CAJ | 학술논문

目的以微创理念改良翼点手术入路,减少动脉瘤手术创伤.方法苏州大学附属第二医院于2004年9月至2015年4月期间,通过翼点锁孔入路进行颅内动脉瘤夹闭术123例.以keyhole孔外侧2 cm的翼点为中心,沿发际设计4 cm长手术切口,沿侧裂方向纵行切开颞肌,按动脉瘤部位设计骨孔位置,铣下2.0～2.5 cm直径小骨瓣,磨除蝶骨嵴,分离侧裂,打开脑池释放脑脊液后显露手术部位.123例动脉瘤中,包括大动脉瘤6例,巨大动脉瘤4例,多发动脉瘤17例34个.3例双侧动脉瘤行双侧手术2例,单侧入路夹闭双侧动脉瘤1例.对侧入路1例,夹闭向内侧指向的眼动脉瘤.2例伴发的颅内肿瘤一并切除(大脑中动脉瘤伴发鞍结节脑膜瘤、后交通动脉瘤伴发中颅底脑膜瘤).结果 123例患者140个动脉瘤行夹闭术139个,孤立术1个.术后复查发现4例动脉瘤颈残留.术后3例患者动眼神经不全麻痹,1例肢体轻偏瘫,渐恢复;术后意识障碍加深4例,3例因脑缺血,1例因脑水肿所致.1例Ⅳ级患者手术对侧脑血管痉挛致同侧肢体偏瘫.其余患者术后过程平稳.结论翼点锁孔手术适合用于无需去骨瓣减压的动脉瘤夹闭术,可减少手术创伤,缩短手术时间,微创而有效.
목적 이미창이념개량익점수술입로,감소동맥류수술창상.방법 소주대학부속제이의원우2004년9월지2015년4월기간,통과익점쇄공입로진행로내동맥류협폐술123례.이keyhole공외측2 cm적익점위중심,연발제설계4 cm장수술절구,연측렬방향종행절개섭기,안동맥류부위설계골공위치,선하2.0～2.5 cm직경소골판,마제접골척,분리측렬,타개뇌지석방뇌척액후현로수술부위.123례동맥류중,포괄대동맥류6례,거대동맥류4례,다발동맥류17례34개.3례쌍측동맥류행쌍측수술2례,단측입로협폐쌍측동맥류1례.대측입로1례,협폐향내측지향적안동맥류.2례반발적로내종류일병절제(대뇌중동맥류반발안결절뇌막류、후교통동맥류반발중로저뇌막류).결과 123례환자140개동맥류행협폐술139개,고립술1개.술후복사발현4례동맥류경잔류.술후3례환자동안신경불전마비,1례지체경편탄,점회복;술후의식장애가심4례,3례인뇌결혈,1례인뇌수종소치.1례Ⅳ급환자수술대측뇌혈관경련치동측지체편탄.기여환자술후과정평은.결론 익점쇄공수술괄합용우무수거골판감압적동맥류협폐술,가감소수술창상,축단수술시간,미창이유효.
Objective Modify the pterional approach for intracranial aneurysms clipping with minimally invasive concept to reduce the risk of iatrogenic surgical trauma.Methods A 4.0 cm skin incision was made along the temporal hairline and centered on the pterion, temporal muscle was incised along the sylvian fissure.A bone flap with 2.0 to 2.5 cm in diameter was milled after a bone hole was drilled just on the sphenoid ridge, which was drilled off as needed then.Aneurysms were exposed after dissection of sylvian fissure and cistern, as well as cerebrospinal fluid releasing.A total of 123 cases with 140 intracranial aneurysms were treated surgically via the pterional keyhole approach, including 6 large aneurysms, 4 giant aneurysms, and 17 cases with multiple aneurysms (34 aneurysms).Of 3 cases with bilateral aneurysms, 2 were treated via bilateral approach as well as 1 via unilateral approach.Contralateral approach was used in 1 case with ophthalmic artery aneurysm, which pointed medial.Concomitant intracranial tumors were removed simultaneously in 2 cases, and one of them was diagnosed with middle cerebral artery aneurysm and tuberculum sellae meningioma, the other one with posterior communicating artery aneurysm and middle cranial fossa menigioma.Results Of the 140 aneurysms, 139 aneurysms were clipped and 1 was trapped.Postoperative image showed 4 cases had residual of aneurysm neck.3 cases had incomplete dysfunction of oculomotor nerve and 1 had mild hemiplegia after surgery and recovered eventually.4 cases presented with aggravated disturbance of consciousness, of whom 3 cases were caused by ischemia and 1 by brain edema.Unusual ipsilateral hemiplegia occurred in 1 case in Hunt&Hess grade Ⅳ, which caused by contralateral vasospasm.Postoperative courses in other cases were uneventful.Conclusions As a minimally invasive and effective approach, the pterional keyhole approach is applicable to intracranial aneurysms clipping for patients without any necessary for decompressive craniectomy.Surgical related complications and operative duration can be reduced significantly.