Department of Neurovascular Surgery, N.N. Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia.
Department of Neurovascular Surgery, N.N. Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia.
World Neurosurg. 2021 Apr;148:196-197. doi: 10.1016/j.wneu.2021.01.095. Epub 2021 Feb 2.
A 57-year-old man who had previously suffered a transient episode of retrograde amnesia was admitted to the vascular department of the Burdenko Neurosurgical Center. Computed tomography angiography revealed a complex trifurcation aneurysm of the right middle cerebral artery (MCA) bifurcation. There were no clear focal symptoms after the neurologic examination. The patient underwent a right-sided craniotomy to approach the Sylvian fissure and MCA branches. The MCA aneurysm with 2 lobes had been exposed. One of the M2 branches densely adhered to the aneurysm dome. Attempts of the M2 separation along the dome stopped because there was a high risk of injury to the M2, the aneurysm, or both. To cutoff M2 without bleeding from the aneurysm, a curved clip was used, which we called an insulating clip. After this manipulation, it was already possible to try the neck closing with additional clips, however, according to manual sensations, we were not sure that the insulating clip would not shift and there would be no bleeding. The insulating clip interfered with the final clipping and should have been removed. Temporal aneurysmorrhaphy was used to ensure that the surgeon's manipulations were not complicated by bleeding. This also acted as a guarantee that, in the event of bleeding, the rupture would not spread to the neck of the aneurysm. Thus the M2 cutting-off with an insulating clip and temporal aneurysmorrhaphy were options that allowed for adequate final clipping. There were no intraoperative or postoperative complications. The patient remained neurologically intact and was discharged 7 days after surgery (Figure 1).
一位 57 岁男性，曾有短暂的逆行性遗忘发作，被收入 Burdenko 神经外科中心血管科。计算机断层血管造影显示右侧大脑中动脉（MCA）分叉处有一个复杂的三分叉动脉瘤。神经检查后没有明显的局灶性症状。患者接受了右侧开颅手术，以接近外侧裂和 MCA 分支。MCA 动脉瘤有 2 个叶，已暴露。其中一个 M2 分支紧密附着在动脉瘤顶。由于 M2、动脉瘤或两者都有很高的损伤风险，沿着瘤顶分离 M2 的尝试停止了。为了在不使动脉瘤出血的情况下阻断 M2，使用了一个弯曲的夹，我们称之为绝缘夹。在这种操作之后，已经可以尝试用附加的夹来关闭颈部，但是，根据手动感觉，我们不能确定绝缘夹不会移位，也不会发生出血。绝缘夹干扰了最终的夹闭，应该被移除。颞动脉结扎术用于确保手术操作不受出血影响。这也起到了保证作用，如果发生出血，破裂不会扩散到动脉瘤颈部。因此，使用绝缘夹阻断 M2 并进行颞动脉结扎术是可以进行充分的最终夹闭的选择。术中及术后均无并发症。患者神经功能完整，术后 7 天出院（图 1）。
