摘要目的 总结个性化手术治疗大脑中动脉复杂动脉瘤的方法.方法 回顾性研究2009年12月至2012年11月解放军总医院神经外科治疗的20例大脑中动脉复杂动脉瘤患者资料.其中男性12例,女性8例;年龄14 ～ 58岁,平均43岁.6例为巨大动脉瘤(最大径＞2.5 em),7例为宽颈,3例为梭形,2例有穿支起自瘤颈,6例有重要的分支起自瘤体,2例为介入栓塞后复发的动脉瘤.根据术前影像资料制定个性化手术策略.常规采用额颞入路,术中常规应用体感诱发电位、多普勒血流探测、荧光素血管造影等辅助设备进行监测.术后复查数字减影血管造影(DSA)或CT血管造影(CTA)判断动脉瘤夹闭和架桥血管通畅情况.结果 20例动脉瘤中,7例行多动脉瘤夹组合夹闭,同时载瘤动脉夹闭重建;3例大脑中动脉第一段动脉瘤行动脉瘤近端阻断-颅内外血管高流量架桥术;2例行动脉瘤切除-颞浅动脉-大脑中动脉分支低流量架桥;1例行动脉瘤切除-颞浅动脉-大脑中动脉分支低流量架桥-分支血管侧侧吻合术;2例行动脉瘤切除-远近端吻合术;1例行动脉瘤切除-远近端吻合-豆纹动脉再植术;3例行单侧入路夹闭双侧大脑中动脉瘤;1例行单纯动脉瘤孤立术.出院时格拉斯哥预后评分4～5分19例(良好),1分1例(术后1周死于心肌梗死).19例存活患者16例获得随访,随访时间6～39个月,平均20个月,随访期间无再次出血,均复查DSA或CTA,其中14例动脉瘤完全消失,2例有残颈.结论 有经验医师采用个性化手术可安全有效地治疗大脑中动脉复杂动脉瘤,血管重建技术是重要的治疗手段.

abstractsObjective To summarize individualized surgical treatment strategies for complex middle cerebral artery (MCA) aneurysms.Methods Twenty patients with complex MCA aneurysms treated by microsurgery in Chinese People's Liberation Army General Hospital between December 2009 and November 2012 were retrospectively analyzed.There were 12 male and 8 female patients,with a mean age of 43 years (range:14-58 years).Giant aneurysms (size ＞ 2.5 cm) were found in 6 cases,wide-neck aneurysms in 7 cases and serpentine ones in 3 patients.Important perforators were involved in aneurysm neck in 2 cases.Important branches originated from aneurysms in 6 patients.Two patients harbored recurrent aneurysms after coiling.Individualized surgical strategies were planned according to preoperative imaging.A frontotemporal approach was routinely used.Intraoperative somatosensory evoked potential monitoring,indocyanine green videoangiography and microvascular Doppler ultrasonography were regularly used.A postoperative digital subtraction angiography (DSA) or computed tomography angiography (CTA) was performed to verify the efficacy of treatment and patency of bypass vessels.Results Of the 20 cases,7 aneurysms were clipped with clipping and reconstruction of parent artery with multiple clips,3 M1 segment aneurysms were proximally occluded with extra-intracranial high-flow revascularization,2 aneurysms were treated with aneurysmectomy with superficial temporal artery to middle cerebral artery low-flow revascularization,1 aneurysm was treated with aneurysmectomy with superficial temporal artery to middle cerebral artery lowflow revascularization and branch side-to-side anastomosis,2 aneurysms were treated with aneurysmectomy and re-anastomosis of parent artery,1 aneurysm was treated with aneurysmectomy and re-anastomosis of parent artery and reinplantation of lenticulostriate artery,3 bilateral MCA aneurysms were clipped by unilateral approach,and 1 was trapped.Nineteen patients were favorable with Glasgow Ontcome Scale score 4-5 at discharge,and 1 patient died of cardiac infarction one week after surgery.The mean clinical followup was 20 months (range:6-39 months).During follow-up,no bleeding occurred.DSA or CTA confirmed absence of aneurysm in 14 cases and residual neck in 2 patients.The other 3 patients were lost to follow-up.Conclusions Individualized,multi-modality surgical treatment strategies are effective and safe solution for treatment of complex MCA aneurysms.Revascularization remains imperative surgical technique.