大脑中动脉分叉处动脉瘤夹闭术中显露大脑中动脉M1段的手术策略

doi:10.3760/cma.j.issn.2095-7041.2019.04.013

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摘要目的探讨大脑中动脉分叉处(MCBIF)动脉瘤开颅夹闭术中安全显露大脑中动脉M1段的手术策略。方法回顾性分析2012年3月—2018年3月山西大医院神经外科手术治疗的60例(65个)MCBIF动脉瘤患者的临床资料,其中男29例、女31例,发病年龄35～65(40±0.5)岁。动脉瘤出血Hunt-Hess分级0级3例,Ⅰ级13例,Ⅱ级13例,Ⅲ级16例,Ⅳ级7例,Ⅴ级8例。在冠状位最大密度投影(MIP)图像上观察到,动脉瘤指向上方27个、指向外侧22个、指向下方16个。测量动脉瘤同侧大脑中动脉M1段的长度,观察M1段的曲度,模拟翼点开颅手术入路;采取近端或远端入路手术,指向下方和外侧的动脉瘤从上方显露大脑中动脉M1段,指向上方的动脉瘤从下方显露大脑中动脉M1段,并选择合适的动脉瘤夹夹闭动脉瘤。随访并观察动脉瘤复发情况,预后评价采用格拉斯哥预后评分(GOS),并比较不同指向动脉瘤的预后差异。结果大脑中动脉M1段长度为8.2～16.5( 13.5±0.3)mm。M1段曲度向下,动脉瘤指向上;M1段曲度向上,动脉瘤指向下;M1段平直向外,动脉瘤指向外。 CTA三维影像模拟手术入路中动脉瘤以及与周围血管的解剖关系与手术中所见解剖结构完全相符。所有动脉瘤夹闭可靠,术后6个月复查头颅CTA未见动脉瘤复发。随访6～36(18.0±2.5)个月,末次随访结果GOS评分:5分37例,4分10例,3分4例,2分3例,1分6例,不同指向动脉瘤的预后良好率比较差异无统计学意义(P＞0.05)。结论充分利用CTA三维重建技术,明确动脉瘤的指向、大脑中动脉M1段的长度和曲度,精确评估大脑中动脉分叉处动脉瘤和M1段在侧裂内的投影方位,避开动脉瘤顶,采取合适的策略显露M1段,有效做到近端控制,是手术安全进行的可靠保障。

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关键词 ：大脑中动脉, 颅内动脉瘤, 成像,三维, CT血管成像, 手术策略

Abstract：Objective To explore the strategy of exposing M1 segment safely in the craniotomy clipping surgery of the middle cerebral artery bifurcation(MCBIF) aneurysms.Methods The clinical data of sixty patients with sixty-five MCBIF aneurysms performed surgical management between March 2012 and March 2018 in Shanxi Dayi Hospital were retrospectively analyzed, including 29 males and 31 females, with the onset age ranging from 35 to 65(40±0.5) years old. There were 3 cases in level 0, 13 cases in levelⅠ, 13 cases in level Ⅱ, 16 cases in level Ⅲ, 7 cases in level Ⅳ, 8 cases in level Ⅴ by aneurysm bleeding Hunt-Hess classification in admission. The MCBIF aneurysms were divided into projecting superiorly (27), projecting laterally (22) and projecting inferiorly (16) according to the coronal planes of MIP. Meanwhile the length of M1 segment was measured and the curvature of M1 segment was observed in the ipsilateral middle cerebral artery of the aneurysm. Reconstructed images to simulate the pterional approach. The sylvian fissure was splitted by proximal or distal approach. The M1 segment was exposed from its upward side for the aneurysm that projecting inferiorly and laterally. Alternatively, the M1 segment was exposed from its downward side for the aneurysm that projecting superiorly. The right clips should be selected to occlude the aneurysms. All patients were followed up to observe aneurysm reappear. Glasgow outcome score (GOS) was used for prognosis evaluation. The difference in prognosis of aneurysm with different projection was compared.Results The length of M1 segment was 8.2-16.5(13.5±0.3) mm. Projection of the aneurysms depended on the curvature of M1 segment: the projection superiorly with the downward curvature, the projection inferiorly with the upward curvature and the projection laterally with straight M1 segment. The anatomic relationship between the aneurysm and its parent artery in the 3D-CTA image of simulated pterional approach was in accordance with the actual condition in operation. All aneurysms were clipped and didn't reappear in 6 months after surgery. The follow-up period was 6 to 36 months(Mean 18.0±2.5 months).The GOS was 5 in 37 cases, 4 in 10 cases, 3 in 4 cases, 2 in 3 cases, and 1 in 6 cases according to the last follow-up. There was no statistically significant difference in the favorable prognosis rate of the aneurysms with different projection. (P＞0.05).Conclusions We should make full use of the technology of 3D-CTA to identify the projection of the aneurysm and both the length and curvature of M1 segment, assess accurately the orientation of the aneurysm and M1 segment in sylvian fissure. In this way, we can avoid the dome of aneurysm, take the appropriate strategy to expose M1 segment and accomplish effectively the proximal control of the parent artery. These strategies are the reliable guarantee for the operation safety.

