Matsukawa Hidetoshi, Kamiyama Hiroyasu, Miyazaki Takanori, Kinoshita Yu, Ota Nakao, Noda Kosumo, Shonai Takaharu, Takahashi Osamu, Tokuda Sadahisa, Tanikawa Rokuya
1Department of Neurosurgery, Stroke Center, and.
2Department of Radiology, Teishinkai Hospital, Sapporo; and.
J Neurosurg. 2019 Mar 1;132(4):1088-1095. doi: 10.3171/2018.11.JNS181235. Print 2020 Apr 1.
Perforator territory infarction (PTI) is still a major problem needing to be solved to achieve good outcomes in aneurysm surgery. However, details and risk factors of PTI diagnosed on postoperative MRI remain unknown. The authors aimed to investigate the details of PTI on postoperative diffusion-weighted imaging (DWI) in patients with surgically treated unruptured intracranial saccular aneurysms (UISAs).
The data of 848 patients with 1047 UISAs were retrospectively evaluated. PTI was diagnosed on DWI, which was performed the day after aneurysm surgery. Clinical and radiological characteristics were compared between UISAs with and without PTI. Poor outcome was defined as an increase in 1 or more modified Rankin Scale scores at 12 months after aneurysm surgery.
Postoperative DWI was performed in all cases, and it revealed PTI in 56 UISA cases (5.3%). Forty-three PTIs occurred without direct injury and occlusion of perforators (43 of 56, 77%). Poor outcome was more frequently observed in the PTI group (17 of 56, 30%) than the non-PTI group (57 of 1047, 5.4%) (p < 0.0001). Thalamotuberal arteries (p < 0.01), lateral striate arteries (p < 0.01), Heubner's artery (p < 0.01), anterior median commissural artery (p < 0.05), terminal internal carotid artery perforators (p < 0 0.01), and basilar artery perforator (p < 0 0.01) infarctions were related to poor outcome by adjusted residual analysis. On multivariate analysis, statin use (OR 10, 95% CI, 3.3-31; p < 0.0001), specific aneurysm locations (posterior communicating artery [OR 4.1, 95% CI 2.1-8.1; p < 0.0001] and basilar artery [OR 3.1, 95% CI 1.1-8.9; p = 0.031]), larger aneurysm size (OR 1.1, 95% CI 1.1-1.2; p = 0.043), and permanent decrease of motor evoked potential (OR 38, 95% CI 3.1-468; p = 0.0045) were related to PTI.
Despite efforts to avoid PTI, it occurred even without direct injury, occlusion of perforators, or evoked potential abnormality. Therefore, surgical treatment of UISAs, especially with the aforementioned risk factors of PTI, should be more carefully considered. The evaluation of PTI in the territory of the above-mentioned perforators could be useful in helping predict the clinical course in patients after aneurysm surgery.
在动脉瘤手术中实现良好预后，穿支动脉供血区梗死（PTI）仍是一个亟待解决的主要问题。然而，术后MRI诊断的PTI的细节及危险因素仍不明确。作者旨在研究手术治疗未破裂颅内囊状动脉瘤（UISAs）患者术后弥散加权成像（DWI）上PTI的细节。
回顾性评估848例患者1047个UISAs的数据。PTI通过动脉瘤手术后次日进行的DWI诊断。比较发生PTI和未发生PTI的UISAs的临床和影像学特征。不良预后定义为动脉瘤手术后12个月改良Rankin量表评分增加1分或更多。
所有病例均进行了术后DWI，其中56例UISAs（5.3%）显示有PTI。43例PTI发生时穿支动脉无直接损伤和闭塞（56例中的43例，77%）。PTI组（56例中的17例，30%）比非PTI组（1047例中的57例，5.4%）更常观察到不良预后（p<0.0001）。经校正残差分析，丘脑结节动脉（p<0.01）、外侧纹状体动脉（p<0.01）、Heubner动脉（p<0.01）、前连合正中动脉（p<0.05）、颈内动脉终末穿支（p<0.01）和基底动脉穿支（p<0.01）梗死与不良预后相关。多因素分析显示，使用他汀类药物（OR 10，95%CI，3.3 - 31；p<0.0001）、特定动脉瘤位置（后交通动脉[OR 4.1，95%CI 2.1 - 8.1；p<0.0001]和基底动脉[OR 3.1，95%CI 1.1 - 8.9；p = 0.031]）、较大的动脉瘤尺寸（OR 1.1，95%CI 1.1 - 1.2；p = 0.043）和运动诱发电位永久性降低（OR 38，95%CI 3.1 - 468；p = 0.0045）与PTI相关。
尽管努力避免PTI，但即使没有穿支动脉的直接损伤、闭塞或诱发电位异常，PTI仍会发生。因此，对于UISAs的手术治疗，尤其是存在上述PTI危险因素的情况，应更谨慎考虑。评估上述穿支动脉供血区的PTI可能有助于预测动脉瘤手术后患者的临床病程。
