摘要：

目的 探讨颅内外血管搭桥术在颅内大型和巨大型血栓性动脉瘤中的应用。方法 纳入2013年3月至2020年7月在苏州大学附属第一医院行颅内外血管搭桥术的共15例颅内大型和巨大型血栓性动脉瘤患者，动脉瘤最大径为1.50~2.50 cm （大型）9例，> 2.50 cm （巨大型）6例；动脉瘤位于颈内动脉床突旁段7例、床突上段3例、大脑中动脉（MCA）3例、颈内动脉分叉部2例；有6例行颞浅动脉（STA）-MCA低流量搭桥术联合动脉瘤夹闭术，2例行STA-MCA低流量搭桥术联合动脉瘤切除术，1例行STA-MCA低流量搭桥术联合颈内动脉结扎术，4例行颈外动脉（ECA）-桡动脉（RA）-MCA高流量搭桥术联合动脉瘤孤立术，2例行ECA-RA-MCA高流量搭桥术联合动脉瘤切除术。结果 15例患者术中吲哚菁绿荧光血管造影术和血管超声以及术后复查DSA或CTA均显示桥血管通畅和动脉瘤消失。13例术后临床症状明显改善；1例术后对侧肢体肌力下降，急诊行CT提示基底节区梗死，经康复治疗后肌力恢复至5级；1例术后7 d突发急性硬膜下血肿，手术治疗后呈浅昏迷；无死亡病例。平均随访12.70个月，术后6个月14例预后良好[Glasgow预后分级（GOS）评分4~5]，1例预后欠佳（GOS评分≤ 3）。结论 颅内外血管搭桥术可用于个体化治疗颅内大型和巨大型血栓性动脉瘤，术前脑血流动力学评估和动脉瘤分型可为治疗提供有利支持。

关键词: 颅内动脉瘤, 颅内血栓形成, 颈内动脉, 大脑中动脉, 脑血管重建术, 脑血管造影术

Abstract:

Objective To investigate the extracrainal-intracranial (EC-IC) bypass for large and giant intracranial thrombotic aneurysms. Methods Fifteen patients of large or giant intracranial thrombotic aneurysms were treated with EC-IC bypass from March 2013 to July 2020 in The First Affiliated Hospital of Soochow University. Among them, there were 9 patients with large aneurysms (maximum diameter of aneurysm 1.50-2.50 cm) and 6 patients with giant aneurysms (maximum diameter of aneurysm > 2.50 cm). According to locations, there were 7 paraclinoid internal carotid artery (ICA) aneurysms, 3 supraclinoid ICA aneurysms, 3 middle cerebral artery (MCA) aneurysms and 2 ICA bifurcation aneurysms. Six cases were treated with low-flow superficial temporal artery (STA)-MCA bypass and aneurysmal clipping, 2 cases with STA-MCA bypass and aneurysmectomy, one with STA-MCA bypass and ligation of extracranial ICA, 4 patients with high-flow external carotid artery (ECA)-radial artery (RA)-MCA bypass and trapping of aneurysms, 2 patients with high-flow ECA-RA-MCA bypass and aneurysmectomy. Results Aneurysm occlusion was confirmed in postoperative DSA or CTA in 15 patients and intraoperative TCD and indocyanine green angiography (ICGA) verified the patency of grafts. Thirteen patients achieved better outcome postoperatively. The muscle strength of contralateral limb in another one decrease following bypass. Emergency CT indicated ipsilateral basal ganglia infarction, and the muscle strength recovered to grade 5 after rehabilitation treatment. A mean 12.70 months follow-up was carried out. One patient suffered acute subdural hematoma 7 d following bypass and presented coma after a second craniotomy. Fourteen patients achieved good outcomes (GOS score 4-5) at last 6 months follow-up. One patient had a poor outcome (GOS score ≤ 3) at last 6 months follow-up. Conclusions EC-IC bypass can be individually carried out for large or giant intracranial thrombotic aneurysm. Preoperative assessment of cerebral hemodynamic and classification of aneurysms can provide favorable support for treatment.

Key words: Intracranial aneurysm, Intracranial thrombosis, Carotid artery, internal, Middle cerebral artery, Cerebral revascularization, Cerebral angiography