Fujimura N, Hirohata M, Abe T, Tokutomi T, Shigemori M
Department of Neurosurgery, Kurume University Medical School, Japan.
No Shinkei Geka. 1999 Jan;27(1):49-54.
We report a case with radical neck clipping following incomplete embolization with coils and imperfect neck clipping. A 43-year-old woman suffered from a subarachnoid hemorrhage (Hunt & Hess Grade IV) due to the rupture of a left paraclinoid internal carotid aneurysm on 28 October, 1996. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at 2 weeks after surgery showed however a small residual aneurysm. The second angiogram 1.5 months later showed the growth of the residual aneurysm. The residual part of the aneurysm was then treated with endovascular embolization using interlocking detachable coils (IDC), resulting in incomplete occlusion of the aneurysm. The direct surgical clipping of the residual aneurysm was performed via Dolenc approach. A fenestrated clip was applied to the partial embolized aneurysm, when the aneurysmal wall was ruptured between the occluded part of the aneurysm and the residual dome. The fenestrated clip was then reapplied successfully under temporary occlusion of the parent artery. Because of the stenosis of the parent artery, STA-MCA anastomosis was then performed. Postoperative recovery of the patient was uneventful and postoperative angiogram showed stenosis of the parent artery with patent bypass flow. The patient was discharged without complications. Technical problems in neck clipping following incomplete embolization with coils are discussed.
我们报告了一例在使用弹簧圈不完全栓塞和颈部夹闭不完善后进行根治性颈部夹闭的病例。一名43岁女性于1996年10月28日因左侧床突旁颈内动脉瘤破裂而发生蛛网膜下腔出血（Hunt & Hess分级IV级）。在第1天对动脉瘤进行了颈部夹闭。然而，术后2周的随访血管造影显示有一个小的残留动脉瘤。1.5个月后的第二次血管造影显示残留动脉瘤增大。然后使用可解脱弹簧圈（IDC）对动脉瘤的残留部分进行血管内栓塞治疗，导致动脉瘤不完全闭塞。通过Dolenc入路对残留动脉瘤进行直接手术夹闭。当动脉瘤壁在动脉瘤闭塞部分和残留瘤顶之间破裂时，将带窗夹应用于部分栓塞的动脉瘤。然后在临时阻断载瘤动脉的情况下成功重新应用带窗夹。由于载瘤动脉狭窄，随后进行了STA-MCA吻合术。患者术后恢复顺利，术后血管造影显示载瘤动脉狭窄，搭桥血流通畅。患者无并发症出院。讨论了使用弹簧圈不完全栓塞后颈部夹闭的技术问题。
