谢成惠林樊友武刘承基邬祖良谭启富

【摘要】目的颅内巨大动脉瘤虽然少见，但手术治疗困难，手术病死率和致废率仍较高。本文对我院1980年以来手术治疗的30例颅内巨大动脉瘤作一回顾性分析。方法动脉瘤瘤颈夹闭术13例；动脉瘤孤立或孤立后切除术11例；动脉瘤切除或孤立后载瘤动脉重建术2例；颈部颈内动脉结扎术2例；动脉瘤包裹术2例。结果术后早期恢复良好者为73.3％，中、重残者为20％，死亡2例，病死率6.6％。动脉瘤瘤颈夹闭组的13例病人中，除1例术前Ⅳ级的前交通动脉瘤病人术后重残外，均恢复顺利。动脉瘤孤立或孤立后切除的11例病人中，4例术后早期出现不同程度的对侧肢体瘫痪，其中2例在术后3周内恢复正常，另2例分别在术后3个月和28个月恢复正常；1例大脑中动脉（MCA）动脉瘤术后因术野血肿再次手术清除血肿后，病人出院时能独立行走。单纯行颈部颈动脉结扎的2例病人出院时病情无明显变化。而仅行动脉瘤包裹术的2例病人均在术后因再出血死亡。结论为消除巨大动脉瘤的占位效应和出血的潜在性，对颅内巨大动脉瘤提倡积极的直接手术治疗。动脉瘤瘤颈直接夹闭并保留载瘤动脉通畅是首选治疗，对必需行动脉瘤孤立且交叉循环不良的病例，应尽可能重建载瘤动脉。

Surgical treatment for the giant intracranial aneurysms

SHI Jixin，WANG Handong，HANG Chunhua，et al.

（Department of Neurosurgery，Nanjing General Hospital of PLA, Nanjing, 210002）

【Abstract】ObjectiveThe giant intracranial aneurysms are lesions which represent only 3 to 6％ of all cerebral aneurysms．Due to the anatomical complexity and the technical difficulty of their surgical management，the mortality and morbidity for these entities remain high．The purpose of this paper is intended to show the results of the retrospective analysis of 30 patients with the giant intracranial aneurysms．MethodsDirect clipping of the aneurysms was accomplished in 13 cases，aneurysm trapping or removal after trapping in 11cases，aneurysm excision or trapping with parent artery anastomosis in 2 cases（the end to end anastomosis of the main trunk of middle cerebral artery （MCA） being performed in one with giant aneurysm of MCA，and interposition great saphenous vein grafting between the ICA in the neck and intracranial ICA in the other with the giant transitional cavernous aneurysm），aneurysm wrapping in 2 and the ligation of the carotid artery in the neck were completed in 2 cases．ResultsEarly postoperative neurological function was evaluated using Glasgow Outcome Scale scores．21 patients had an excellent or good outcome，5 patients had moderate disability and 1 patient had severe disability．2 patients with aneurysm wrapping died due to postoperative aneurysm bleeding．All 13 patients with direct clipping of the aneurysms and 2 patients with aneurysm excision or trapping with parent artery reconstruction gained good recovery except for one who had preoperative Ⅳ grade according to Hunt and Hess Grades after SAH and underwent severe disability postoperatively．In 11 patients of the group of the aneurysm trapping or excision after trapping，4 patients experienced contralateral hemiparesis，of which，2 patients had their normal neurological function 3 weeks after operation and the other 2 patients had their normal function 3 months and 28 months after operation respectively．Another patient in this group underwent the hemorrhage in the operative field and recovered smoothly after the further operation for eliminating hematoma．In 2 patients with the ICA ligation in the neck，their function remained unchanged．ConclusionDirect clipping of the aneurysms is the preferred method for the giant intracranial aneurysms，unclippable aneurysms require alternative methods that might compromise parent arteries and may require revascularization to restore sufficient cerebral blood flow．

【Key words】Giant aneurysmIntracranialSurgeryGreat saphenous vein grafting interposition

最大径等于或大于2.5 cm的颅内动脉瘤称为颅内巨大动脉瘤^［1］，其发生率虽然不高，但手术治疗困难，手术残废率和病死率仍较高^［2，3］。现将我院1980年以来手术治疗的30例颅内巨大动脉瘤作一介绍。

资料和方法

一、一般资料：30例病人中，男16例，女13例；年龄16～63岁，平均43.7岁。

二、动脉瘤部位：位于前循环20例，其中眼段动脉瘤6例，大脑中动脉动脉瘤4例，后交通动脉（PCoA）段动脉瘤6例，前交通动脉（ACoA）段动脉瘤2例，颈内动脉(ICA)分叉部动脉瘤1例，移行性海绵窦内动脉瘤1例；后循环动脉瘤10例，其中大脑后动脉（PCA）动脉瘤8例，小脑后下动脉（PICA）动脉瘤2例。动脉瘤最大径在25～70 mm之间。

