床突旁颈内动脉动脉瘤的外科治疗

目的 探讨床突旁颈内动脉动脉瘤的外科治疗方法.方法 回顾性分析67例71个床突旁颈内动脉动脉瘤的临床资料.结果 67例患者共71个床突旁动脉瘤.同侧或对侧改良翼点入路直接手术夹闭42例;5例采用颅内外血管搭桥+动脉瘤孤立术;9例采用血管内介入治疗;11例海绵窦段动脉瘤未采取任何治疗措施.在56例治疗病例中,KPS评分90分以上有49例,80分者6例,70分者1例,无死亡、重残者.结论 床突旁颈内动脉动脉瘤手术直接夹闭预后良好.对于复杂、巨大动脉瘤或海绵窦内动脉瘤,血管搭桥手术是必要的治疗手段之一.     

三维CT对颈内动脉硬膜环附近动脉瘤的诊断

目的总结应用三维CT血管造影(3D-CTA)对颈内动脉硬膜环附近动脉瘤(juxta-dural ring aneurysm, JDRAn)的诊断经验。方法分析23例该部位动脉瘤患者的26个动脉瘤与海绵静脉窦及硬脑膜的位置关系,评价3D-CTA在判定动脉瘤是否向硬膜内突出上的作用。结果3D-CTA诊断出26个JDRAn中的25个,诊断率为96%。仅在高CT值表面遮盖显示法(shaded surface display,SSD)处理影像上显示的6个动脉瘤均位于硬膜外;6个颈内动脉窦部动脉瘤(carotid cave aneurysm, CCAn)中3个位于硬膜内,1个位于硬膜外,另2个颈部的一部分突出于硬膜内。低CT值处理影像上显示的其它13个非CCAn均突出于硬膜内。结论3D-CTA可以有效地诊断JDRAn,为手术适应证的选择提供有益的参考。     

改良翼点入路夹闭颈内动脉床突旁动脉瘤20例分析

目的探讨采用显微外科技术夹闭颈内动脉床突旁动脉瘤的有效方法及其手术的安全性。方法对20例床突旁动脉瘤(颈内动脉-眼动脉动脉瘤17例,颈内动脉-垂体上动脉动脉瘤3例)在常规翼点入路经硬脑膜外充分咬除蝶骨嵴的基础上,继续向内侧分离硬脑膜,并用高速磨钻磨除前床突,然后再切开硬脑膜,采用显微外科技术处理床突旁动脉瘤。结果20例动脉瘤完全手术夹闭19例,仅1例颈内动脉-眼动脉瘤因其颈部的前侧壁与周围紧密粘连,分离困难而进行了动脉瘤壁包裹术。随访6月,病人情况良好,无相关的手术并发症。结论改良翼点入路手术中,自硬脑膜外分离并切除前床突,可以改善颅内鞍区的手术显露,降低分离、夹闭床突旁动脉瘤时动脉瘤破裂的危险性。     

海绵窦及床突旁大型和巨大型动脉瘤的手术治疗

目的 探讨海绵窦和床突旁大型、巨大型动脉瘤的特点、手术适应证及手术方法.方法 1998至2006年对36例床突旁和海绵窦大型、巨大型动脉瘤经外科于术治疗.常规采取翼点入路,暴露颈部颈内动脉.分别采用动脉瘤直接夹闭,动脉壁修补及动脉瘤孤立加颅内外血管搭桥等方式处理动脉瘤.术中使用脑电图(EEG)及体感诱发电位(SEP),以及多普勒(Doppler)、内镜等辅助设备.结果 32例床突旁动脉瘤直接夹闭,1例海绵窦内假性动脉瘤行载瘤动脉修补术,3例海绵窦动脉瘤行孤立加颅内外血管搭桥术.出院时GOS评分良好者32例(89%),重残2例(5.6%),死亡2例(5.6%).结论 不适宜栓塞治疗的海绵窦动脉瘤应采取手术治疗,而床突旁动脉瘤则首选手术治疗.     

