经鼻内镜入路夹闭基底动脉尖部区域动脉瘤的评估。
Assessment of the endoscopic endonasal approach to the basilar apex region for aneurysm clipping.
作者信息
Tayebi Meybodi Ali, Benet Arnau, Vigo Vera, Rodriguez Rubio Roberto, Yousef Sonia, Mokhtari Pooneh, Dones Flavia, Kakaizada Sofia, Lawton Michael T
机构信息
1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and.
2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California.
出版信息
J Neurosurg. 2018 Jun 22;130(6):1937-1948. doi: 10.3171/2018.1.JNS172813. Print 2019 Jun 1.
OBJECTIVE
The expanded endoscopic endonasal approach (EEA) has shown promising results in treatment of midline skull base lesions. Several case reports exist on the utilization of the EEA for treatment of aneurysms. However, a comparison of this approach with the classic transcranial orbitozygomatic approach to the basilar apex (BAX) region is missing.The present study summarizes the results of a series of cadaveric surgical simulations for assessment of the EEA to the BAX region for aneurysm clipping and its comparison with the transcranial orbitozygomatic approach as one of the most common approaches used to treat BAX aneurysms.
METHODS
Fifteen cadaveric specimens underwent bilateral orbitozygomatic craniotomies as well as an EEA (first without a pituitary transposition [PT] and then with a PT) to expose the BAX. The following variables were measured, recorded, and compared between the orbitozygomatic approach and the EEA: 1) number of perforating arteries counted on bilateral posterior cerebral arteries (PCAs); 2) exposure and clipping lengths of the PCAs, superior cerebellar arteries (SCAs), and proximal basilar artery; and 3) surgical area of exposure in the BAX region.
RESULTS
Except for the proximal basilar artery exposure and clipping, the orbitozygomatic approach provided statistically significantly greater values for vascular exposure and control in the BAX region (i.e., exposure and clipping of ipsilateral and contralateral SCAs and PCAs). The EEA with PT was significantly better in exposing and clipping bilateral PCAs compared to EEA without a PT, but not in terms of other measured variables. The surgical area of exposure and PCA perforator counts were not significantly different between the 3 approaches. The EEA provided better exposure and control if the BAX was located ≥ 4 mm inferior to the dorsum sellae.
CONCLUSIONS
For BAX aneurysms located in the retrosellar area, PT is usually required to obtain improved exposure and control for the bilateral PCAs. However, the transcranial approach is generally superior to both endoscopic approaches for accessing the BAX region. Considering the superior exposure of the proximal basilar artery obtained with the EEA, it could be a viable option when surgical treatment is considered for a low-lying BAX or mid-basilar trunk aneurysms (≥ 4 mm inferior to dorsum sellae).
目的
扩大经鼻内镜入路（EEA）在治疗中线颅底病变方面已显示出有前景的结果。已有多篇关于利用EEA治疗动脉瘤的病例报告。然而，该入路与经典经颅眶颧入路至基底动脉尖（BAX）区域的比较尚缺失。本研究总结了一系列尸体手术模拟的结果，以评估EEA至BAX区域进行动脉瘤夹闭的情况，并将其与经颅眶颧入路进行比较，经颅眶颧入路是用于治疗BAX动脉瘤最常用的入路之一。
方法
对15个尸体标本进行双侧眶颧开颅以及EEA（首先不进行垂体移位[PT]，然后进行PT）以暴露BAX。在眶颧入路和EEA之间测量、记录并比较以下变量：1）双侧大脑后动脉（PCA）上计数的穿支动脉数量；2）PCA、小脑上动脉（SCA）和基底动脉近端的暴露和夹闭长度；3）BAX区域的手术暴露面积。
结果
除了基底动脉近端的暴露和夹闭外，眶颧入路在BAX区域的血管暴露和控制方面提供了统计学上显著更大的值（即同侧和对侧SCA和PCA的暴露和夹闭）。与未进行PT的EEA相比，进行PT的EEA在暴露和夹闭双侧PCA方面明显更好，但在其他测量变量方面并非如此。三种入路之间的手术暴露面积和PCA穿支计数没有显著差异。如果BAX位于鞍背下方≥4 mm，则EEA提供更好的暴露和控制。
结论
对于位于鞍后区域的BAX动脉瘤，通常需要进行PT以改善双侧PCA的暴露和控制。然而，经颅入路在进入BAX区域方面通常优于两种内镜入路。考虑到EEA获得的基底动脉近端的良好暴露，当考虑对低位BAX或基底动脉中段动脉瘤（鞍背下方≥4 mm）进行手术治疗时，它可能是一个可行的选择。
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