颅内动脉瘤术中破裂原因及应急处理措施.docVIP

颅内动脉瘤术中破裂原因及应急处理措施 　 作者：谢家斌，郑佳坤，林小聪，蔡玮，汪朝阳 【摘要】 目的：探讨颅内动脉瘤术中破裂的原因及应急处理措施。方法：35例颅内动脉瘤行开颅夹闭手术。结果：本组术中破裂7例(麻醉诱导至切开硬脑膜时破裂1例，解剖粘连脑池、分离载瘤动脉时破裂2例，牵拉、剥离动脉瘤体及暴露、游离瘤颈时破裂3例，夹闭瘤颈时破裂1例)。其中5例经处理后顺利夹闭；2例术后死于脑疝。结论：术前降颅压及术中仔细操作、良好的暴露和主动截断载瘤动脉供血能减少破裂概率。 【关键词】 颅内动脉瘤;手术;动脉瘤破裂 　　［Abstract］Objective：To find out causes and emergent management of intracranial aneurysmal rupture during operation. Methods： The clipping technique was performed in 35 patients with intracranial aneurysm. Results： One case aneurysm ruptured during the operation was from anesthesia induction to endocranium exposure, two cases were ruptured when the adhesive cistern was dissected and the parent artery was separated, three cases were ruptured when the body of aneurysm was dragged and the neck of aneurysm was dissected, one case was ruptured when the neck of aneurysm was clipped. Five in seven cases were treated successfully and two cases died of cerebral hernia. Conclusion： The rupture rate can reduce for decreasing pre-operational intracranial pressure，operating carefully, revealing the parent artery successfully and blocking blood flow of the parent artery initiatively. 　　［Key Words］intracranial aneurysm; operation; aneurysm rupture 颅内动脉瘤临床常见。动脉瘤夹闭术是处理其理想和最常用的方法。颅内动脉瘤夹闭术最大的风险是动脉瘤术中破裂(Intraoperative aneurysm rupture,IAR)。而手术成功的关键是怎样在术中有效预防动脉瘤的破裂及正确处理破裂的动脉瘤。1999-07～2007-05我科收治颅内动脉瘤35例，现报道如下。 　　1 资料与方法 　　1.1 一般资料 本组(男性23例，女性12例。年龄23～62岁，平均32.3岁)术前均有蛛网膜下隙出血及颅内血肿史，经数字减影血管造影(Digital saubtraction angiograph，DSA)或计算机断层扫描血管造影(Computer tomography angiograph，CTA)确诊为颅内动脉瘤。本组均为前循环动脉瘤：其中颈内动脉床突段2例，前交通动脉瘤10例，后交通动脉瘤20例，大脑中动脉瘤2例，大脑前动脉瘤1例。动脉瘤大小0.5～1.4cm，平均0.9cm。31例首次出血，4例2次出血。手术距最后一次出血时间为20h～13d，平均5.4d。术前病情按Hunt分级：1级8例，2级21例，3级4例，4级2例。其中12例合并高血压病史。 　　1.2 手术方法 本组在气管内插管全麻控制血压下施行手术。术前均行腰穿腰大池持续引流脑脊液以降低颅内压，并分离术侧颈总动脉以备临时结扎。6例直视，29例显微镜下选择改良Yasagil入路开颅，开放脑池，解剖出载瘤动脉及动脉瘤颈部，准确辨认瘤周组织结构，将瘤颈两侧解剖到可安放动脉瘤夹程度并选择适当动脉瘤夹稳妥地夹闭瘤蒂。 　　2 结果 　　2.1 本组术中动脉瘤破裂7例，其中麻醉诱导至切开硬脑膜时破裂1例，解剖粘连脑池、分离载瘤动脉时破裂2例，牵拉、剥离动脉瘤体及暴露、游离瘤颈时破裂3例，夹闭瘤颈时破裂1例。 　　2.2 本组降血压为平均动脉压的2/3(60～