摘要目的 评价额外侧微骨窗入路非透视下阻断夹闭颈内动脉床突旁段大型动脉瘤的临床应用价值与效果.方法 回顾性分析2014年6月至2017年12月于天津医科大学总医院神经外科接受应用额外侧微骨窗入路联合球囊非透视下阻断并夹闭载瘤动脉的18例颈内动脉床突旁段大型动脉瘤患者的临床资料.男性8例,女性10例,年龄(63±4)岁.未破裂动脉瘤6例,破裂动脉瘤蛛网膜下腔出血12例(Hunt-Hess分级Ⅱ级6例,Ⅲ级4例,Ⅳ级2例).手术在复合手术室进行,采取额外侧入路切口(平均长约5 cm),骨窗大小约3 cm×3 cm,不需要颈部切开暴露颈内动脉进行临时阻断.结果 18个动脉瘤在复合手术室内均顺利完成夹闭,14例夹闭后造影提示动脉瘤颈夹闭完全,载瘤动脉无狭窄.4例夹闭术中造影提示瘤颈存在残留,调整动脉瘤夹,复查造影动脉瘤夹闭满意.术后随访3个月至1年,10例患者恢复良好[改良Rankin评分(mRS)0分],3例患者无明显残障(mRS:1分).2例Hunt-Hess分级Ⅲ级的患者轻度残障(mRS:2分).1例Hunt-Hess分级Ⅲ级的患者中度残障(mRS:3分).1例Hunt-Hess分级Ⅳ级的患者重度残障(mRS:4分).1例Hunt-Hess分级Ⅳ级的高龄患者严重残障(mRS:5分).结论 应用额外侧微骨窗入路球囊辅助下夹闭颈内动脉床突旁段动脉瘤具有较好的安全性和有效性.

abstractsObjective To evaluate the clinical value and outcomes of technical improvement of hybrid operatical clipping for large paraclinoid internal carotid artery aneurysms.Methods A review was conducted on 18 cases of large paraclinoid internal carotid artery aneurysm which were clipped by balloon non-fluoroscopic occlusion of the parent artery via a micro-bone window frontolateral approach in hybrid operating room at Neurosurgery Department of Tianjin Medical University General Hospital from June 2014 to December 2017.There were 8 males and 10 females with age of (63±4) years.There were 6 cases of unruptured aneurysm and 12 cases of ruptured aneurysm of subarachnoid hemorrhage (6 cases of grade Ⅱ,4 cases of grade Ⅲ and 2 cases of grade Ⅳ in Hunt-Hess classification).Frontolateral approach incision (average length of about 5 cm) and bone window about 3 cm×3 cm were performed.No incision of the neck was needed to expose the internal carotid artery for temporary occlusion.In the operation,the balloon was slowly pushed to the preset position of the internal carotid artery under non-fluoroscopy.The balloon was expanded to block the blood flow of internal carotid artery.Then aneurysm was clipped.The balloon was loosened and retraced to the guiding catheter after clipping.The clipping condition was examined by cerebral angiography.If there was residual aneurysm neck or stenosis of the parent artery,the balloon was pushed under non-fluoroscopy again to temporary occlusion and the clip was adjusted until the aneurysm neck was clamped satisfactorily.Results Eighteen aneurysms were successfully clipped in hybrid operating room.Fourteen aneurysms showed complete occlusion of the aneurysm neck and no stenosis of the parent artery.Four cases showed residual aneurysm neck after clipping by intraoperative angiography,then aneurysms were clipped satisfy by adjusting the aneurysm clip.The patients were followed up for 3 months to 1 year.Ten patients recovered well (modifed Rankin score (mRS):0),and 3 patients had no obvious disability (mRS:1).Two patients with Hunt-Hess grade Ⅲ were slightly disabled (mRS:2).1 patients with Hunt-Hess grade Ⅲ were moderately disabled (mRS:3).1 patients with Hunt-Hess grade Ⅳ were severely disabled (mRS:4).One elderly patients with Hunt-Hess grade Ⅳ were seriously disabled (mRS:5).Conclusions Application of balloon non-fluoroscopic occlusion clipping for large paraclinoid internal carotid artery aneurysm via a micro-bone window frontolateral approach is safe,effective and minimally invasive.