颈内动脉床突旁动脉瘤影像学分类探讨

研究背景颈内动脉床突旁动脉瘤的命名和分类多种多样,大部分为外科手术所用。本文介绍一种适用于血管内治疗的床突旁动脉瘤的改良分类方法,并概述其命名和分类。方法尝试将126例患者共142个床突旁动脉瘤分为两类,即类型Ⅰ(眼动脉动脉瘤)和类型Ⅱ(垂体上动脉动脉瘤)。每一类型再被眼动脉与后交通动脉之间的假想等分线分为两类,其中Ⅰa和Ⅱa类动脉瘤主要位于等分线的近心端,Ⅰb和Ⅱb类型位于等分线的远心端。结果全部动脉瘤均获得成功分类,其中Ⅰa类动脉瘤45个占31.69%(45/142),Ⅰb类动脉瘤11个占7.75%(11/142);Ⅱa类动脉瘤78个占54.93%(78/142),Ⅱb类动脉瘤8个占5.63%(8/142)。结论颈内动脉床突旁动脉瘤分类复杂多样,选择适当的分类方法有利于制定合理的治疗方案。     

床突旁动脉瘤的显微手术治疗

床突旁动脉瘤起自颈内动脉近环至后交通动脉起始部之间。采用颅底入路,自硬膜外或/和硬膜下切除前床突、视柱,切开镰状韧带,打开视神经管,必要时切开颈内动脉远环及硬膜袖是显露床突旁动脉瘤,实施颅内近端控制的关键。术中需根据动脉瘤的位置、瘤颈的宽度及粥样硬化和钙化的程度、动脉瘤与周围结构的关系等因素决定治疗方案。术后主要的并发症是神经损伤和缺血性脑梗死。     

海绵窦解剖学新概念

目的探讨海绵窦区解剖学新概念,为海绵窦区手术提供详实的解剖学依据。方法利用手术显微镜对经福尔马林固定、彩色乳胶灌注的国人成年尸颅21例进行手术观察、测量海绵窦区的硬膜关系、神经与血管走行及相邻结构的关系;利用组织化学技术对硬膜、神经及血管之间的关系进行组织学观察。结果中颅窝鞍旁两层硬膜形成一个腔,即鞍旁硬膜间腔;在鞍旁硬膜间腔内,硬脑膜结缔组织包裹动眼神经、滑车神经、外展神经、Meckel腔、三叉神经节及其三个分支组成一纵行板层样结构,我们称之为神经隔。颈内动脉及颅内、外静脉亦穿行于鞍旁硬膜间腔内;神经隔将海绵窦区分隔成硬膜间隙区、血液间隙区及床突间隙区。结论通过对海绵窦区显微外科解剖学研究,提出了该区构筑学新概念,为颅底手术经硬膜间隙侧壁入路提供了外科解剖学依据。     

手术夹闭颈内动脉床突上段外伤性动脉瘤1例

目的探索颈内动脉床突上段外伤性动脉瘤手术夹闭治疗的方法。方法回顾性分析1例外伤性动脉瘤病人的临床资料,头部CT示左鞍旁椭圆形高密度占位影像,全脑血管造影发现左颈内动脉床突上段圆圈状不规则形动脉瘤影像,急诊全麻下行左侧扩大翼点入路开颅见颈内动脉床突上段局部棱形增粗,血管外膜下可见血液流动,用2枚动脉瘤夹（1枚直角夹,1枚直夹）封闭破裂处。结果用2枚动脉瘤夹能完全封闭动脉瘤破裂处而又保留载瘤动脉的1/2通畅,术后辅以抗凝治疗,疗效满意。结论外伤性动脉瘤发现后应急诊治疗,根据具体情况选用不同的治疗方式。     

