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》著作第七期。本期主要内容为 夹闭后的检查，《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.脑皮层造瘘；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
第七期：Inspection--夹闭后的检查
■ Look,Listen, and Feel--看、听、感觉
Clipping an aneurysm can be such arelief that it is tempting to consider the operation over. However,post-clipping inspection is an important part of aneurysm dissection. Clippedaneurysms can be aggressively de-tethered, mobilized, and deflated. The addedvisualization from these maneuvers enables mistakes to be caught.
动脉瘤夹闭后如释重负，容易被看做是手术的结束。然而，夹闭后的检查是动脉瘤手术的重要一部分。夹闭后的动脉瘤可以大胆地剥离、移动和穿刺或切开。通过这些过程可以看到更多情况，能够发现错误。
Inspection checks seven points:(1) aneurysm occlusion; patency of the (2) parent artery, (3) efferentbranches, (4) perforating arteries, and (5) adjacent arteries; (6) no neckremnant beneath the clips; and (7) surgical blind spots. The inspection sequence is ordered. A dome should not be mobilized to explore ablind spot until complete aneurysm occlusion is confirmed; additionalmini-clips should not be applied to a small neck remnant if primary clips needan adjustment to open an occluded branch.
夹闭后的检查有七个关键点：1、动脉瘤是否闭塞；2、载瘤动脉是否完整；3、流出动脉分支是否完整；4、穿支动脉是否完整；5、邻近的动脉是否完整；6、动脉瘤夹下方是否有残余瘤颈；7、手术的盲点。检查顺序有固定的遵循：在动脉瘤没有确定夹闭完全之前，不要推移动脉瘤顶部去检查手术盲点；在调整动脉瘤夹以松开误夹的分支动脉之前，不要应用迷你夹加固小的瘤颈残余。
Visual inspection is mostinformative: swirling blood is no longer seen through the aneurysm wall;intraluminal red blood cells settle to blanch the aneurysm; afferent andefferent arteries are red and pulsating; the entire path of each clip blade isfree of perforators; and clip tips pass beyond the deep portion of theneck. Palpation with a Rhoton No. 6dissector (Codman; Raynham, MA) on the aneurysm confirms complete clipping whenthe instrument is still and persistent filling when the instrument pulsates.Auscultation with a Doppler flow probe assesses the patency of criticalarteries.
视觉检查能够提供最多的信息：透过动脉瘤壁再也看不到湍流；瘤腔内的红细胞沉积使动脉瘤发白；流入及流出动脉是红色的且有搏动；每个动脉瘤夹全程没有伤及穿支；瘤夹尖端超过深部瘤颈；用Rhoton 6号剥离子触探动脉瘤，利用其感知完全夹闭后的动脉瘤壁静止不动、以及（未完全夹闭动脉瘤的）持续充盈时的搏动；利用多普勒探头（听诊）来评估关键血管的通畅。
Other adjuncts take post-clippinginspection to another level of sophistication. Indocyanine green (ICG)videography is quick and easy, and it addresses aneurysm occlusion and arterialpatency; however, it can only check what is visible through the microscope, andwill miss errors that lie outside the field of view. Intraoperativeangiography checks arterial anatomy beyond what is visible through themicroscope, but it is more complicated and time-consuming than ICG videography,and consequently its use is decreasing.
其它辅助方法将夹闭后的检查确认提高到一个更精细的水平。吲哚菁绿荧光造影迅速简便，可以显示动脉瘤夹闭和动脉通畅程度；不过，它只能检查显微镜下看到的结构，显微镜视野之外的错误则不能发现。术中血管造影能够检查显微镜看不到的动脉解剖，但是它比ICG荧光造影更复杂和耗时，所以它的应用在逐渐减少。
Neurophysiologic monitoring candetect problems with blood flow in large branch arteries and small perforatingarteries to motor and sensory tracts. Somatosensory evoked potentials (SSEPs)measure conduction along the dorsal columns, brainstem, thalamus, and primarysensory cortex. Motor evoked potentials (MEPs) measure conduction along thecorticospinal tract, the anterior horn cells, peripheral nerves, and muscleafter cortical stimulation. Ischemia resulting from imperfect clip application mayproduce electrophysiologic changes that lead to the identification of atechnical error not detected by inspection. Imperfect clip application can beavoided with most anterior circulation aneurysms because operative exposure isexcellent. However, complex aneurysms at the basilar artery apex often do notpermit panoramic inspection. Perforators are at greatest risk of occlusion andthey hide so well behind the distal neck. Even intraoperative angiography failsto visualize these perforators because of their small size. Missed perforatorscan cause devastating infarctions in the thalamus, internal capsule, and midbrain,which make neurophysiologic monitoring especially beneficial with basilarartery aneurysms.
