Acevedo J C, Turjman F, Sindou M
Service de Neurochirugie A, Hôpital Neurologique Pierre-Wertheimer, Lyon.
Neurochirurgie. 1997;43(5):275-84.
We present the results of a prospective study of post-operative angiographic data in a consecutive series of 267 intracranial aneurysms (in 217 patients) operated on by the same surgeon (M.S.).
All patients underwent a preoperative as well as a postoperative angiographic control. Besides, an analysis of the operative reports was done in order to correlate the surgical and angiographic data.
Out of 267 operated aneurysms, 257 (96%) were located in the anterior circulation, and 10 (4%) in the posterior circulation. The surgical clipping was considered incomplete in 17 aneurysms (6.3%). Aneurysmal remnants were classified in 5 grades; grade I: remnant less than 50% of the neck size; grade II: remnant more than 50% of the neck size; grade III: remnant of a multilobed aneurysmal sac; grade IV: residual sac less than 75% of the aneurysmal size; and grade V: residual sac more than 75% of the aneurysmal size. The analysis of the operative reports helped in understanding the favoring factors of incomplete clipping: large neck and/or huge sized sac, insufficient exposure and dissection of the neck. The presence of a collateral artery with a large infundibulum in the vicinity of the neck-implantation zone on the parent artery.
In most cases the surgeon can easily control peroperatively under the microscope, after puncture-evacuation of the sac, the watertightness of clipping and the absence of any residual neck or sac of the aneurysm. Therefore the remaining place for a postoperative arteriography can be limited to those cases when the surgeon has some doubt concerning the perfection of clipping, as well as for giant and/or "difficult" aneurysms. A re-operation or a complementary endovascular treatment can be discussed for remnants in graded III, IV or V. Knowledge concerning the percentages of aneurysm with neck remnant only and of aneurysms with sac remnant obtained by surgery is interesting at the present time when endovascular treatment is becoming popular. In our series they amounted at 4.1% and 2.2%, respectively. These percentages are those of a series comprising all types of aneurysms. Needless to say, that the percentage of incomplete occlusion will be less if only the aneurysms with small-sized neck were taken into account.
我们展示了一项前瞻性研究的结果，该研究针对由同一位外科医生（M.S.）手术的连续267例颅内动脉瘤（217例患者）的术后血管造影数据。
所有患者均接受了术前和术后血管造影检查。此外，对手术报告进行了分析，以便将手术和血管造影数据相关联。
在267例接受手术的动脉瘤中，257例（96%）位于前循环，10例（4%）位于后循环。17例动脉瘤（6.3%）的手术夹闭被认为不完全。动脉瘤残余物分为5级；I级：残余物小于瘤颈大小的50%；II级：残余物大于瘤颈大小的50%；III级：多叶状动脉瘤囊的残余物；IV级：残余囊小于动脉瘤大小的75%；V级：残余囊大于动脉瘤大小的75%。对手术报告的分析有助于了解夹闭不完全的有利因素：瘤颈大及/或瘤囊巨大、瘤颈暴露和分离不足。在载瘤动脉瘤颈植入区附近存在带有大漏斗状结构的侧支动脉。
在大多数情况下，外科医生在显微镜下手术时，在穿刺排空瘤囊后，能够轻松控制夹闭的水密性以及动脉瘤有无残余瘤颈或瘤囊。因此，术后血管造影的剩余必要性可局限于外科医生对夹闭的完美性存在疑问的情况，以及巨大和/或“困难”动脉瘤。对于III、IV或V级残余物，可讨论再次手术或辅助性血管内治疗。在血管内治疗日益普及的当下，了解仅存在瘤颈残余的动脉瘤和手术获得的有瘤囊残余的动脉瘤的百分比很有意义。在我们的系列研究中，它们分别为4.1%和2.2%。这些百分比是包含所有类型动脉瘤的系列研究中的数据。不用说，如果仅考虑瘤颈小的动脉瘤，不完全闭塞的百分比会更低。
