Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and.
Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona.
J Neurosurg. 2019 Feb 22;132(2):434-441. doi: 10.3171/2018.11.JNS182416. Print 2020 Feb 1.
During the microsurgical clipping of known aneurysms, angiographically occult (AO) aneurysms are sometimes found and treated simultaneously to prevent their growth and protect the patient from future rupture or reoperation. The authors analyzed the incidence, treatment, and outcomes associated with AO aneurysms to determine whether limited surgical exploration around the known aneurysm was safe and justified given the known limitations of diagnostic angiography.
An AO aneurysm was defined as a saccular aneurysm detected using the operative microscope during dissection of a known aneurysm, and not detected on preoperative catheter angiography. A prospective database was retrospectively reviewed to identify patients with AO aneurysms treated microsurgically over a 20-year period.
One hundred fifteen AO aneurysms (4.0%) were identified during 2867 distinct craniotomies for aneurysm clipping. The most common locations for AO aneurysms were the middle cerebral artery (60 aneurysms, 54.1%) and the anterior cerebral artery (20 aneurysms, 18.0%). Fifty-six AO aneurysms (50.5%) were located on the same artery as the known saccular aneurysm. Most AO aneurysms (95.5%) were clipped and there was no attributed morbidity. The most common causes of failed angiographic detection were superimposition of a large aneurysm (type 1, 30.6%), a small aneurysm (type 2, 18.9%), or an adjacent normal artery (type 3, 36.9%). Multivariate analysis identified multiple known aneurysms (odds ratio [OR] 3.45, 95% confidence interval [CI] 2.16-5.49, p < 0.0001) and young age (OR 0.981, 95% CI 0.965-0.997, p = 0.0226) as independent predictors of AO aneurysms.
Meticulous inspection of common aneurysm sites within the surgical field will identify AO aneurysms during microsurgical dissection of another known aneurysm. Simultaneous identification and treatment of these additional undiagnosed aneurysms can spare patients later rupture or reoperation, particularly in those with multiple known aneurysms and a history of subarachnoid hemorrhage. Limited microsurgical exploration around a known aneurysm can be performed safely without additional morbidity.
在已知动脉瘤的显微夹闭过程中，有时会发现血管造影隐匿性（AO）动脉瘤，并同时进行治疗，以防止其生长并保护患者免受未来破裂或再次手术的风险。作者分析了与 AO 动脉瘤相关的发生率、治疗和结局，以确定在已知血管造影诊断局限性的情况下，对已知动脉瘤进行有限的手术探查是否安全和合理。
AO 动脉瘤定义为在已知动脉瘤解剖过程中使用手术显微镜发现的囊状动脉瘤，而在术前导管血管造影中未发现。回顾性分析了一个前瞻性数据库，以确定在 20 年期间接受显微手术治疗的 AO 动脉瘤患者。
在 2867 例不同的开颅夹闭动脉瘤手术中，共发现 115 个 AO 动脉瘤（4.0%）。AO 动脉瘤最常见的部位是大脑中动脉（60 个动脉瘤，54.1%）和大脑前动脉（20 个动脉瘤，18.0%）。56 个 AO 动脉瘤（50.5%）位于与已知囊状动脉瘤相同的动脉上。大多数 AO 动脉瘤（95.5%）被夹闭，没有发生相关的发病率。未能进行血管造影检测的最常见原因是大动脉瘤的重叠（类型 1，30.6%）、小动脉瘤（类型 2，18.9%）或相邻正常动脉（类型 3，36.9%）。多变量分析确定了多个已知动脉瘤（比值比 [OR] 3.45，95%置信区间 [CI] 2.16-5.49，p < 0.0001）和年轻年龄（OR 0.981，95%CI 0.965-0.997，p = 0.0226）是 AO 动脉瘤的独立预测因素。
在另一个已知动脉瘤的显微外科解剖过程中，对手术野内常见动脉瘤部位进行仔细检查，可以识别 AO 动脉瘤。同时识别和治疗这些额外的未诊断的动脉瘤可以使患者避免以后破裂或再次手术，特别是在有多个已知动脉瘤和蛛网膜下腔出血病史的患者中。在已知动脉瘤周围进行有限的显微手术探查可以安全进行，不会增加发病率。
