Kato Y, Sano H, Imizu S, Yoneda M, Viral M, Nagata J, Kanno T
Department of Neurosurgery, Fujita Health University, Toyoake, Aichi 470-1192, Japan.
Minim Invasive Neurosurg. 2003 Dec;46(6):339-43. doi: 10.1055/s-2003-812499.
Giant or large intracranial aneurysms are the vascular neurosurgeon's greatest challenge. At our department, we have treated one hundred and thirty nine patients with giant or large intracranial aneurysms between 1975 and 2001. These included 37 partially thrombosed giant aneurysms. 75 aneurysms were giant (> 2.5 cm) and 64 were large aneurysms (2-2.5 cm). Three-dimensional computed tomography angiograms were performed in patients besides MRI angiography and digital subtraction angiography. These were found to be very valuable in the preoperative assessment of surgical anatomy of the aneurysm with respect to the branch arteries and perforators origin besides knowing the relations to the skull base. With our experience in surgical treatment of these 139 cases, we find that the basic technique is trapping and evacuation and not just clipping of the aneurysm neck but also reconstruction of the artery bearing the aneurysm, especially with wide-necked aneurysms. Use of multiple clipping, tandem clipping or dome clipping as per the intraoperative situation, is very helpful in dealing with giant aneurysms as also is the use of different types of clips like fenestrated clip with straight clip (combination clipping), booster clip, dome clips etc. While selecting surgical strategy for partially thrombosed giant aneurysm, securing the neck is most important. If the neck is too narrow to reconstruct, aneurysmectomy with anastomosis is one of the surgical strategies. An extracranial intracranial bypass should be considered in cases where clipping or parent artery ligation is expected to be associated with compromise of cerebral circulation.
巨大或大型颅内动脉瘤是血管神经外科医生面临的最大挑战。在我们科室，1975年至2001年间共治疗了139例巨大或大型颅内动脉瘤患者。其中包括37例部分血栓形成的巨大动脉瘤。75例为巨大动脉瘤（>2.5 cm），64例为大型动脉瘤（2 - 2.5 cm）。除了磁共振血管造影和数字减影血管造影外，还对患者进行了三维计算机断层扫描血管造影。结果发现，这些检查在术前评估动脉瘤与分支动脉及穿支动脉起源的手术解剖结构方面非常有价值，同时也有助于了解动脉瘤与颅底的关系。根据我们对这139例病例的手术治疗经验，我们发现基本技术是夹闭和排空，不仅要夹闭动脉瘤颈部，还要重建承载动脉瘤的动脉，尤其是对于宽颈动脉瘤。根据术中情况使用多个夹子、串联夹子或瘤顶夹子，以及使用不同类型的夹子，如带直夹子的开窗夹子（联合夹闭）、增强夹子、瘤顶夹子等，对处理巨大动脉瘤非常有帮助。在选择部分血栓形成的巨大动脉瘤的手术策略时，确保颈部安全最为重要。如果颈部太窄无法重建，动脉瘤切除并吻合术是手术策略之一。对于预计夹闭或结扎载瘤动脉会导致脑循环受损的病例，应考虑进行颅外 - 颅内旁路手术。