三、临床表现：以蛛网膜下腔出血（SAH）为首发症状者10例，出血次数1～4次，出血后Hunt和Hess分级Ⅳ级者2例，Ⅲ级1例，Ⅱ级者3例，Ⅰ级者4例。颅神经功能障碍7例；对侧肢体瘫痪2例；癫痫发作1例；头晕和共济运动障碍8例。术前误诊3例，其中1例因头部轻微外伤后行头颅CT检查时意外发现颅内病变，诊断颅内肿瘤进行手术，术中证实为PCA动脉瘤；1例因视力进行性恶化，头颅CT检查诊断为蝶骨嵴内侧肿瘤进行手术，术中证实为眼动脉动脉瘤；另1例PICA动脉瘤病人表现为急性小脑出血，手术清除血肿时发现系PICA动脉瘤。

四、影像学检查：26例行头颅CT检查，其中SAH 9例，脑内血肿3例；增强前表现为环形或斑片状钙化者6例，强化后出现靶环征者7例，不规则强化者16例。25例行头颅MRI检查，呈现流空现象者16例，信号高低不均者9例。血管造影25例，能作出动脉瘤诊断者22例，另外2例因瘤内血栓形成较完全未显示动脉瘤影像。

五、手术方法：

1.动脉瘤瘤颈夹闭术13例，其中眼动脉瘤3例，PCoA动脉瘤3例，大脑中动脉(MCA)动脉瘤2例，PCA动脉瘤2例，ACoA动脉瘤2例，ICA分叉部动脉瘤1例。13例病人动脉瘤内缺乏或只有少量血栓，其中4例在动脉瘤颈夹闭后将动脉瘤切除。

2.动脉瘤孤立或孤立后切除11例，其中眼动脉瘤2例，PCoA动脉瘤1例，PCA动脉瘤6例，MCA动脉瘤1例，PICA动脉瘤1例，这些动脉瘤腔内多充满血栓，或进出动脉瘤的载瘤动脉相距较远，无法进行夹闭。由于这些含血栓的动脉瘤占位效应明显，孤立后均切开动脉瘤清除血栓或将动脉瘤切除。

3.动脉瘤切除或孤立后载瘤动脉重建2例，其中1例MCA（M₁段）动脉瘤切除后进行MCA主干端端吻合；1例移行性海绵窦内动脉瘤行大隐静脉移植颈部ICA-大隐静脉-床突上ICA端端吻合术。

4.颈内动脉结扎术2例，均为PCoA动脉瘤，系80年代早期的病例。

5.动脉瘤包裹术2例，均为术前误诊的病例，1例为PICA动脉瘤出血引起小脑血肿（Ⅳ级），另1例为误诊颅内肿瘤进行手术的眼动脉动脉瘤。

六、载瘤动脉的控制：为便于动脉瘤的分离和夹闭，本组对起源于ICA主干的动脉瘤施行术中颈部ICA控制者5例，其中4例行颈部ICA暂时性阻断，1例眼动脉动脉瘤在颈部ICA阻断点的远端插入动脉导管鞘，在分离和夹闭动脉瘤时将颈部ICA和动脉瘤远侧ICA暂时阻断后，从动脉导管内持续逆行抽吸使ICA和动脉瘤萎陷后将动脉瘤夹闭。1例手术中切开海绵窦上壁，游离海绵窦内ICA后将其暂时性阻断。

结果

根据Glasgow预后计分，术后早期恢复良好者为73.3％，中、重残者为20％，死亡2例，病死率6.6％。经对术后中、重残病人进行3～28个月随访，所有病人恢复良好者达到90％，除死亡的2例病人外，实际上只有1例术前Ⅳ级者为中残。

在动脉瘤瘤颈夹闭组的13例病人中，12例恢复良好，仅1例术前Ⅳ级的病人术后为重残；动脉瘤孤立或孤立后切除的11例病人中，6例恢复良好，4例（3例系PCA动脉瘤）出现与手术方式有关的神经功能障碍，其中2例在术后3周内恢复正常，1例发生颞叶脑梗死，手术后28个月门诊随访时对侧肢体肌力已恢复正常；另1例PCoA动脉瘤，术前血管造影虽证实侧枝循环充分，但动脉瘤孤立术后对侧肢体肌力下降到3级，术后3个月复查偏瘫症状已完全消失。另1例出现与手术方式无关的术后并发症，病人系MCA动脉瘤，术后第6天因术野血肿再次手术清除血肿，手术后病人很快清醒，出院时能独立行走。动脉瘤切除或孤立后载瘤动脉重建组的2例和颈部颈内动脉结扎组的2例均恢复良好。而单纯行动脉瘤包裹术的2例均为术前误诊病例，术中缺乏对处理巨大动脉瘤的充分准备，仅行动脉瘤包裹，术后均因动脉瘤再出血死亡。