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本期为Worldneurosurgery定期连载的河南省人民医院张长远医师终审的《动脉瘤大师级神作--Seven Aneurysms》著作第八期。本期主要内容为 必要的脑切除，《Seven Aneurysms 》系列内容包括 Section I The Tenets：1. 在显微镜下操作；2. 蛛网膜下腔的解剖；3.脑牵拉；4.血管控制；5.临时夹闭；6.永久夹闭；7.夹闭后的检查；8.必要的脑切除；9.术中破裂。Section II The Approaches: 10.翼点入路; 11.眶颧入路; 12.前纵裂入路; 13.远外侧入路。Section IIIThe Seven Aneurysms: 14.后交通动脉瘤; 15.大脑中动脉瘤; 16.前交通动脉瘤; 17.眼动脉动脉瘤; 18.胼周动脉瘤; 19.基底动脉分叉动脉瘤; 20.小脑后下动脉动脉瘤。 【Seven Aneurysms】往期回顾 第八期：Inspection--必要的脑切除 ■ Violation--脑保护与脑切除的冲突 Vascular neurosurgery is a refined art. The dexterity, grace, and precision of a master neurosurgeon are awe-inspiring; the movement of microsurgical instruments among arteries and nerves is like a ballet; and the otherworld of anatomy underneath the brain is exquisite. Vascular neurosurgeons pride themselves on their ability to reach remote territories through the subarachnoid space without having to violate the brain. Therefore, dissections that violate pia and trans- gress brain are disappointing and a little embarrassing. Brain transgression stirs an unnatural feeling, but resection of some brain has clear advantages in certain situations. 血管神经外科手术是一门精细的艺术。神经外科手术大家灵巧、优雅和精细的操作令人肃然。显微外科器械在动脉和神经之间的游走就像跳芭蕾舞。脑底部的解剖非常精致。血管神经外科医生对自己通过蛛网膜下腔到达深部而不损伤脑组织的能力颇为自得。因此，损伤软脑膜及脑组织的解剖分离是令人失望、稍有尴尬的。虽然脑组织切除使人本能的抵触，但在某些情况下切除部分脑组织却对手术明显有利。
■ Gyrus Rectus--直回切除 The gyrus rectus resection is the best example of tissue removal that improves access to and visualization of an aneurysm. This gyrus lies in the surgical corridor between the olfactory tract and the interhemispheric fissure and can block exposure of the ipsilateral A2 segment and proximal neck. Gentle retraction with a retractor blade lateral to the olfactory tract causes the brain tissue to bulge over the tip of the blade. Pia is coagulated and incised to enter the brain. Cautery and suction are used to remove tissue. The orbito-frontal artery often courses over the middle of the gyrus rectus, and two pial openings on both sides of the artery preserve it while allowing brain removal beneath it. Resection continues until pia on the opposite side of the lobule is reached or until sufficient room is created around the aneurysm. Bleeding is controlled within the resection cavity with cautery, and the retractor is repositioned with its tip at the deep pial plane. 通过切除部分组织以便于处理和显露动脉瘤，直回切除是最好的例子。直回位于嗅束和纵裂之间的手术通路上，遮挡了同侧A2段和近端瘤颈的显露。用牵开器叶片轻柔牵开嗅束外侧脑组织，这样叶片尖端前方的脑组织会凸起。电凝此处的软脑膜，切开并进入脑组织。用电凝和吸引去除脑组织。眶额动脉通常跨过直回的中部，在其两侧切开软脑膜以便保护此动脉，同时可以在其下方吸除脑组织。吸除脑组织一直到脑叶对侧软膜或直到动脉瘤周围有足够的显露空间。术腔出血用电凝控制，重新调整牵开器位置使其尖端到深部软膜的平面。 Brain resection is performed subpially to safely avoid the aneurysm as well as arteries and veins in the subarachnoid space. Any artery of importance, specifically the recurrent artery of Heubner, is identified and dissected away from the lobule before any brain is resected. Inadvertent injury to this artery is the biggest risk of this maneuver, and it should not be performed if the artery cannot be protected. The recurrent artery of Heubner is freed completely from the frontal lobe, following a plane of dissection from the shoulder of its origin from the A2 segment, along the A1 segment, to well beyond the gyrus rectus. 在软膜下进行脑组织切除以安全地避开蛛网膜下腔的动脉瘤以及动脉和静脉。任何重要的动脉，特别是Heubner回返动脉，需要在脑组织切除之前将其辨识并将其与脑叶分离。此动脉的无意损伤是操作的最大风险，如果不能保留此动脉，直回切除即不应该进行。顺着Heubner回返动脉从A2段起源的肩部解剖平面，沿A1走行的方向，将其从额叶充分分离，直到超出直回的范围。 After the gyrus rectus is resected, the subarachnoid plane is reestablished in the interhemispheric fissure. The inner surface of this deep pia is cauterized, inspected, and incised carefully to avoid injury to underlying arteries or the aneurysm itself. The ipsilateral A2 segment is identified in the fissure and traced proximally to the aneurysm. 直回切除后，在纵裂内重新进入蛛网膜下腔。要谨慎地电凝、检查和切开此处深部软脑膜的内表面，避免损伤其下面的动脉或动脉瘤。在纵裂内，辨认同侧A2段并沿其向近心端追踪即可发现动脉瘤。
