Sharma Bhawani Shankar, Gupta Aditya, Ahmad Faiz Uddin, Suri Ashish, Mehta Veer Singh
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
Clin Neurol Neurosurg. 2008 Jul;110(7):674-81. doi: 10.1016/j.clineuro.2008.04.001. Epub 2008 May 19.
The natural history of giant intracranial aneurysms is generally morbid. Mortality and morbidity associated with giant aneurysms is also higher than for smaller aneurysms. This study was carried out to assess the demographic profile, presenting features, complications, and outcome after surgical treatment of giant intracranial aneurysms.
A retrospective review of the medical records of all patients with giant intracranial aneurysms treated in the Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, from January 1995 through June 2007 was performed. The demographic profiles, presenting features, radiological findings, surgical treatments, and outcomes were assessed.
A total of 1412 patients harboring 1675 aneurysms were treated. Out of these, 222 patients had 229 (13.7%) giant aneurysms, and of those, 181 aneurysms in 177 patients were managed surgically while 48 were treated with endovascular therapy. In the patients treated with surgery, common clinical presentations included subarachnoid hemorrhage (SAH) in 110 (62%) cases followed by mass effect in 57 (32%) cases. In patients who presented with SAH, the Hunt and Hess SAH grading was: grade I in 43 (39%), grade II in 40 (36%), grade III in 23 (21%), grade IV in two (2%), and grade V in 2 (2%) patients. One hundred and seven aneurysms (in 103 patients) were treated using direct surgical clipping. Forty-six patients with good collateral circulation were treated by gradual occlusion and ligation of the internal carotid artery (ICA) in the neck with a Silverstone clamp. Another nine patients with good collateral circulation, but persisting symptoms after ICA ligation, required trapping for obliteration of the aneurysm. Eleven patients with poor collateral circulation required extracranial-intracranial (EC-IC) bypass before proximal ICA ligation. A post-operative digital subtraction angiography (DSA) was performed in 118 patients and revealed well-obliterated aneurysm in 106 patients. The total treatment mortality rate was 9%. In the last 5 years, 117 patients were operated on with four operative deaths. Overall, the outcome was excellent in 131 (74.0%), good in 22 (12.4%), and poor in eight (4.5%) cases.
It is concluded that 14% of all intracranial aneurysms are giant. The most common clinical presentation is SAH followed by features of an intracranial mass lesion. The cavernous ICA is the most common portion of the ICA affected. Direct surgical clipping is a safe and effective method of treatment and should be considered the first line of treatment whenever possible. With proper case selection, optimal radiological evaluation, and appropriate surgical strategy, it is possible to achieve a favorable outcome in almost 90% of the cases.
巨大颅内动脉瘤的自然病程通常预后不佳。与巨大动脉瘤相关的死亡率和发病率也高于较小的动脉瘤。本研究旨在评估巨大颅内动脉瘤手术治疗后的人口统计学特征、临床表现、并发症及预后。
对1995年1月至2007年6月在新德里全印度医学科学研究所神经科学中心神经外科接受治疗的所有巨大颅内动脉瘤患者的病历进行回顾性分析。评估人口统计学特征、临床表现、影像学检查结果、手术治疗及预后。
共治疗了1412例患有1675个动脉瘤的患者。其中，222例患者有229个（13.7%）巨大动脉瘤，其中177例患者的181个动脉瘤接受了手术治疗，48个动脉瘤接受了血管内治疗。在接受手术治疗的患者中，常见的临床表现包括蛛网膜下腔出血（SAH）110例（62%），其次是占位效应57例（32%）。在以SAH就诊的患者中，Hunt和Hess SAH分级为：Ⅰ级43例（39%），Ⅱ级40例（36%），Ⅲ级23例（21%），Ⅳ级2例（2%），Ⅴ级2例（2%）。107个动脉瘤（103例患者）采用直接手术夹闭治疗。46例侧支循环良好的患者采用Silverstone夹逐步夹闭并结扎颈部颈内动脉（ICA）。另外9例侧支循环良好但ICA结扎后仍有症状的患者需要进行动脉瘤包裹术。11例侧支循环不良的患者在近端ICA结扎前需要进行颅外-颅内（EC-IC）搭桥术。118例患者术后进行了数字减影血管造影（DSA），106例患者显示动脉瘤完全闭塞。总治疗死亡率为9%。在过去5年中，117例患者接受了手术，4例手术死亡。总体而言，131例（74.0%）预后极佳，22例（12.4%）良好，8例（4.5%）较差。
得出结论，所有颅内动脉瘤中有14%为巨大动脉瘤。最常见的临床表现是SAH，其次是颅内占位性病变的特征。海绵窦段ICA是ICA最常受累的部位。直接手术夹闭是一种安全有效的治疗方法，应尽可能作为一线治疗方法。通过适当的病例选择、最佳的影像学评估和合适的手术策略，几乎90%的病例有可能获得良好的预后。
