all patients who were grade III or below without specific regard to intracranial pressure or angiographic vasospasm, and on occasional grade IV and V patients with intracerebral clots. With this strategy, 81 of 86 grade I-III patients came to surgery. There were 4 operative deaths (4.9%), 10 permanent neurological deficits (12%), and a survival rate of 90% (77/86). Including three of six grade IV and V patients who were successfully operated upon for intracerebral clots, the overall survival of the second group (80%) was more than twice that of the first group (35%). Taken together, these data suggest that, whereas early surgical intervention for ruptured intracranial aneurysms invites a higher operative mortality, patient mortality, by far the most important statistic, can be significantly reduced without increasing long-term morbidity.     

The role of surgery when endovascular treatment is considered the first choice therapy for ruptured intracranial aneurysms

AIM: Nowadays endovascular therapy is more and more considered as first choice treatment for ruptured intracranial aneurysms. The aim of this study was to understand the impact that endovascular treatment (EVT), chosen as first therapeutic strategy, has had in the selection of ruptured intracranial aneurysms submitted to surgery at our Institution and what role neurosurgeons still play in this setting. METHODS: From 1998 to 2002, 272 consecutive patients were treated at the Hospital of Toulouse for ruptured intracranial aneurysms: 222 by embolization and 50 by surgery. The two groups were homogeneous for sex, age and aneurysms multiplicity. RESULTS: The patients of the surgical group had a worst clinical-radiological status at the treatment time than those treated by EVT. Clipping was performed for different reasons: 16% for failure of attempted EVT; 32% for intracranial hematoma requiring surgical evacuation; 30% for aneurysm morphology unsuitable for EVT and 22% for absence of the endovascular operator. Aneurysms of the middle cerebral artery (MCA) represented the main surgical group. The aneurysms judged unsuitable for EVT and addressed to surgery had often a complex morphology representing a challenge also for surgery. Mid-term outcome is significantly better for patients treated by EVT. CONCLUSION: The results show that microsurgery continues to have a role in the treatment of ruptured intracranial aneurysms even when EVT is the first choice. The precarious clinical conditions of the patients submitted to surgery and the frequent complexity of their aneurysms explain their worst outcome. This would advise training dedicated vascular Neurosurgeons to guaranty a high level treatment when EVT is not possible.     

126例颅内动脉瘤破裂的早期显微外科治疗

目的探讨早期显微外科手术治疗颅内动脉瘤破裂的疗效。方法126例颅内动脉瘤破裂患者根据Hunt—Hess分级,Ⅰ级20例、Ⅱ级37例、Ⅲ级42例、Ⅳ级18例、Ⅴ级9例。126例患者第一次手术均在出血后72h内,13例颅内多发动脉瘤患者进行了二次手术,所有患者术后用格拉斯哥评分表（GOS）随访1—3年。结果恢复良好98例;中度病残,但生活自理18例;重度病残,生活不能自理4例;植物生存1例;死亡5例。结论早期显微外科手术是治疗颅内动脉瘤破裂的有效方法,能改善动脉瘤患者的生存质量。     

Unruptured intracranial aneurysms in polycystic kidney disease

Summary To detect unruptured intracranial aneurysms, we performed cerebral angiography in five patients with polycystic kidney disease (PKD) who had no neurological deficits and no history of subarachnoid haemorrhage. Three of the five patients had unruptured intracranial aneurysms and two underwent surgery with no mortality or morbidity. Our review of the literature revealed that the surgical risk of unruptured intracranial aneurysms is smaller than the risk of bleeding in conservatively treated patients. We discuss the importance of an early diagnosis, and early operation for unruptured aneurysms in patients with polycystic kidney disease and stress the need for intensive care for their renal dysfunction and hypertension during and after the operation.     

Neuroendoscope-assisted minimally invasive microsurgery for clipping intracranial aneurysms.

OBJECTIVE: The aim of this study was to evaluate the efficacy of intracranial aneurysm treatment with the help of the neuroendoscope. METHODS: Eighty-eight patients were treated from February 2000 to November 2003 for intracranial aneurysms of which 89 lesions were clipped with the help of neuroendoscope, including 82 anterior circulation aneurysms (in 81 cases) and 7 posterior circulation aneurysms. The diameters of the aneurysms were between 5 and 40 mm with mean value of 12.5 mm. In the Hunt and Hess preoperative classification, 10 cases were grade 0, 37 cases were grade I, 36 cases were grade II, and 5 cases were grade III. RESULTS: Postoperative complications were observed in 7 cases (7.9%), including hemiplegia in 5 cases (1 case with combination of aphasia), pseudomembranous enteritis in 1 case and optic blur in 1 case. We did not observe any neuroendoscope-related complications and had no postoperative deaths. CONCLUSIONS: The operative efficacy in aneurysm neurosurgery can be improved by the use of the neuroendoscope, especially for minimally invasive microsurgery operation. The neurosurgeon should pay more attention to the training of the endoscope procedure and master more knowledge about endoscopic anatomy.     

