Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
Neurosurgery. 2012 Aug;71(2):285-94; discussion 294-5. doi: 10.1227/NEU.0b013e318256c3eb.
Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described.
A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice.
A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification.
Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P < .01), large/giant size (P = .04), and complex clipping (P = .05) were associated with increased neurological worsening.
Because endovascular therapy alters the surgical population, neurosurgeons should recalibrate their expectations with this once straightforward aneurysm. The current mix of PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.
许多神经外科医生认为夹闭后交通动脉瘤（PCoA）的能力绰绰有余，并将其纳入自己的治疗范畴。然而，血管内治疗去除了那些原本最简单的、夹闭后效果最好的单纯动脉瘤。剩下的都是解剖结构复杂、技术难度大的动脉瘤，而且这些复杂的病例没有得到充分的描述。
本研究回顾了一组采用现代显微神经外科技术治疗 PCoA 动脉瘤的患者，以明确目前的患者群体、显微外科技术和治疗效果。
在 11 年期间，共有 218 例 PCoA 动脉瘤患者接受了显微外科治疗。影响动脉瘤处理的复杂性因素包括：（1）瘤体巨大；（2）胚胎型后交通动脉；（3）既往弹簧圈栓塞；（4）前床突磨除；（5）脉络膜前动脉（AChA）黏附；（6）术中动脉瘤破裂；（7）复杂夹闭；（8）动脉粥样硬化钙化。
单纯性 PCoA 动脉瘤见于 113 例（51.8%）患者，复杂性动脉瘤见于 105 例（48.2%）患者。最常见的复杂性因素包括黏附的 AChA（13.8%）和术中破裂（11.5%）。单纯性动脉瘤患者的预后良好率为 86.6%，而具有 1 种或多种复杂性因素的患者预后良好率分别为 78.2%和 75.0%。术中破裂（P<.01）、瘤体巨大（P=.04）和复杂夹闭（P=.05）与神经功能恶化有关。
由于血管内治疗改变了手术人群，神经外科医生应该重新调整对这类曾经简单的动脉瘤的治疗预期。目前 PCoA 动脉瘤的混合情况需要采用先进的技术，包括前床突磨除、AChA 显微解剖、复杂夹闭以及应对术中破裂的能力。对于弹簧圈栓塞后复发的动脉瘤、复杂分支、引起动眼神经麻痹的动脉瘤、多发动脉瘤以及合并血肿的患者，推荐采用显微外科治疗。
