Gewirtz R J, Awad I A
Department of Neurological Surgery, Cleveland Clinic Foundation, Ohio, USA.
Surg Neurol. 1996 May;45(5):409-20; discussion 420-1. doi: 10.1016/0090-3019(95)00437-8.
There is no uniform agreement to date regarding the optimal management of giant aneurysms (GAs) of the anterior circle of Willis. Endovascular therapeutic techniques have yielded unacceptable rates of aneurysm growth and recanalization (endosaccular) or high rates of complications (distal parent vessel occlusion). Despite size, frequent thrombosis and calcification (incollapsibility), and splaying of parent vessels, these aneurysms are readily amenable to direct surgical exposure and control of parent vessels intracranially. Published series have not considered these lesions separately and have often reflected a mixture of management strategies for these and other GAs.
Thirty-eight consecutive patients with symptomatic GAs of the anterior circle of Willis were managed by the senior author over a 7-year period. Twenty-six of these patients (68%) presented with subarachnoid hemorrhage (SAH). Temporary occlusion was performed under a protocol to enhance brain protection. Direct clip reconstruction or trapping was used in all instances, with intraoperative angiographic control. Revascularization procedures and suture vascular reconstructions were not used in any case.
All patients were considered for direct microsurgical treatment. One patient refused surgery, and two patients were deemed a prohibitive medical risk. Thirty-five patients were treated surgically with complete obliteration of the aneurysm in 34 cases (97%), and patency of all parent arteries in 30 cases (86%). Overall mortality was 6% in the surgical cohort, with good or excellent clinical outcome in 71%. Mortality and poor outcome occurred exclusively in the setting of recent hemorrhage.
The results are compared to the natural history of these lesions and to outcome (safety and effectiveness) of currently available endovascular techniques. This experience supports direct microsurgical intervention as the primary therapeutic modality for these lesions.
迄今为止，对于 Willis 前循环巨大动脉瘤（GA）的最佳治疗方法尚无统一共识。血管内治疗技术导致动脉瘤生长和再通（瘤内）的发生率不可接受，或并发症发生率较高（远端供血动脉闭塞）。尽管这些动脉瘤体积较大、常伴有血栓形成和钙化（难以塌陷）以及供血动脉迂曲，但它们易于在颅内直接进行手术暴露和控制供血动脉。已发表的系列研究未将这些病变单独考虑，并且常常反映了这些病变与其他巨大动脉瘤的混合治疗策略。
在 7 年期间，资深作者对 38 例有症状的 Willis 前循环巨大动脉瘤患者进行了治疗。其中 26 例患者（68%）出现蛛网膜下腔出血（SAH）。根据一项旨在增强脑保护的方案进行了临时闭塞。所有病例均采用直接夹闭重建或夹闭术，并在术中进行血管造影控制。所有病例均未使用血管重建术和缝合血管重建术。
所有患者均考虑进行直接显微手术治疗。1 例患者拒绝手术，2 例患者被认为手术风险过高。35 例患者接受了手术治疗，34 例（97%）动脉瘤完全闭塞，30 例（86%）所有供血动脉通畅。手术队列的总体死亡率为 6%，71%的患者临床结局良好或极佳。死亡和不良结局仅发生在近期出血的情况下。
将这些结果与这些病变的自然病程以及当前可用血管内技术的结局（安全性和有效性）进行了比较。该经验支持将直接显微手术干预作为这些病变的主要治疗方式。