内镜下经鼻蝶入路治疗鞍区病变的解剖学研究

目的研究内镜下蝶窦和鞍区的解剖结构。方法对8例成人头颅标本在内镜下模拟经鼻蝶手术入路,解剖观察蝶窦后壁和鞍区。结果将蝶窦后壁“井”字线划分为九个区,中间从上到下分别为视交叉区、鞍区和斜坡区,两侧从上到下分别为视神经管区、鞍旁海绵窦区和斜坡旁海绵窦区。鞍型蝶窦后壁中常见的解剖标志有斜坡凹陷、视神经管隆突、颈内动脉隆突和视神经颈内动脉隐窝;其中视神经颈内动脉隐窝是恒定的骨性解剖标志,毗邻视神经、海绵窦、海绵窦内颈内动脉、眶尖;两侧视神经颈内动脉隐窝的连线是鞍结节的投影。鞍旁海绵窦区是骨缺损好发的位置。结论对蝶窦后壁的九分区法适用于骨质层、硬膜层和颅内层,使复杂的鞍区及附近结构相对简化,易于识别和定位;视神经颈内动脉隐窝是重要的解剖标志。     

颈内动脉床突旁动脉瘤的血管内治疗

目的 探讨血管内治疗床颈内动脉突旁动脉瘤的效果和安全性。方法 对接受血管内治疗的104例（共112个）床突旁颈内动脉动脉瘤患者的临床资料进行回顾性分析。结果 栓塞后即时造影显示,83个动脉瘤（74.1%）完全闭塞,16个（14.3%）瘤颈残留,13个（11.6%）瘤体残留。93个（83%）动脉瘤获造影随访3个月~2年,88个（94.6%）动脉瘤显示稳定或完全闭塞,5个（5.4%）复发。发生手术相关并发症2例（1.9%）,无死亡病例。结论 血管内弹簧圈栓塞治疗床突旁动脉瘤是一种安全有效的方法。     

Surgical treatment of internal carotid siphon aneurysms

Abstract

Surgical treatment of internal carotid artery aneurysms around the carotid siphon is discussed. The surgical approach to the aneurysms in this region, is as follows: 1. A fronto-temporal approach with the patient in a 45° semi-sitting position to decrease venous pressure. 2. A Dolenc approach cutting a part of the dura mater of the superior orbital fissure to facilitate removal of the anterior clinoid process and unroofing of the optic canal. 3. Opening the medial triangle followed by transection of the optic canal duraI sheath. Carotid siphon aneurysms can be divided into three groups anatomically; aneurysms of the ophthalmic segment (C2), those of the clinoid segment (C3), and those of the horizontal segment (C4). We present 29 cases of aneurysms arising from the C2 or C2/3 segment, 14 cases arising from the C3 or C3/4 segment, and 11 cases arising from the C4 segment. Anatomic localization of the aneurysms was established preoperatively by angiography and three-dimensional CT imaging. Small aneurysms of the ophthalmic segment projecting infero-medially can be clipped using a contralateral approach via the prechiasmatic root. Aneurysms of the ophthalmic segment projecting superiorly can be clipped following resection of the anterior clinoid process. The clinoid process should be resected intradurally with direct visualization of the aneurysms. Straight side-angled clips are suitable for these aneurysms. Carotid cave aneurysms, which include aneurysms of the ophthalmic segment oriented infero-medially and of the clinoid segment projecting postero-medially can be clipped using curved fenestrated clips via Dolenc's extradural approach. For accurate clipping, opening of the medial triangle and full mobilization of the 1C at the clinoid segment and optic nerve by unroofing the optic canal are required. Aneurysms of the horizontal portion are clipped after full exposure of the artery in the cavernous sinus only when the aneurysms are large and symptomatic. We used the fronto-temporal and Dolenc approaches and applied fenestrated clips to aneurysms oriented or postero-medially and straight or oblique clips to aneurysms projecting antero-laterally. Out of 40 aneurysms which underwent surgical clipping, 37 resulted in good post-operative recovery. There were three deaths secondary to complications of vasospasm and three cases with post-operative visual loss. The classification of these aneurysms and the surgical techniques we employed are discussed in detail. [Neurol Res 1996; 18: 409-415]     

A classification of juxta-dural ring aneurysms with reference to surgical anatomy.

