Menon Girish, Srinivasan Siddharth, Pai Ashwin, Hegde Ajay
Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher education, Manipal, India.
Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher education, Manipal, India.
Clin Neurol Neurosurg. 2023 Mar;226:107598. doi: 10.1016/j.clineuro.2023.107598. Epub 2023 Jan 16.
Aneurysms of the A3 segment of the distal anterior cerebral artery (DACA), in relation to the genu of the corpus callosum, are specific sub-group which pose unique surgical challenges due to their discrete anatomical location. We describe a mini-anterior interhemispheric approach which can be safely utilised to clip these aneurysms rather than the traditional bifrontal approach.
Retrospective analysis of the clinical and radiological data of ruptured DACA-A3 aneurysms operated between 2014 and 2021 at our institute. A curvilinear scalp incision within the hairline followed by raising small, unilateral, free frontal bone flap, avoiding the opening of frontal sinus. Superior sagittal sinus is displaced medially, inter-hemispheric dissection carried out with posterior trajectory and small callosotomy is performed. DACA is skeletonised, proximal control is established, and the A3 aneurysm is dissected and clipped.
Our cohort of 18 patients had a definite female preponderance (F:M::2:1) with mean age of 55.6 years. On admission three patients were categorized as WFNS Grade I, thirteen in Grade II, and two in Grade III for subarachnoid haemorrhage. All the patients had evidence of blood in the interhemispheric fissure; intraparenchymal haemorrhage was seen in seven, with intraventricular haemorrhage in six patients. Within the A3 segment six aneurysms were infragenu (inferior), eight were at the genu (anterior) and four were supragenu (superior). Two (11.1%) elderly patients succumbed post-surgery following ischemic infarcts and associated complications. At the time of follow-up at 3 months of the remaining sixteen (72.2%) patients, thirteen had a good outcome (mRS 0-3) and three (16.7%) had a poor outcome (mRS > 3).
The mini anterior interhemispheric is an effective minimally invasive alternative for A3 segments aneurysms and helps to avoid the complications of the conventional bifrontal interhemispheric approach.
大脑前动脉远端A3段（DACA）与胼胝体膝部相关的动脉瘤是一个特殊的亚组，由于其独特的解剖位置，给手术带来了独特的挑战。我们描述了一种微型经半球间前入路，该入路可安全用于夹闭这些动脉瘤，而不是传统的双额入路。
回顾性分析2014年至2021年在我院接受手术的破裂DACA-A3动脉瘤的临床和放射学资料。在发际线内做一个曲线形头皮切口，然后掀起小的单侧游离额骨瓣，避免打开额窦。上矢状窦向内侧移位，采用后入路进行半球间分离，并进行小的胼胝体切开术。显露DACA的骨骼结构，建立近端控制，然后解剖并夹闭A3段动脉瘤。
我们的18例患者队列中女性明显居多（女：男为2：1），平均年龄55.6岁。因蛛网膜下腔出血入院时，3例患者为世界神经外科联盟（WFNS）I级，13例为II级，2例为III级。所有患者的半球间裂均有血液证据；7例有脑实质内出血，6例有脑室内出血。在A3段，6个动脉瘤位于膝部下（下方），8个位于膝部（前方），4个位于膝部上（上方）。2例（11.1%）老年患者术后因缺血性梗死及相关并发症死亡。在其余16例（72.2%）患者术后3个月随访时，13例预后良好（改良Rankin量表评分0 - 3分），3例（16.7%）预后不良（改良Rankin量表评分>3分）。
微型经半球间前入路是治疗A3段动脉瘤的一种有效的微创替代方法，有助于避免传统双额经半球间入路的并发症。
