小脑后下动脉瘤的手术治疗

目的 探讨小脑后下动脉瘤的临床特点及手术方法 .方法 回顾性分析21例小脑后下动脉瘤的临床特点、影像学特征及手术方法 .其中男9例,女12例,平均40.6岁.1例表现为后颅窝占位;20例为动脉瘤破裂出血.入院时患者Hunt-Hess分级:Ⅰ级1例,Ⅱ级14例,Ⅲ级5例,Ⅳ级1例.头颅CT表现为幕下为主的蛛网膜下腔出血,或第四脑室出血或二者兼有.脑血管造影提示小脑后下动脉近端动脉瘤13例,远端动脉瘤8例,分别采用枕下旁正中及枕下正中入路进行手术.结果 19例行动脉瘤蒂夹闭术,1例行孤立术,1例行载瘤动脉近端切断术.3例术后出现切口一过性脑脊液漏;1例术后偏瘫、后组脑神经麻痹和长期昏迷,2例轻度后组脑神经受损,3个月后完全恢复;其余患者术后无神经功能损伤或并发症,恢复良好.结论 小脑后下动脉瘤的治疗首选动脉瘤夹闭术,术中保护后组脑神经和后下动脉是手术的关键.

Surgical treatment for posterior inferior cerebellar artery aneurysms

Objective To explore the clinical characteristics and surgical managements of posterior inferior cerebellar artery (PICA) aneurysms. Methods Retrospective analysis of the clinical features, imaging characteristics and clipping results of 21 PICA artery aneurysms. This series included 9 men and 12 women, mean age was 40.6 years. One presented with mass pressure effects of infrotentoria fossa; 20 patients presented with severe and sudden onset of symptoms, reflecting a hemorrhage from a PICA aneurysm. Hunt-Hess and Hess grades at presentation were: Grade Ⅰ in 1 patient, Grade Ⅱ in 14 patients, Grade Ⅲ in 5 patients, Grade Ⅳ in 1 patient. The bleeding was confined to the infrotentoria subarachnoid space (SAH) and/or the fourth ventricle. Arteriographies revealed 13 proximal PICA aneurysms and 8 distal PICA aneurysms. Results Lateral suboccipital and midline suboccipital surgical approaches were used to secure the aneurysms in all patients, either by direct clipping in 19 cases, parent artery's occlusion in 1 case and parent artery's sacrifice in 1 case. Transient CSF leak occurred in 3 patents; paresis and lower cranial nerve dysfunction and long-term coma occurred in 1 patient; mild lower cranial nerve dysfunctions occurred in 2 patients, and had good recovery at 3 months of follow-up; no complication in other patients. Conclusions The favorable outcomes and low postoperative morbidity in our patients argues that surgical clipping be considered a first-line therapeutic option. The protection of the low cranial nerves and the preservations of PICA are major contributors to good long-term results.