颅内前循环巨大动脉瘤的个体化显微手术治疗(附22例报告)

目的 探讨颅内前循环巨大动脉瘤的个体化显微手术治疗方案和疗效.方法 回顾性分析2006年5月至2016年5月间收治的经显微手术治疗的22例颅内前循环巨大动脉瘤的临床资料,其中破裂动脉瘤9例,未破裂动脉瘤13例.手术方式包括:直接夹闭5例,动脉瘤切开、瘤壁塑形12例,动脉瘤切除加脑血管重建2例,动脉瘤孤立术2例,颈内动脉颅外段结扎1例.采用Glasgow预后评分法(COS)进行疗效评估.结果 出院时恢复良好、恢复正常生活的患者(GOS 5分)有14例,轻度病残(GOS 4分)5例,重度病残(GOS 3分)2例,死亡(GOS1分)1例.21例生存患者术后随访3～118个月,平均随访(39±30)个月,三维CT血管造影(3D-CTA)或三维数字减影血管造影(3D-DSA)结果显示动脉瘤均消失.GOS评估恢复良好者17例,轻度残疾2例,重残1例,死亡1例.本组病例致死率为9.1％ (2/22),致残率为13.6％ (3/22).预后的影响因素分析显示,术中是否行微血管多普勒(MVD)监测有统计学意义(P=0.036),而年龄(P=1.324)、性别(P=2.346)、动脉瘤大小(P=0.856)、Hunt-Hess分级(P=0.196)、动脉瘤是否破裂(P=0.172)等指标均无统计学意义.结论 颅内前循环巨大动脉瘤患者的治疗需要详细的术前评估和个体化的治疗方案.术者的经验与技巧配合良好的术中监测是保证满意的显微手术治疗效果的基础.

Individualized microsurgical treatment of intracranial anterior circulation giant aneurysms: a report of 22 cases

Objective To investigate the individualized microsurgical treatment regimens for intracranial anterior circulation giant aneurysms and to assess their effectiveness. Methods We retrospectively analyzed the clinical data of 22 patients with anterior circulation giant aneurysms who were treated with microsurgery from May 2006 to May 2016. There were 9 ruptured aneurysms and 13 unruptured aneurysms. The surgical methods included direct clipping of the aneurysmal neck in 5 cases, thrombectomy-aneurysm clip reconstruction in 12 cases, aneurysm excision combined with vessels reconstruction in 2 cases, trapping of the aneurysm in 2 cases, and cervical internal carotid artery ligation in 1 case. Prognoses of patients were evaluated by Glasgow Outcome Scale (GOS). Results At discharge, 14 of the 22 patients recovered well and regained normal life (GOS 5), 5 patients had mild disability (GOS 4), 2 had severe disability (GOS 3), and one died (GOS 1). The mean follow-up time was (39±30) months (ranging from 3 to 118 months). Post-operative three-dimensional CT angiography (3D-CTA) or three-dimensional digital subtraction angiography (3D-DSA) showed that complete angiographic obliteration was achieved in all the 21 survivors; there were 17 survivors with GOS 5, 2 with GOS 4, 1 with GOS 3, and 1 with GOS 1. The mortality and morbidity of patients were 9.1% (2/22) and 13.6% (3/22), respectively. Analysis of factors influencing of prognosis showed that there was no significant difference in patients outcomes between groups of age (P=1.324), sex (P=2.346), aneurysm size (P=0.856), Hunt-Hess grade (P=0.196), or aneurysmal rupture (P=0.172), and there was significant difference in patients outcomes between microvascular Doppler (MVD) group and none MVD group (P=0.036). Conclusion Detailed pre-operative evaluation and individualized surgical plan are necessary for patients with intracranial anterior circulation giant aneurysms. Surgeon''s microsurgical experiences and skills together with intra-operative monitoring is the guarantee for satisfactory effectiveness of microsurgery treatment.