■ Dome Avoidance--避开动脉瘤顶 Brain transgression removes surgical obstacles such as the gyrus rectus, but is equally important in avoiding dangerous dissection adjacent to aneurysm domes. With middle cerebral artery (MCA) aneurysms, the dome may adhere to the superior temporal gyrus or the posterior pars orbitalis in the frontal lobe, thereby blocking access to the underlying inferior and superior trunks, respectively. With ophthalmic artery aneurysms, the dome may adhere to the medial or- bital gyrus and limit frontal lobe retraction needed for an anterior clinoidectomy. With pericallosal artery aneurysms, the dome may adhere to the cingulate gyrus and interfere with the dissection of afferent arteries. By deliberately leaving the subarachnoid space, the sometimes tight plane between a thin aneurysm and the adherent pia is avoided. After reestablishing the subarachnoid plane beyond the point of adhesion, a thin patch of brain and pia remains attached to the aneurysm dome. The aneurysm becomes untethered and can be mobilized safely. 必要的脑组织切除去除了手术障碍，如直回，但同样重要的是避免在动脉瘤顶部毗邻区进行危险的分离。对于大脑中动脉(MCA)动脉瘤，瘤顶可能与颞上回或额叶眶回后方粘连，从而分别阻挡了对深部的大脑中动脉上、下干的显露。对于眼动脉动脉瘤，其顶部可能与眶回内侧粘连，使额叶牵拉受限而需要行前床突切除。胼周动脉瘤，瘤顶可能与扣带回粘连，影响对流入动脉的解剖。这种情况下可以通过有意地离开蛛网膜下腔（在脑内分离），避开薄层动脉瘤和紧密粘连的软脑膜之间界面。越过粘连部位后重新进入蛛网膜下腔，这样薄片脑组织及蛛网膜仍然粘连在动脉瘤顶部，动脉瘤的束缚解除后就可以安全地推移。
■ Brain Relaxation-- 脑松弛 A swollen brain with an intraparenchymal clot from a ruptured aneurysm is difficult to dissect. Brain transgression may help access the hematoma and relieve intracranial pressure. Hematoma evacuation before securing an aneurysm is a dangerous move, but sometimes is necessary to facilitate the subarachnoid dissection. Dome projection is carefully considered, and clot near the dome is left alone. Clot away from the dome is slowly and gently removed until the brain slackens. Additional clot evacuation can wait until after the aneurysm is clipped. The dome connects with this remaining clot, and evacuation is easily accomplished from this subarachnoid direction. 肿胀的脑组织伴动脉瘤破裂后脑内血肿，此时分离困难。必要的脑组织切除有助于处理血肿和缓解颅内压。在确保动脉瘤安全之前清除血肿是一个危险的操作，但有时对方便蛛网膜下腔的分离解剖是必要的。动脉瘤顶的指向需要仔细思考判断，瘤顶附近的血凝块单独保留，远离动脉瘤顶的血凝块可以慢慢的、轻柔的清除，直到脑组织松弛。其余的血凝块可以等到动脉瘤夹闭后再清除，动脉瘤顶连着这些剩余的血凝块，在蛛网膜下腔方向很容易清除。 ■ Swollen Brain--脑肿胀 In some cases of swollen brain without frank hematoma, resection of brain tissue may be needed to expose the aneurysm. For example, with a basilar bifurcation aneurysm and a swollen temporal lobe, the uncus may narrow the surgical corridor of the carotid-oculomotor triangle. Subpial resection of some uncus may facilitate retraction and widen the exposure. The uncus is not eloquent or associated with neurologic deficits after resection. Therefore, the advantages of facilitated dissection, enhanced exposure, and relieved intracranial pressure outweigh any morbidity from limited brain resection. In these instances, our natural aversion to brain transgression can and should be dismissed. 有些时候，脑肿胀不伴有明显血肿,可能需要切除部分脑组织以显露动脉瘤。例如，基部动脉分叉部动脉瘤并颞叶肿胀，钩回使颈内动脉-动眼神经三角这个手术通道变窄。软膜下切除部分钩回可以使牵拉容易并扩大显露。钩回是非功能区，切除后不会遗留功能障碍。因此，脑组织部分切除有利于解剖分离、增加显露、缓解颅内压，其益处超过它带来的损伤。在这些情况下，我们对必要的脑组织切除的抵触自然可以而且应该被放弃。 编译者：九江市第一人民医院，神经外科，胡炜，主任医师，医学博士。 审校：九江市第一人民医院，神经外科，杨枫，主任医师。 终审：河南省人民医院，神经外科，张长远。
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