Awake Craniotomy for Microsurgical Obliteration of Mycotic Aneurysms: Technical Report of Three Cases
Awake Craniotomy for Microsurgical Obliteration of Mycotic Aneurysms: Technical Report of Three Cases
复制标题
清醒开颅手术治疗霉菌性动脉瘤：三例技术报告
DOI：
10.1227/01.neu.0000144491.14623.92
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发表时间：
2005
期刊：
影响因子：
4.8
通讯作者：
M. Mayberg
中科院分区：
文献类型：
--
作者：
J. Lüders;M. Steinmetz;M. Mayberg
目标和重要性：药物治疗不能解决的感染性（myocardial）动脉瘤需要手术闭塞，通常需要牺牲载瘤动脉。此外，患有肌层动脉瘤的患者经常需要随后的心脏瓣膜修复术，这通常需要抗凝治疗。本文报告三例清醒开颅显微手术夹闭肌间动脉瘤的病例。在计算机断层扫描血管造影的基础上，使用无框架立体定向引导的清醒微创开颅术可以在动脉瘤闭塞前暂时闭塞载瘤动脉并进行神经评估。临床表现：一名56岁女性，二尖瓣疾病进行性恶化，30年前有亚急性细菌性心内膜炎和蛛网膜下腔出血病史。脑血管造影显示4 mm左侧大脑中动脉（MCA）角分支动脉瘤，需要在二尖瓣置换术前闭塞。第2例患者为64岁女性，有风湿热病史，在二尖瓣疾病导致肺脓肿和心功能恶化的情况下诊断为8 mm右侧远端MCA动脉瘤。第3例患者为57岁男性，有发热、盗汗和进行性二尖瓣疾病病史，尽管使用了抗生素，但左侧MCA角分支动脉瘤仍在扩大。由于其位于远端MCA分支上，因此没有动脉瘤适合术前试验球囊闭塞。干预措施：在使用基准标记物进行立体定向计算机断层扫描血管造影术后，患者接受了无框架立体定向导航的微创清醒开颅术。在所有病例中，暂时性载瘤动脉闭塞期间神经系统检查结果无变化，动脉瘤成功闭塞。结论：清醒微创开颅术治疗位于功能区脑内的感染性动脉瘤，可在永久夹闭或血管牺牲前进行清醒测试。结合无框架立体定向导航和计算机断层血管造影术，我们可以通过一个小的开颅手术，以最小的探索，快速进行手术。
OBJECTIVE AND IMPORTANCE: Infectious (mycotic) aneurysms that do not resolve with medical treatment require surgical obliteration, usually requiring sacrifice of the parent artery. In addition, patients with mycotic aneurysms frequently need subsequent cardiac valve repair, which often necessitates anticoagulation. Three cases of awake craniotomy for microsurgical clipping of mycotic aneurysms are presented. Awake minimally invasive craniotomy using frameless stereotactic guidance on the basis of computed tomographic angiography enables temporary occlusion of the parent artery with neurological assessment before obliteration of the aneurysm. CLINICAL PRESENTATION: A 56-year-old woman presented with progressively worsening mitral valve disease and a history of subacute bacterial endocarditis and subarachnoid hemorrhage 30 years previously. A cerebral angiogram revealed a 4-mm left middle cerebral artery (MCA) angular branch aneurysm, which required obliteration before mitral valve replacement. The second patient, a 64-year-old woman with a history of rheumatic fever, had an 8-mm right distal MCA aneurysm diagnosed in the setting of pulmonary abscess and worsening cardiac function as a result of mitral valve disease. The third patient, a 57-year-old man with a history of fevers, night sweats, and progressive mitral valve disease, had an enlarging left MCA angular branch aneurysm despite the administration of antibiotics. Because of their location on distal MCA branches, none of the aneurysms were amenable to preoperative test balloon occlusion. INTERVENTION: After undergoing stereotactic computed tomographic angiography with fiducial markers, the patients underwent a minimally invasive awake craniotomy with frameless stereotactic navigation. In all cases, the results of the neurological examination were unchanged during temporary parent artery occlusion and the aneurysms were successfully obliterated. CONCLUSION: Awake minimally invasive craniotomy for an infectious aneurysm located in eloquent brain enables awake testing before permanent clipping or vessel sacrifice. Combining frameless stereotactic navigation with computed tomographic angiography allowed us to perform the operation quickly through a small craniotomy with minimal exploration.