We report a subgroup of internal carotid artery (ICA) aneurysms located near the carotid ring which we call juxtadural ring aneurysms. These aneurysms are classified into three types: paraclinoid intradural, carotid cave and infraclinoid extradural aneurysms. The paraclinoid intradural aneurysms arise from the ICA distal to the origin of the ophthalmic artery and are close to the dural ring, which may include some so-called carotid-ophthalmic aneurysms. The carotid cave aneurysms are located in the carotid cave which is seated in the infraclinoid carotid groove and proximal to the origin of the ophthalmic artery. They are located at the angiographical genu and in the intradural space anatomically. The infraclinoid extradural aneurysms are located close to the dural ring extradurally in the infraclinoid carotid groove sinus, a peripheral venous space of the cavernous sinus. The infraclinoid extradural aneurysms should be differentiated from aneurysms in the cavernous sinus, because they are located in the infraclinoid carotid groove sinus.     

Surgical results and the related topographic anatomy in paraclinoid internal carotid artery aneurysms

Abstract

Paraclinoid internal carotid artery aneurysms arising between the roof of the cavernous sinus and the origin of the posterior communicating artery are of considerable interest with regard to their anatomical variations and technical surgical challenges. Twenty-seven patients with 30 paraclinoid aneurysms were treated surgically through pterional intradural approach. Neck clipping was performed in 22 (73%) of the 30 aneurysms; coating in seven, and trapping in one. The surgical outcome was excellent in 24 patients (24/27, 89%), with two patients showing ipsilateral partial visual field defect (2/27, 7%). There was one death (4%) due to infarction after unintended carotid artery trapping. The characteristic topographic anatomical features which we considered to pose technical difficulties and to be responsible for the complications or failure in neck clipping were aneurysmal dome extending into the anterior clinoid process; atheroma at the neck, multiple paraclinoid aneurysms, ophthalmic artery originating at the neck, and marked supero-medial shift of the C2 segment of the carotid artery. Pre-operative depiction of the topographical anatomy around the paraclinoid aneurysm is essential but not always possible on the basis of conventional angiography. Magnetic resonance or three-dimensional computerized tomographic angiography, and their axial source imaging, were useful in delineating the topography with unusual aneurysmal growth, overlap of aneurysm with the parent artery, and uncommon variations of the surrounding structures. [Neurol Res 1996; 18: 401-408]     

Distinction between Intradural and Extradural Aneurysms Involving the Paraclinoid Internal Carotid Artery with T2-Weighted Three-Dimensional Fast Spin-Echo Magnetic Resonance Imaging

Objective

The precise intra- vs. extradural localization of aneurysms involving the paraclinoid internal carotid artery is critical for the evaluation of patients being considered for aneurysm surgery. The purpose of this study was to investigate the clinical usefulness of T2-weighted three-dimensional (3-D) fast spin-echo (FSE) magnetic resonance (MR) imaging in the evaluation of unruptured paraclinoid aneurysms.

Methods

Twenty-eight patients with unruptured cerebral aneurysms in their paraclinoid regions were prospectively evaluated using a T2-weighted 3-D FSE MR imaging technique with oblique coronal sections. The MR images were assessed for the location of the cerebral aneurysm in relation to the dural ring and other surrounding anatomic compartments, and were also compared with the surgical or angiographic findings.

Results

All 28 aneurysms were identified by T2-weighted 3D FSE MR imaging, which showed the precise anatomic relationships in regards to the subarachnoid space and the surrounding anatomic structures. Consequently, 13 aneurysms were determined to be intradural and the other 15 were deemed extradural as they were confined to the cavernous sinus. Of the 13 aneurysms with intradural locations, three superior hypophyseal artery aneurysms were found to be situated intradurally upon operation.

Conclusion

High-resolution T2-weighted 3-D FSE MR imaging is capable of confirming whether a cerebral aneurysm at the paraclinoid region is intradural or extradural, because of the MR imaging''s high spatial resolution. The images may help in identifying patients with intradural aneurysms who require treatment, and they also can provide valuable information in the treatment plan for paraclinoid aneurysms.     