Characteristics of intracranial aneurysms associated with moyamoya disease

Summary A retrospective analysis of 111 patients with aneurysms associated with Moyamoya disease is presented. The subjects comprised of our 12 cases and 99 other well-documented cases. These 111 cases had 131 aneurysms. There were 48 males and 63 females. The average age was 40.3 years. The clinical manifestations were intracranial haemorrhage in 99 cases (89%), and ischaemic events in 9 cases (8%), but no mention was made of these in the last three cases (2%). The Hunt and Kosnik grades were grade 1 in 8%, grade 2 in 23%, grade 3 in 31%, grade 4 in 35%, and grade 5 in 3%. Of the 131 aneurysms, 73 (56%) were found distributed around the circle of Willis, 24 (18%) in the basal ganglia, 29 (22%) on collateral vessels, and 5 (4%) on other vessels. Forty-six percent of the cases were treated surgically, 51% conservatively, and 3% by endovascular procedures. The surgical procedures for the aneurysms were; neck clipping in 49%, aneurysmectomy in 18%, wrapping of the aneurysm in 11%, coating or cautery of the aneurysm in 7%, and revascularization only in 11%. The outcomes were Glasgow Outcome Scale 1 in 30%, 2 in 22%, 3 in 11%, 4 in 1%, and 5 in 25%. The main reasons for the unfavourable outcome were initial poor clinical grade and rebleeding. Follow-up angiography of 25 aneurysms demonstrated that all aneurysms in the basal ganglia or on the collateral vessels disappeared. We recommend surgical intervention for aneurysms associated with Moyamoya disease to prevent rupture or rebleeding, especially for aneurysms around the circle of Willis. However, direct surgery is not recommended for aneurysms found in the basal ganglia or on the collateral vessels.     

CT三维血管造影诊断出血动脉瘤

目的 评价CT血管造影(CTA)在颅内动脉瘤破裂后蛛网膜下腔出血诊断中的价值及手术指导意义。方法 对63例急性蛛网膜下腔出血病人急诊行螺旋CT扫描,然后行脑血管三维成像。结果 发现颅内动脉瘤24例。有1例阴性经全脑血管造影(DSA)发现存在动脉瘤。诊断均以手术证实。结论 CTA对动脉瘤蛛网膜下腔出血是一种微创、快速、准确的诊断技术,对于急诊或危重病人应为首选。     

Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization.

OBJECT: Certain intracranial aneurysms, because of their fusiform or complex wide-necked structure, giant size, or involvement with critical perforating or branch vessels. are unamenable to direct surgical clipping or endovascular coil treatment. Management of such lesions requires alternative or novel treatment strategies. Proximal and distal occlusion (trapping) is the most effective strategy. In lesions that cannot be trapped, alteration in blood flow to the "inflow zone," the site most vulnerable to aneurysm growth and rupture, is used. METHODS: From 1991 to 1999 the combined neurosurgical-neuroendovascular team at the Massachusetts General Hospital (MGH) managed 48 intracranial aneurysms that could not be clipped or occluded. Intracavernous internal carotid artery aneurysms were excluded from this analysis. By applying a previously described aneurysm rupture risk classification system (MGH Grades 0-5) based on the age of the patient, aneurysm size, Hunt and Hess grade, Fisher grade, and whether the aneurysm was a giant lesion located in the posterior circulation, the authors found that a significant number of patients were at moderate risk (MGH Grade 2; 31.3% of patients) and at high risk (MGH Grades 3 or 4; 22.9%) for treatment-related morbidity. The lesions were treated using a variety of strategies--surgical, endovascular, or a combination of modalities. Aneurysms that could not be trapped or occluded were treated using a paradigm of flow alteration, with flow redirected from either native collateral networks or from a surgically performed vascular bypass. Overall clinical outcomes were determined using the Glasgow Outcome Scale (GOS). A GOS score of 5 or 4 was achieved in 77.1%, a GOS score of 3 or 2 in 8.3%, and death (GOS 1) occurred in 14.6% of the patients. Procedure-related complications occurred in 27.1% of cases; the major morbidity rate was 6.3% and the mortality rate was 10.4%. Three patients experienced aneurysmal hemorrhage posttreatment; in two patients this event proved to be fatal. Aneurysms with MGH Grades 0, 1, 2, 3, and 4 were associated with favorable outcomes (GOS scores of 5 or 4) in 100%, 92.8%, 71.4%, 50%, and 0% of instances, respectively. CONCLUSIONS: Despite a high incidence of transient complications, intracranial aneurysms that cannot be clipped or occluded require alternative surgical and endovascular treatment strategies. In those aneurysms that cannot safely be trapped or occluded, one approach is the treatment strategy of flow alteration.     

The surgical treatment of intracranial aneurysms based on computer tomographic angiography alone--streamlining the acute mananagement of symptomatic aneurysms

BACKGROUND: We aimed to prospectively assess the usefulness of computer tomographic angiography (CTA) in streamlining the management of symptomatic intracranial aneurysms in a tertiary neurosurgical unit, from admission to surgery. METHODS: We performed a prospective evaluation over a 2-year period of all symptomatic intracranial aneurysms managed according to a standardized departmental protocol, to assess how CTA has impacted the decision-making process pertaining to the suitability of this investigation to proceed directly to surgery. FINDINGS: A total of 90 patients with intracranial aneurysms were treated over the 2-year period. 23 (26%) underwent endovascular occlusion while 67 (74%) patients underwent a surgical clipping procedure. In the surgical group, 22 (33%) patients had their aneurysms clipped based on CTA alone, while 45 (67%) required additional conventional angiography prior to surgery. Thus around one quarter of all patients treated for symptomatic intracranial aneurysms in our unit had their aneurysm secured surgically based solely on CTA. INTERPRETATION: CTA significantly influences the acute management of symptomatic intracranial aneurysms by streamlining the decision-making process during the early and acute management of these lesions.