Pancucci Giovanni, Potts Matthew B, Rodríguez-Hernández Ana, Andrade Hugo, Guo LanJun, Lawton Michael T
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
Neurophysiological Monitoring Service, University of California, San Francisco, San Francisco, California, USA.
World Neurosurg. 2015 Jun;83(6):912-20. doi: 10.1016/j.wneu.2015.02.001. Epub 2015 Feb 17.
Surgical trapping or endovascular deconstruction commonly is used for the treatment of giant or complex intracranial aneurysms. Preoperative balloon test occlusion and cerebral blood flow studies and intraoperative neurophysiologic monitoring can indicate whether sufficient collateralization exists or whether revascularization is needed. Hemodynamic insufficiency can occur, however, despite passing these tests, necessitating posttreatment revascularization.
We conducted a retrospective review of patients who underwent surgical or endovascular parent vessel occlusion for the management of giant or complex intracranial aneurysms and subsequently required rescue bypass for symptoms of hemodynamic insufficiency. Pre- and postrevascularization functional status was measured with the modified Rankin Scale.
During a 15-year period from 1997 to 2012, a rescue bypass was performed in 5 patients each harboring a giant or complex intracranial internal carotid artery (ICA) aneurysm that was treated with surgical trapping or endovascular deconstruction in a previous procedure. All bypasses were extracranial-to-intracranial and included cervical ICA to middle cerebral artery, subclavian to middle cerebral artery, and cervical ICA to supraclinoid ICA anastomoses via either a saphenous vein or radial artery graft. Functional outcome at time of last follow-up was improved in each patient (improvement in modified Rankin Scale of 1-3 points).
Ischemic complications must always be anticipated in the treatment of giant or complex intracranial aneurysms, even if pre- and intraoperative blood flow studies indicate sufficient collateralization. Here we show that extracranial-to-intracranial bypass is an effective option to rescue unanticipated hemodynamic insufficiency after parent vessel occlusion. This study emphasizes the need for cerebrovascular surgeons to maintain proficiency in complex bypass techniques.
手术夹闭或血管内重建术常用于治疗巨大或复杂颅内动脉瘤。术前球囊试验闭塞和脑血流研究以及术中神经生理监测可表明是否存在足够的侧支循环或是否需要血管重建。然而，尽管通过了这些测试，仍可能发生血流动力学不足，需要进行治疗后血管重建。
我们对因巨大或复杂颅内动脉瘤接受手术或血管内母血管闭塞治疗且随后因血流动力学不足症状需要行挽救性搭桥手术的患者进行了回顾性研究。采用改良Rankin量表测量血管重建前后的功能状态。
在1997年至2012年的15年期间，对5例患者进行了挽救性搭桥手术，这些患者均患有巨大或复杂的颅内颈内动脉（ICA）动脉瘤，此前已接受手术夹闭或血管内重建术治疗。所有搭桥均为颅外-颅内搭桥，包括颈内动脉至大脑中动脉、锁骨下动脉至大脑中动脉以及颈内动脉至床突上段颈内动脉吻合，通过大隐静脉或桡动脉移植物进行。每位患者在最后一次随访时的功能结局均得到改善（改良Rankin量表改善1-3分）。
在治疗巨大或复杂颅内动脉瘤时，即使术前和术中血流研究表明有足够的侧支循环，也必须始终预见到缺血性并发症。我们在此表明，颅外-颅内搭桥是挽救母血管闭塞后意外血流动力学不足的有效选择。本研究强调脑血管外科医生需要保持对复杂搭桥技术的熟练掌握。
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