Steiger H J, Medele R, Brückmann H, Schroth G, Reulen H J
Department of Neurosurgery, Ludwig-Maximilians-University Munich, Germany.
Acta Neurochir (Wien). 1999;141(4):359-66; discussion 366-7. doi: 10.1007/s007010050311.
The authors report on a series of 100 posterior circulation aneurysms managed by surgical and endovascular procedures. The series consisted of 41 elective admissions more than 14 days after SAH or for unruptured aneurysms and 59 acute admissions after subarachnoid haemorrhage (SAH). In this first interdisciplinary series after the introduction of electrolytically detachable coils, surgical clipping was maintained as treatment of choice in good grade patients while endovascular therapy was primarily offered for patients in poor clinical grade or if the aneurysm was judged difficult to be accessed surgically. A total of 70 patients underwent aneurysm elimination, 54 surgically and 16 by the endovascular route. In 30 patients the aneurysm was not treated, either because of persisting grade 5 WFNS after SAH or because the risk of treatment appeared excessive with some complex unruptured aneurysms. A complication leading to permanent morbidity or mortality occurred after 5 surgical and 1 endovascular procedure (8.6%). Regarding overall management results after acute SAH, 14 of the total of 59 patients admitted with acute SAH died, corresponding to a management mortality of 24%. Although the present series cannot provide statistically firm conclusions, the authors believe from the actual experience and the accumulating literature, that the principal complementary aspect of the two treatment modalities is aneurysm location. Size and shape do not appear to be a primary factor to favour one or the other modality. The hope that endovascular therapy improves the prognosis of poor grade patients with posterior circulation aneurysms probably has been overstated. The good results of endovascular treatment with small narrow-necked aneurysms on proximal arteries of the posterior circulation, as seen in the present series and as reported in the accumulating literature, suggest that in future surgical and endovascular treatment should be considered as alternatives in these special cases while in large and broad-necked aneurysms surgery should be considered first.
作者报告了一系列通过手术和血管内介入治疗的100例后循环动脉瘤。该系列包括41例在蛛网膜下腔出血（SAH）14天以上择期入院或未破裂动脉瘤患者，以及59例蛛网膜下腔出血（SAH）后急性入院患者。在引入电解可脱弹簧圈后的首个跨学科系列研究中，对于病情分级良好的患者，手术夹闭仍是首选治疗方法；而对于临床分级较差的患者或判断手术难以触及的动脉瘤患者，则主要采用血管内治疗。共有70例患者的动脉瘤得以消除，其中54例接受了手术治疗，16例通过血管内途径治疗。30例患者的动脉瘤未予治疗，原因要么是SAH后持续处于WFNS 5级，要么是某些复杂未破裂动脉瘤的治疗风险过高。5例手术和1例血管内介入治疗后发生了导致永久性致残或死亡的并发症（8.6%）。关于急性SAH后的总体治疗结果，59例急性SAH入院患者中共有14例死亡，治疗死亡率为24%。尽管本系列研究无法得出具有统计学说服力的结论，但作者基于实际经验和不断积累的文献认为，这两种治疗方式的主要互补方面在于动脉瘤的位置。大小和形状似乎并非倾向于选择某种治疗方式的主要因素。血管内治疗可改善后循环动脉瘤分级较差患者预后的期望可能被高估了。正如本系列研究及不断积累的文献所报道的，后循环近端动脉小型窄颈动脉瘤的血管内治疗效果良好，这表明未来在这些特殊情况下，手术和血管内治疗应被视为可替代的选择；而对于大型宽颈动脉瘤，则应首先考虑手术治疗。
