Bypass Surgery for the Treatment of Dolichoectatic Basilar Trunk Aneurysms: A Work in Progress
Bypass Surgery for the Treatment of Dolichoectatic Basilar Trunk Aneurysms: A Work in Progress
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DOI：
10.1227/neu.0000000000001175
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发表时间：
2016-07-01
期刊：
影响因子：
4.8
通讯作者：
Halbach, Van V.
中科院分区：
文献类型：
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作者：
Lawton, Michael T.;Abla, Adib A.;Halbach, Van V.
背景技术背景：由于非囊状形态、位置深和脑干穿支受累，长扩张基底动脉干动脉瘤的治疗无效或病态。采用旁路手术治疗一直被提倡以消除恶性血流动力学和稳定动脉瘤生长。目的：验证旁路和载瘤动脉闭塞的血流改变对动脉瘤进展的有利影响。方法：手术治疗分为3个阶段，每个阶段有不同的血流动力学改变。结果：在17年的时间里，回顾性地确定了37例长扩张基底动脉干动脉瘤患者，其中21例患者接受了观察，12例立即治疗，4例在临床进展后选择治疗。在第1阶段，尽管使用了肝素，但血流逆转过度血栓形成（N = 5，最终死亡率，100%）。在第2阶段，颅内-颅内分流术的血流减少比血流逆转更安全，但不能防止动脉瘤进行性扩大（N = 3，最终死亡率67%）。在第3阶段，尽管使用氯吡格雷治疗，基底动脉干动脉瘤的远端夹闭术保留了动脉瘤内的顺行血流而没有破裂，但血流减少威胁到交通支的通畅（N = 8，最终死亡率62%）。延长扩张型基底动脉干动脉瘤的手术治疗策略改进（80%-50%）和最终死亡率（100%-62%），3期存活者动脉瘤稳定。良好的结局取决于交通支保留和减轻动脉瘤血栓形成。增加远端流出量的闭塞技术似乎有利于穿支血管。通过在专门的中心集中管理，协同努力使用计算方法研究形态学和血流动力学，以及广泛收集登记数据，可以推进长扩张基底动脉干动脉瘤的治疗。
BACKGROUND: The treatment of dolichoectatic basilar trunk aneurysms has been ineffectual or morbid due to nonsaccular morphology, deep location, and involvement of brainstem perforators. Treatment with bypass surgery has been advocated to eliminate malignant hemodynamics and to stabilize aneurysm growth.OBJECTIVE: To validate that flow alteration with bypass and parent artery occlusion favorably impacts aneurysm progression.METHODS: Surgical management evolved in 3 phases, each with different hemodynamic alterations.RESULTS: During a 17-year period, 37 patients with dolichoectatic basilar trunk aneurysms were retrospectively identified, of whom 21 patients were observed, 12 treated immediately, and 4 selected for treatment after clinical progression. In phase 1, flow reversal was overly thrombogenic, despite heparin (N = 5, final mortality, 100%). In phase 2, flow reduction with intracranial-to-intracranial bypass was safer than flow reversal, but did not prevent progressive aneurysm enlargement (N = 3, final mortality 67%). In phase 3, distal clip occlusion of the basilar trunk aneurysm preserved anterograde flow in the aneurysm without rupture, but reduced flow threatened perforator patency, despite treatment with clopidogrel (N = 8, final mortality 62%).CONCLUSION: Shifting treatment strategy for dolichoectatic basilar trunk aneurysms improved surgical (80% to 50%) and final mortalities (100% to 62%), with stabilization of aneurysms in the phase 3 survivors. Good outcomes are determined by perforator preservation and mitigating aneurysm thrombosis. Occlusion techniques with increased distal run-off seem to benefit perforators. The treatment of dolichoectatic basilar trunk aneurysms can advance through concentrated management in dedicated centers, concerted efforts to study morphology and hemodynamics with computational methods, and widespread collection of registry data.