Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA.
Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA.
World Neurosurg. 2019 Nov;131:166. doi: 10.1016/j.wneu.2019.07.192. Epub 2019 Aug 2.
In this video, we present the case of a 61-year-old female who was brought to the emergency department after she had partial complex seizures. Computed tomography and magnetic resonance imaging of the brain revealed a right temporal lobe mass, which was initially thought to be a tumor. The patient was therefore referred to us for further management. The round nature of the lesion raised suspicion for an aneurysm. Computed tomography angiography was performed, followed by a diagnostic conventional cerebral angiogram, and confirmed the presence of a giant thrombosed aneurysm. Giant aneurysms represent 3%-5% of all cerebral aneurysms. They are more common in females with a ratio of 2:1 to 3:1. They have a high risk of rupture up to 50% in the posterior circulation and 40% in the anterior circulation over 5 years according to the International Study of Unruptured Intracranial Aneurysms Investigators. Their treatment can be complex and treacherous. Treatment options vary widely from parent artery sacrifice in select cases to clip reconstruction to an array of endovascular approaches such as flow diversion. In some cases a combination of both open and endovascular approaches might be necessary. In our case, we opted for an open surgical clip reconstruction. A superior temporal artery-middle cerebral artery bypass was attempted to allow for trapping of the aneurysm without risking ischemic complication distal to it. Unfortunately, the patient's vessels were too atherosclerotic to maintain patency. A strategy was then devised, which consisted of cutting the dome of the aneurysm and clearing the distal two thirds of the clot ("tulip technique") and then completing thrombus resection under temporary occlusion. Once clot removal was completed, the aneurysm was clipped using the "shingle clip cut clip" technique (Video 1). The patient's postoperative course was uneventful, and the patient remained seizure free.
在这段视频中，我们介绍了一位 61 岁女性的病例，她因部分复杂癫痫发作被送往急诊科。脑部的计算机断层扫描和磁共振成像显示右颞叶有一个肿块，最初被认为是肿瘤。因此，患者被转介给我们进行进一步治疗。病变的圆形特征引起了对动脉瘤的怀疑。进行了计算机断层血管造影，随后进行了诊断性常规脑血管造影，证实存在巨大血栓形成的动脉瘤。巨大动脉瘤占所有脑动脉瘤的 3%-5%。它们在女性中更为常见，比例为 2:1 至 3:1。根据国际未破裂颅内动脉瘤研究人员的研究，它们在 5 年内破裂的风险高达 50%在后循环中，40%在前循环中。它们的治疗可能很复杂且具有潜在危险。治疗选择因病例而异，从选择性牺牲母动脉到夹闭重建，再到多种血管内方法，如血流转向。在某些情况下，可能需要结合开放和血管内方法。在我们的病例中，我们选择了开放式手术夹闭重建。尝试进行颞浅动脉-大脑中动脉搭桥术，以便在不使动脉瘤下游发生缺血性并发症的情况下对其进行夹闭。不幸的是，患者的血管过于动脉粥样硬化，无法保持通畅。然后制定了一项策略，包括切开动脉瘤的穹顶并清除血栓的远端三分之二（“郁金香技术”），然后在临时闭塞下完成血栓切除。一旦完成血栓清除，就使用“瓦楞夹剪夹”技术（视频 1）对动脉瘤进行夹闭。患者术后情况平稳，无癫痫发作。
