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Early retreatment after surgical clipping of ruptured intracranial aneurysms
背景：虽然破裂颅内动脉瘤夹闭术后再破裂罕见，但是其并发症发生率和死亡率均高。而且，动脉瘤夹闭术后再次手术及动脉瘤再破裂的原因并不明确。 BACKGROUND Although a rerupture after surgical clipping of ruptured intracranial aneurysms is rare, it is associated with high morbidity and mortality. The causes for retreatment and rupture after surgical clipping are not clearly defined.
方法：从囊括了244例接受过手术夹闭治疗的破裂颅内动脉瘤患者的前瞻性数据库中，选取夹闭术后30天内再手术或动脉瘤再破裂的患者入组。经由微血管多普勒超声检查和吲哚菁绿荧光视频血管造影明确动脉瘤闭塞程度。再次手术的适应证包括动脉瘤再破裂或部分闭塞。进而对动脉瘤早期再次手术的特征及原因进行分析。 METHODS From a prospectively maintained database of 244 patients who had undergone surgical clipping of ruptured intracranial aneurysms, we selected patients who experienced retreatment or rerupture within 30 days after surgical clipping. Aneurysm occlusions were examined by microvascular Doppler ultrasonography and indocyanine green video-angiography. Indications for retreatment included rerupture and partial occlusion. We analyzed the characteristics and causes of early retreatment.
结果：全组动脉瘤夹闭术后30天内再手术患者6例（占2.5%，95% CI：0.9-5.3%），其中动脉瘤再破裂患者2例（占0.8%，95% CI：0.1-2.9%）。再次手术的患者中，动脉瘤位于前交通动脉（AcomA）者5例，位于基底动脉者1例。AcomA动脉瘤再手术率（7.5%）显著高于其他部位动脉瘤（0.56%）（P＜0.01）。向侧方突出的AcomA动脉瘤再次手术的比例（17.4%）同样高于其他类型的动脉瘤（2.3%）。经动脉瘤突出方向对侧翼点入路处理突向侧方的AcomA动脉瘤，不完全夹闭的可能性更高。 RESULTS Six patients (2.5%, 95% CI 0.9 to 5.3%) were retreated within 30 days after surgical clipping, including two patients (0.8%, 95% CI 0.1 to 2.9%) who experienced a rerupture. The retreated aneurysms were found in the anterior communicating artery (AcomA) (n = 5) and basilar artery (n = 1). Retreatment of the AcomA (7.5%) was performed significantly more frequently than that of other arteries (0.56%) (p < 0.01). A laterally projected AcomA aneurysm (17.4%) was more frequently retreated than were other aneurysm types (2.3%). Cases of laterally projecting AcomA aneurysms tended to result from an incomplete clip placed using a pterional approach from the opposite side of the aneurysm projection.
结论：尽管有所进步，动脉瘤夹闭术后再次手术或动脉瘤再破裂的比例仍旧近似于先前的报道。AcomA动脉瘤的再手术率显著高于其他部位。特别是初次治疗时选择了经动脉瘤突出方向对侧翼点入路的外侧型AcomA动脉瘤患者，再次手术的比例更高。因此，AcomA动脉瘤的治疗方法和评价方式尤其需要深思熟虑。 CONCLUSIONS Despite developments, the rates of retreatment and rerupture after surgical clipping remain similar to those reported previously. Retreatment of the AcomA was significantly more frequent than was retreatment of other arteries. Patients underwent retreatment more frequently when they were originally treated for lateral type aneurysms using a pterional approach from the opposite side of the aneurysm projection. The treatment method and evaluation modalities should be considered carefully for AcomA aneurysms in particular.
关键词：早期再手术，手术夹闭，破裂颅内动脉瘤，不完全夹闭，吲哚菁绿荧光视频血管造影 KEYWORDS Early retreatment, Surgical clipping, Ruptured intracranial aneurysm, Incomplete clip, Indocyanine green video-angiography
原文出处：Ito Y, Yamamoto T, Ikeda G, et al. Early retreatment after surgical clipping of ruptured intracranial aneurysms. Acta Neurochir. 2017; 159(9): 1627-1632. |
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