Stendel R, Pietilä T, Al Hassan A A, Schilling A, Brock M
Department of Neurosurgery, Benjamin Franklin Medical Center, Free University of Berlin, Hindenburgdamm 30, 12200 Berlin, Germany.
J Neurol Neurosurg Psychiatry. 2000 Jan;68(1):29-35. doi: 10.1136/jnnp.68.1.29.
Outcome of surgical treatment of cerebral aneurysms may be severely compromised by local cerebral ischaemia or infarction resulting from the inadvertent occlusion of an adjacent vessel by the aneurysm clip, or by incomplete aneurysm closure. It is therefore mandatory to optimise clip placement in situ to reduce the complication rate. The present study was performed to investigate the reliability of intraoperative microvascular Doppler ultrasonography (MDU) in cerebral aneurysm surgery, and to assess the impact of this method on the surgical procedure itself.
Seventy five patients (19 men, 56 women, mean age 54.8 years, range 22-84 years) with 90 saccular cerebral aneurysms were evaluated. Blood flow velocities in the aneurysmal sac and in the adjacent vessels were determined by MDU before and after aneurysm clipping. The findings of MDU were analysed and compared with those of visual inspection of the surgical site and of postoperative angiography. Analysis was also made of the cases in which the clip was repositioned due to MDU findings.
A relevant stenosis of an adjacent vessel induced by clip positioning that had escaped detection by visual inspection was identified by Doppler ultrasonography in 17 out of 90 (18.9%) aneurysms. In addition, Doppler ultrasound demonstrated a primarily unoccluded aneurysm in 11 out of 90 (12.2%) patients. The aneurysm clip was repositioned on the basis of the MDU findings in 26 out of 90 (28.8%) cases. In middle cerebral artery (MCA) aneurysms, the MDU results were relevant to the surgical procedure in 17 out of 44 (38.6%) cases. Whereas with aneurysms of the anterior cerebral artery significant findings occurred in only five of 32 cases (15.6%; p<0.05). The clip was repositioned on the basis of the MDU results in 18 out of 50 (36%) aneurysms in patients with subarachnoid haemorrhage (SAH) grade I-V compared with only eight out of 40 (20%) aneurysms in patients without SAH (p<0.05).
MDU should be used routinely in cerebral aneurysm surgery, especially in cases of MCA aneurysms and after SAH. Present data show that a postoperative angiography becomes superfluous whenever there is good visualisation of the "working site" and MDU findings are clear.
脑动脉瘤手术的预后可能会因动脉瘤夹意外夹闭相邻血管或动脉瘤夹闭不完全导致局部脑缺血或梗死而严重受损。因此，必须在原位优化夹子放置以降低并发症发生率。本研究旨在调查术中微血管多普勒超声（MDU）在脑动脉瘤手术中的可靠性，并评估该方法对手术过程本身的影响。
对75例患者（19例男性，56例女性，平均年龄54.8岁，范围22 - 84岁）的90个囊状脑动脉瘤进行评估。在动脉瘤夹闭前后，通过MDU测定动脉瘤囊和相邻血管中的血流速度。分析MDU的结果，并与手术部位的目视检查结果和术后血管造影结果进行比较。还对因MDU结果而重新放置夹子的病例进行了分析。
在90个（18.9%）动脉瘤中，有17个通过多普勒超声检测到因夹子定位导致相邻血管出现相关狭窄，而这在目视检查中未被发现。此外，多普勒超声显示90例患者中有11例（12.2%）的动脉瘤最初未被夹闭。在90个（28.8%）病例中，根据MDU结果重新放置了动脉瘤夹。在大脑中动脉（MCA）动脉瘤中，44个病例中有17个（38.6%）的MDU结果与手术过程相关。而在前交通动脉瘤中，32个病例中只有5个出现显著结果（15.6%；p<0.05）。在蛛网膜下腔出血（SAH）I - V级患者中，50个动脉瘤中有18个（36%）根据MDU结果重新放置了夹子，而在无SAH患者中，40个动脉瘤中只有8个（20%）（p<0.05）。
MDU应在脑动脉瘤手术中常规使用，尤其是在MCA动脉瘤病例和SAH后。目前的数据表明，只要“手术部位”可视化良好且MDU结果清晰，术后血管造影就变得多余。