CTA影像模拟眶上锁孔入路手术中颈内动脉的显露

目的 应用CT血管造影（CTA）模拟去除前床突前后颈内动脉颅内段的显露情况,为眶上锁孔入路处理颈内动脉动脉瘤提供解剖数据。方法 收集30例双侧颈内动脉及颅底骨质无解剖异常的CTA影像数据,利用容积再现技术+图像融合技术重建颅骨及颅内主要动脉影像,然后用CTA重建影像模拟眶上锁孔入路手术时颈内动脉和颅骨的显露情况,测量去除前床突前后双侧颈内动脉颅内段的显露长度。结果 30例CTA影像获得60组去骨前后颈内动脉颅内段长度共120个。去除前床突前,颈内动脉的显露长度为4.1~21.9 mm,平均（14.7±3.7） mm;去除前床突后,颈内动脉的显露长度为21.4~39.4 mm,平均（30.6±4.1） mm。去骨前后测量长度有统计学差异（P<0.01）。去除前床突后,增加的长度为10.0~25.5 mm,平均（15.8±3.5） mm。结论 眶上锁孔入路中磨除同侧前床突能增加颈内动脉颅内段的显露范围,术中可利用此方法处理被前床突遮挡的颈内动脉动脉瘤。     

Strategy for the treatment of inaccessible unruptured giant and large aneurysms of the internal carotid artery

Abstract

Our goal was to clarify the optimum management of the inaccessible unruptured giant and large aneurysms of the internal carotid artery (ICA). Since 1981, we have treated 18 patients with unclippable unruptured giant or large aneurysms of the ICA. Aneurysms were classified as either intracavernous or intradural. We performed proximal carotid occlusion in 12 patients and conservatively treated six patients. We retrospectively analyzed long-term outcomes in these patients. Four of seven patients with intradural aneurysm underwent proximal carotid occlusion, with good long-term outcomes. The three patients with intradural aneurysm, who were treated conservatively, died of subarachnoid hemorrhage. Eight of 11 patients with intracavernous aneurysm underwent proximal carotid occlusion, one dying of massive nasal bleeding 25 months after the procedure. In this case, the aneurysm was partially thrombosed, and residual lumen growth was revealed 22 months after proximal carotid occlusion. Cranial nerve paresis improved in five of the eight patients (63%), and two patients had a minor ischemic attack. Neurological problems failed to occur in the three patients with intracavernous aneurysm who were treated conservatively. The risk of rupture is relatively high in intradural giant and large aneurysms. Proximal carotid occlusion can effectively prevent bleeding from intradural aneurysms. Aggressive management is justified for intradural aneurysms with poor collateral circulation. Operative procedures in the management of an intracavernous aneurysm require careful consideration.     

床突旁复杂动脉瘤术中出血的防与止

目的 探讨颈内动脉前床突旁动脉瘤术中瘤体破裂出血的预防和控制.方法 回顾性分析3例术中破裂的眼动脉瘤的手术经验.手术均采用翼点入路,床突旁动脉瘤病例预先暴露颈总、颈内、颈外动脉以备临时阻断.从硬脑膜内快速咬除前床突,以显露动脉瘤的近侧角.术中监测脑电图和体感诱发电位,并采用术中超声多普勒检查动脉血流.结果 2例动脉瘤直接夹闭,1例行动脉瘤孤立术.术后行检查加入数字减影血管造影(DSA),3例动脉瘤均不显影.结论 充分显露、合理应用临时阻断技术,以及术中应用电生理监测和超声多普勒检查等辅助措施,能够取得动脉瘤的满意处理,减少脑损伤.     

MRI localization of paraclinoid carotid aneurysms

AIM: The distal dural ring plane (DDRP) separates the intracavernous from the supracavernous paraclinoid internal carotid artery. The purpose of this MRI protocol is to evaluate the position of this plane for the characterization of paraclinoid aneurysms. METHOD: The protocol uses a T2 weighted sequence in two orthogonal planes (diaphragmatic and carotid planes) and two correlation lines in each plane. These lines pass through anatomo-radiological reference points correlated with the medio-lateral and antero-posterior margins of the DDRP. We use the intersection angle of these lines as the inferior radiological limit of the DDRP curve. RESULTS: An aneurysm located above this angle is supracavernous; an aneurysm located below this angle is intracavernous; an aneurysm crossing this angle is transitional. CONCLUSION: In difficult cases, this MRI protocol could help better characterize the exact localization of paraclinoid aneurysms on both sides of the cavernous sinus roof.     

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

Objective

Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications.

Methods

Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography.

Results

Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely.

Conclusion

The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.