A Case of Bilateral Giant Internal Carotid Artery Aneurysms at the Cavernous Portion Managed by 2-stage Extracranial-Intracranial Bypass with Parent Artery Occlusion: Consideration for Bypass Selection and Timing of Surgeries.
A Case of Bilateral Giant Internal Carotid Artery Aneurysms at the Cavernous Portion Managed by 2-stage Extracranial-Intracranial Bypass with Parent Artery Occlusion: Consideration for Bypass Selection and Timing of Surgeries.
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两阶段颅外-颅内搭桥术伴载瘤动脉闭塞治疗双侧颈内动脉海绵状部巨大动脉瘤一例：搭桥选择和手术时机的考虑。
DOI：
10.1016/j.jstrokecerebrovasdis.2014.02.020
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发表时间：
2014
影响因子：
2.5
通讯作者：
Tominaga T.
中科院分区：
文献类型：
--
作者：
Fujimura M;Sato K;Kimura N;Inoue T;Shimizu H;Tominaga T.
摘要双侧巨大颈内动脉瘤在海绵窦部合并双侧脑神经症状是非常罕见的。载瘤动脉闭塞（PAO）的颅外-颅内（EC-IC）搭桥术是海绵窦部巨大伊卡动脉瘤伴颅神经麻痹的首选手术之一;然而，最佳搭桥术选择和手术时机存在争议，特别是在双侧病例中。一名28岁女性在双侧海绵窦部分出现左侧第三神经麻痹伴巨大伊卡动脉瘤。因为只有左侧动脉瘤有症状，她最初接受了左EC-IC旁路术，使用隐静脉移植物与PAO，没有并发症，这缓解了她的症状。然而，她在10个月后出现右侧第三/第五神经麻痹，此时磁共振（MR）成像和MR血管造影显示右侧伊卡动脉瘤增大，左侧伊卡动脉瘤缩小。右侧伊卡的球囊试验闭塞确定了足够的缺血耐受性;因此，她接受了右颞浅动脉-大脑中动脉旁路术伴PAO。术后经MR血管造影证实两条旁路通畅。术后颅神经麻痹逐渐改善，单光子发射计算机断层扫描证实了静态脑血流动力学。总之，建议在单侧症状侧手术的第一阶段采用高流量EC-IC旁路术和PAO，以最大限度地减少对侧动脉瘤的术后血流动力学应力。一旦对侧出现症状，根据球囊试验闭塞的结果，建议进行第二阶段EC-IC旁路术和PAO，无论是低流量旁路术还是高流量旁路术。
Bilateral giant internal carotid artery (ICA) aneurysms at the cavernous portion with bilateral cranial nerve symptoms are extremely rare. Extracranial–intracranial (EC-IC) bypass with parent artery occlusion (PAO) is one of the preferred procedures for giant ICA aneurysm at the cavernous portion with cranial nerve palsy; however, optimal bypass selection and the timing of surgery are controversial, particularly in bilateral cases. A 28-year-old woman developed left third nerve palsy with giant ICA aneurysms at the bilateral cavernous portion. Because only the left aneurysm was symptomatic, she initially underwent left EC-IC bypass using a saphenous vein graft with PAO without complications, which relieved her symptoms. However, she developed right third/fifth nerve palsy 10 months later, at which time magnetic resonance (MR) imaging and MR angiography revealed an enlarged right ICA aneurysm and shrunken left ICA aneurysm. Balloon test occlusion of the right ICA identified sufficient ischemic tolerance; therefore, she underwent right superficial temporal artery–middle cerebral artery bypass with PAO. Both bypasses were confirmed by MR angiography to be patent after surgery. Cranial nerve palsy gradually improved postoperatively, and single-photon emission computed tomography confirmed static cerebral hemodynamics. In conclusion, high-flow EC-IC bypass with PAO is recommended in the first stage of surgery on a unilaterally symptomatic side to minimize postoperative hemodynamic stress to the contralateral aneurysm. Once the contralateral side becomes symptomatic, second stage EC-IC bypass with PAO, either low-flow or high-flow bypass, is recommended based on the results of balloon test occlusion.