Key words： Middle cerebral artery Intracranial aneurysm Imaging, three dimensional Computed tomography angiography Surgical strategy

收稿日期: 2019-02-22

通讯作者: 仝海波,Email:13403459753@126.com

引用本文:

杨忠平, 吴山, 王向阳, 陈来照, 仝海波. 大脑中动脉分叉处动脉瘤夹闭术中显露大脑中动脉M1段的手术策略[J]. 中华解剖与临床杂志, 2019, 24(4): 380-385.
Yang Zhongping, Wu Shan, Wang Xiangyang, Chen Laizhao, Tong Haibo. The surgical strategy of exposing M1 segment in the clipping of the middle cerebral artery bifurcation aneurysms. Chinese Journal of Anatomy and Clinics, 2019, 24(4): 380-385.

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http://www.cjac.com.cn/CN/10.3760/cma.j.issn.2095-7041.2019.04.013 或 http://www.cjac.com.cn/CN/Y2019/V24/I4/380

[1]	Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion[J]. Lancet, 2005, 366(9488): 809-817. DOI:10.1016/S0140-6736(05)67214-5.
[2]	崔小鹏, 李元垒, 赵岩, 等. 大脑中动脉分叉处动脉瘤最优夹闭方法的临床经验总结[J]. 中华神经医学杂志, 2017, 16(7): 734-737. DOI:10.3760/cma.j.issn.1671-8925.2017.07.017.
[3]	Lawton MT. Seven aneurysms: tenets and techniques for clipping[M]. New York: Thieme, 2011: 73-75.
[4]	李祥, 于如同, 谷佳, 等. 3D-CTA在颅内前循环动脉动脉瘤临床诊疗中的应用[J]. 中华神经外科杂志, 2015, 31(6): 557-559. DOI:10.3760/cma.j.issn.1001-2346.2015.06.005.
[5]	陈伏祥, 康德智, 林元相, 等. 脑肿瘤合并颅内动脉瘤32例临床分析[J]. 中华解剖与临床杂志, 2015, 20(5): 450-453. DOI:10.3760/cma.j.issn.2095-7041.2015.05.017.
[6]	杨忠平, 刘跃亭, 范益民, 等. 40例前交通动脉瘤脑血管造影特点分析[J]. 中华神经外科疾病研究杂志, 2008, 7(1): 10-12. DOI:10.3969/j.issn.1671-2897.2008.01.004.
[7]	Potts MB, Chang EF, Young WL, et al. Transsylvian-transinsular approaches to the insula and basal ganglia: operative techniques and results with vascular lesions[J]. Neurosurgery, 2012, 70(4): 824-834. DOI:10.1227/NEU.0b013e318236760d.
[8]	Maekawa H, Hadeishi H. Venous-preserving sylvian dissection[J]. World Neurosurg, 2015, 84(6): 2043-2052. DOI:10.1016/j.wneu.2015.07.050.
[9]	Samson DS. Intracranial aneurysm surgery: basic principle and technique[M].New York: Thieme, 2012: 56-82.
[10]	Elsharkawy A, Niemelä M, Lehe ˇcka M, et al. Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms[J]. Acta Neurochir (Wien), 2014, 156(1): 17-25. DOI:10.1007/s00701-013-1894-7.
[11]	Park HW, Chung SY, Park MS, et al. Two indices affecting the directions of the sylvian fissure dissection in middle cerebral artery bifurcation aneurysms[J]. J Cerebrovasc Endovasc Neurosurg, 2013, 15(3): 164-170. DOI:10.7461/jcen.2013.15.3.164.
[12]	上山博康,宝金清博.脑动脉瘤手术:基本技术及实践应用[M]. 沈阳:辽宁科学技术出版社,2018: 236-246.
[13]	李太平, 娄平阳. 大脑中动脉动脉瘤分型对术中预防脑梗死的指导意义[J]. 中华神经外科杂志, 2015, 31(5): 458-460. DOI:10.3760/cma.j.issn.1001-2346.2015.05.007.
[14]	Mooney MA, Simon ED, Brigeman S, et al. Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial[J]. J Neurosurg, 2018, 130(3): 895-901. DOI:10.3171/2017.10.JNS172183.
[15]	Elsharkawy A, Leheˇcka M, Niemelä M, et al. A new, more accurate classification of middle cerebral artery aneurysms: computed tomography angiographic study of 1,009 consecutive cases with 1,309 middle cerebral artery aneurysms[J]. Neurosurgery, 2013, 73(1): 94-102. DOI:10.1227/01.neu.0000429842.61213.d5.
[16]	Jeon HJ, Kim SY, Park KY, et al. Ideal clipping methods for unruptured middle cerebral artery bifurcation aneurysms based on aneurysmal neck classification[J]. Neurosurg Rev, 2016, 39(2): 215-223. DOI:10.1007/s10143-015-0671-x.
[17]	丰育功, 李环廷, 唐万忠, 等. 大脑中动脉动脉瘤的影像学分型及对夹闭动脉瘤的指导价值[J]. 中华神经外科杂志, 2012, 28(8): 819-822. DOI:10.3760/cma.j.issn.1001-2346.2012.08.023.
[18]	Dashti R, Hernesniemi J, Niemelä M, et al. Microneurosurgical management of middle cerebral artery bifurcation aneurysms[J]. Surg Neurol, 2007, 67(5): 441-456. DOI:10.1016/j.surneu.2006.11.056.