Giant intracranial aneurysms: evolution of management in a contemporary surgical series.
Giant intracranial aneurysms: evolution of management in a contemporary surgical series.
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DOI：
10.1227/neu.0b013e31822bb8a6
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发表时间：
2011-12
期刊：
影响因子：
4.8
通讯作者：
Lawton MT
中科院分区：
文献类型：
--
作者：
Sughrue ME;Saloner D;Rayz VL;Lawton MT
许多重要的显微外科系列患者的巨大动脉瘤早于实践的变化在血管内时代。本文介绍了一项当代手术经验，以检查相对于早期报告的管理变化，建立开放显微手术在管理策略中的作用，并量化结果，与不断发展的血管内治疗进行比较。在13年的时间里，140个巨大动脉瘤患者接受了手术治疗。100个动脉瘤位于前循环，占71%，41个动脉瘤位于后循环。108个动脉瘤（77%）完全闭塞，14个动脉瘤（10%）残留极小，16个动脉瘤（11%）不完全闭塞，血流逆转或减少。3例钙化动脉瘤在夹闭失败后卷曲。围手术期死亡18例（手术死亡率13%）。旁路相关并发症包括旁路闭塞（7例）、动脉瘤闭塞不全导致的动脉瘤出血（4例）、动脉瘤血栓形成伴穿支或支动脉闭塞（4例）。13例患者随访后期病情加重（永久性神经系统发病率9%，平均随访时间23±1.9个月）。总体而言，114例患者（81%）观察到良好的预后（GOS 5或4），109例患者（78%）治疗后改善或不变。严重依赖搭桥技术加上间接巨动脉瘤闭塞使现代手术经验有别于早期手术经验，并消除了低温循环停搏的需要。经验丰富的神经外科医生可以将手术作为“一线”治疗方法，并将血管内技术作为手术的辅助手段，取得良好的效果。
Many significant microsurgical series of patients with giant aneurysms predate changes in practice during the endovascular era. A contemporary surgical experience is presented to examine changes in management relative to earlier reports, to establish the role of open microsurgery in the management strategy, and to quantify results for comparison with evolving endovascular therapies. During a 13-year period, 140 patients with 141 giant aneurysms were treated surgically. 100 aneurysms (71%) were located in the anterior circulation, and 41 aneurysms were located in the posterior circulation. 108 aneurysms (77%) were completely occluded, 14 aneurysms (10%) had minimal residual aneurysm, and 16 aneurysms (11%) were incompletely occluded with reversed or diminished flow. 3 patients with calcified aneurysms were coiled after unsuccessful clipping attempts. 18 patients died in the perioperative period (surgical mortality, 13%). Bypass-related complications resulted from bypass occlusion (7 patients), aneurysm hemorrhage due to incomplete aneurysm occlusion (4 patients), or aneurysm thrombosis with perforator or branch artery occlusion (4 patients). 13 patients were worse at late follow-up (permanent neurological morbidity, 9%; mean length of follow-up, 23±1.9 months). Overall, good outcomes (GOS 5 or 4) were observed in 114 patients (81%) and 109 patients (78%) were improved or unchanged after therapy. A heavy reliance on bypass techniques plus indirect giant aneurysm occlusion distinguishes this contemporary surgical experience from earlier ones, and obviates the need for hypothermic circulatory arrest. Experienced neurosurgeons can achieve excellent results with surgery as the “first-line” management approach and endovascular techniques as adjuncts to surgery.