【作者】 黄光富； 李自立； 曾益； 王振宇；

【Author】 Huang Guang-fu.Department of Neurourgery,Sichuan Provincial Hospital,Chengdu 610072,China

【机构】 四川省人民医院神经外科；

【摘要】 目的探讨前交通动脉瘤的手术策略。方法回顾性分析142例前交通动脉瘤患者的临床资料、手术治疗技术及治疗效果;86例由一侧前动脉充盈,左侧占64例,右侧仅22例,双侧A1显影56例;经右侧开颅91例,其中137例采用经翼点或眉弓入路手术,5例并发额叶较大血肿采用同侧额下或纵裂入路;142例全部行动脉瘤颈夹闭,5例加包裹术。结果本组病例术前Hunt-Hess分级:Ⅰ级17例,Ⅱ级93例,Ⅲ级25例,Ⅳ级5例,Ⅴ级2例。手术时机包括3天内(早期)手术者31例,4～14d(中期)手术者72例,14d后(后期)手术者39例。治愈或良好123例,致残14例,死亡5例(3例系Ⅳ级、Ⅴ级)。结论开颅手术尽可能选右侧以减少主侧大脑手术后并发症,经翼点入路或经眉弓微骨孔入路手术显露前交通动脉瘤较好。Hunt-HessI级患者发病后任何时间手术均效果良好,但为防止出血应早期手术;Ⅱ级患者类似,但3天后有脑血管痉挛症状者应延后手术;Ⅲ级以上病人应后期手术,但有较大额叶血肿或脑室大量积血者应急诊手术。恰当的手术时机与手术入路,以及娴熟的手术技巧特别是注重对脑血管的保护、尽量不切或少切直回,可以提高前交通动脉瘤手术治疗效果。术中三脑室底造瘘对防治蛛网膜下腔出血后脑积水有积极意义。更多还原

【Abstract】 Objective To investigate the surgical approach and technique in the anterior communicating artery aneurysm.Methods A retrospective study was performed in 142 patients with anterior communicating artery aneurysm,including clinical data,operative neurosurgical techniques,and therapeutic effect.Pterional or transorbital keyhole approach was used in 137 patients and ipsilateral sub-frontal approach or biofrontal interhemisphericapproach in 5 patients with concurrent considerable haematoma in frontal lobe,respectively.Clipping of aneurysmal neck was achieved in all the 142 patients,5 of which underwent extra wrapping of aneurysm.Results In this group,the preoperative clinical condition was Hunt-Hess gradeⅠ in 17 patients,grade Ⅱin 93 patients,grade Ⅲ in 25 patients,grade Ⅳin 5 patients,and grade V in 2 patients.After SAH,operation was performed within 3 days,4～14days and after 14 days.Good result or recovery obtained in 123 patients,disability in 14 patients,and death in 5 patients(2 patients with grade Ⅲ,2 patients with grade V,and 1patient with grade Ⅳ).Conclusion Pterional approach and transorbital keyhole approach are favorable in the exposure of anterior communicating artery aneurysm.Good results can be achieved in Hunt-Hess gradeⅠ patients operated on at any time after SAH,however,the operation should be performed as soon as possible.The same principle can be used in the majority of Hunt-Hess grade Ⅱpatients.For Hunt-Hess grade Ⅲ,Ⅳ,and V,operation should be postponed to 2 weeks later when the conditions get better.But early operation or emergency operation should be considered in those patients with considerable intra-cerebral or intra-ventricular hemorrhage.Proper surgical approach,operative timing,and sophisticated surgical techniques involving the protection of the cerebral vessels and avoidance or minimum of removal of the gyrus rectus,are helpful to improve the surgical effect.Intra-operative third ventriculostomy plays a positive role in precaution of the hydrocephalus after SAH.更多还原