Sano H, Kato Y, Okuma I, Yamaguchi S, Ninomiya T, Arunkumar R, Kanno T
Department of Neurosurgery, Fujita Health University, Aichi, Japan.
Surg Neurol. 1997 Dec;48(6):598-605. doi: 10.1016/s0090-3019(97)00022-0.
For many years, dissecting aneurysms of the intracranial vertebral artery were believed to be quite rare. In recent years, because vascular disorders have been studied more thoroughly by three dimensional-computed tomography (3D-CT), angiographically and pathologically, these aneurysms are being reported with more frequency.
Among the 45 patients diagnosed to have aneurysms arising from the vertebral artery or its branches over a 20-year period, 16 had dissecting aneurysms. The authors present their therapeutic strategy for these patients. Surgery was performed in the 16 patients, the most common technique being clip-occlusion or trapping of the parent artery wherever feasible, in an attempt to optimize cerebral blood flow. The dissecting aneurysms of the vertebral artery were classified into two groups for the purpose of determining a therapeutic approach, namely unilateral and circumferential groups. In the unilateral group, the dissection seemed to involve only on one side of the vessel according to the conventional cerebral angiogram. These patients underwent surgical reconstruction of the vertebral artery by direct clipping. In the circumferential group, the dissection was all around the artery. Proximal clipping or trapping was performed in this group.
In six out of eight patients with unilateral dissecting aneurysms, vascular reconstruction was possible by direct clipping. Of these six patients, the surgical outcome was considered excellent in four, fair in one, and one patient died of cardiac failure after 12 days as his preoperative morbid condition remained the same after surgery. Two other patients with unilateral dissecting aneurysms were treated with trapping technique and the surgical outcome was excellent in one patient and good in the other patient. Both patients resumed a normal social life. In five out of eight patients with circumferential dissecting aneurysms, trapping or proximal clipping was performed and the surgical outcome was excellent in two patients, good in one and fair in one patient. One patient with preoperative brain stem infarction died of aspiration pneumonitis after 8 months. Two patients who were noted to have an increase in the size of aneurysm during follow-up angiography underwent a craniotomy with clipping and wrapping of the aneurysm. There was a favorable surgical outcome in both patients. The remaining three patients had Grade IV subarachnoid hemorrhage (SAH) prior to surgery and at autopsy a disturbed vascular wall was detected.
The authors' experience suggests that when surgically feasible, direct clipping is an effective alternative approach in the treatment of dissecting aneurysms of the vertebral artery in which blood flow in the parent artery is to be preserved.
多年来，颅内椎动脉夹层动脉瘤一直被认为相当罕见。近年来，由于通过三维计算机断层扫描（3D - CT）、血管造影和病理学对血管疾病进行了更深入的研究，这些动脉瘤的报道越来越频繁。
在20年期间诊断为椎动脉或其分支动脉瘤的45例患者中，16例为夹层动脉瘤。作者介绍了针对这些患者的治疗策略。对这16例患者进行了手术，最常用的技术是在可行的情况下夹闭或阻断载瘤动脉，以优化脑血流。为了确定治疗方法，将椎动脉夹层动脉瘤分为两组，即单侧组和环周组。在单侧组中，根据传统脑血管造影，夹层似乎仅累及血管的一侧。这些患者通过直接夹闭进行椎动脉的手术重建。在环周组中，夹层累及动脉周围。该组进行近端夹闭或阻断。
在8例单侧夹层动脉瘤患者中，6例通过直接夹闭实现了血管重建。在这6例患者中，4例手术结果被认为优秀，1例尚可，1例患者术后12天死于心力衰竭，因其术前病情术后未改善。另外2例单侧夹层动脉瘤患者采用阻断技术治疗，1例手术结果优秀，另1例良好。两名患者均恢复了正常的社会生活。在8例环周夹层动脉瘤患者中，5例进行了阻断或近端夹闭，2例手术结果优秀，1例良好，1例尚可。1例术前脑干梗死患者术后8个月死于吸入性肺炎。2例在随访血管造影中发现动脉瘤大小增加的患者接受了开颅夹闭和包裹动脉瘤手术。两名患者手术结果均良好。其余3例患者术前有IV级蛛网膜下腔出血（SAH），尸检时发现血管壁异常。
作者的经验表明，在手术可行时，直接夹闭是治疗椎动脉夹层动脉瘤且保留载瘤动脉血流的一种有效替代方法。
