摘要： 目的 探讨经颅多普勒超声、吲哚菁绿荧光血管造影及神经电生理学等多重术中监测技术在前交通动脉动脉瘤显微外科手术中的应用价值。方法 回顾分析23 例单发性前交通动脉动脉瘤夹闭术患者的临床资料、手术方式及术中监测过程，改良Rankin 量表评分评价术后神经功能缺损程度。结果 23 例患者动脉瘤均夹闭成功。其中，6 例术中阻断A1 段时运动诱发电位出现异常变化，恢复血流待缺血程度改善后继续手术；2 例动脉瘤夹闭过程中经颅多普勒超声及吲哚菁绿荧光血管造影分别探及A2 段及前交通动脉血流不畅，1例探及动脉瘤瘤颈残留，经调整动脉瘤夹位置后血流恢复或动脉瘤彻底夹闭，1 例术后发生短暂性一侧肢体瘫痪，出院时遗留轻度神经功能障碍，改良Rankin 量表评分为1 分；其余患者术后均未发生脑出血或脑缺血性改变，出院时改良Rankin 量表评分为0 分。结论 术中多重监测技术可为前交通动脉动脉瘤夹闭术提供A1 段临时阻断是否耐受缺血、动脉瘤是否残留，以及载瘤动脉和穿通支是否损伤，继而造成的脑缺血事件等重要信息，从而提高手术安全性。

关键词: 颅内动脉瘤, 超声检查, 多普勒, 经颅, 荧光素血管造影术, 诱发电位, 躯体感觉, 诱发电位, 运动

Abstract: Objective To evaluate the efficacy of combined multiple intraoperative monitoring techniques including transcranial Doppler (TCD), indocyanine green angiography (ICGA) and neuroelectrophysiological monitoring consisting of somatosensory evoked potential (SEP) and motor evoked potential (MEP) in the surgical management of anterior communicating aneurysm. Methods Clinical data were analyzed for the 23 patients who underwent microsurgery for anterior communicating aneurysms with assistance of combined multiple intraoperative monitoring techniques. Twenty-three patients [12 males, 11 females; mean age 52 (range 44-63 years)] underwent aneurysm clipping via modified pterional approach. Total vein anaesthesia was used for all patients. Propofol, fentanyl and scoline were administrated before intubation. Remifentanil and propofol were used throughout the procedure. Internal carotid artery and A1 segment of anterior cerebral artery were exposed successively. The parent artery, perforating artery and aneurysm were carefully recognized after the A1 segment was temporarily occluded. The temporary clip was removed after the aneurysm being clipped. Neuroelectrophysiological monitoring, ICGA and TCD were applied for intraoperative monitoring. Results All of the 23 aneurysms were successfully clipped. MEP changes were seen in 6 patients during the temporary occlusion of A1 segment, which directed neurosurgeon to pause for its recovery. TCD and ICGA detected A2 segment or anterior communicating artery stenosis in 2 patients and residual aneurysm in 1 patient during clipping procedure, which directed neurosurgeons to readjust aneurysmal clips. Postoperative transient hemiparalysis were observed in 1 patient with modified Rankin Scale level 1 at discharge. No hemorrhagic or ischemic events were observed in other 22 patients with modified Rankin Scale level 0 at discharge. Conclusion Combined multiple intraoperative monitoring techniques may provide important information for the tolerance of A1 segment temporary occlusion, residual aneurysms and ischemic events in the parent or perforating arteries in microsurgery of anterior communicating aneurysms.

Key words: Intracranial aneurysm, Ultrasonography, Doppler, transcranial, Fluorescein angiography, Evoked potential, somatosensory, Evoked potential, motor