术中神经电生理监测可以发现为运动、感觉神经纤维束供血的大的分支动脉及小的穿支动脉的血供问题。体感诱发电位是测量脊髓后索、脑干、丘脑、主要感觉皮层的感觉传导速度。运动诱发电位是测量刺激皮层后的皮质脊髓束、前角细胞、周围神经和肌肉的传导速度。夹闭不良引发的缺血会产生电生理改变，这可以帮助我们确认一般检查不能发现的技术错误。大多数前循环动脉瘤手术显露好，可以避免夹闭不良。但是，基底动脉尖的复杂动脉瘤常不允许全方位检视，由于穿支血管隐藏在远端瘤颈之后，所以闭塞的风险很高。由于管径太小，即使进行术中血管造影也难以发现这些穿支。这些穿支的闭塞会导致灾难性的丘脑、内囊和中脑缺血。因而，电生理监测对于基底动脉动脉瘤的手术特别有益。
A well-clipped aneurysm thatpasses inspection is punctured away from the neck, just in case it bleeds andan additional clip needs to be stacked. Deflation facilitates the explorationof surgical blind spots and the search for technical errors.
在远离瘤颈部刺破已检视确认夹闭良好的动脉瘤，如果有活动性出血，就需要再追加一个动脉瘤夹。动脉瘤缩小后有利于探查操作盲区及发现技术错误。
■Persistent Aneurysm Filling-- 动脉瘤持续性充盈
Persistent aneurysm filling is themost common problem, and incomplete distal neck occlusion is the most commonreason. This spot is difficult to see because it is furthest from theneurosurgeon and the view is tangential. When applying the clip, the microscopeis oriented to bring both sides of the neck and both clip blades into onepanoramic view down the blades. The relationship between the blade’s tips andthe end of the aneurysm neck is difficult to assess from this tangentialperspective. An oblique perspective is better, but it sacrifices the view ofthe other side of the neck, which is unacceptable during clip application.However, this perspective is acquired easily and safely during inspection.
动脉瘤持续性充盈是最常见问题，远端瘤颈夹闭不完全是最常见的原因。因为它离术者最远并且术者探查这个部位时，视线受到近端瘤颈的遮挡，所以这个部位难以看到。在释放瘤夹时，调整显微镜，视线为顺着动脉瘤夹叶片向下看，使动脉瘤颈部两侧、动脉瘤夹的两个叶片均位于一个视野中。从这样的切线角度看，叶片尖部和动脉瘤颈末端之间的关系很难评估。用一个倾斜的视线更好评估夹闭过程中叶片尖部和动脉瘤颈末端之间的位置关系，但是这样会看不清另一侧的瘤颈，这在施夹过程中是不可接受的。但是，在检视的过程中倾斜角度看则既容易又安全。
“Ovalization” may also explainpersistent aneurysm filling at the distal neck. The circular neck of ananeurysm elongates between clip blades as it is closed by the clip.Mathematically, an aneurysm’s original neck width (W) is equal to the diameterof this circle. With clipping, the aneurysm’s circumference (W × π) iscompressed and flattened into two equal lines as the walls of the neck areopposed. Therefore, the new clipped neck width (Wc) is equal to half thecircumference of the aneurysm [Wc = (W × π)/2 = 1.5 × W]. In other words, the clippedneck width (Wc) is 50% longer than the unclipped neck width. As the neckovalizes, aneurysm tissue is pushed forward and sometimes beyond the clip’stips. This unsecured neck is addressed by advancing the clip or replacing itwith a longer clip.
“椭圆化”也可以解释瘤颈远端的持续性动脉瘤充盈的原因。随着动脉瘤夹的闭合，位于动脉瘤夹两个叶片之间的圆形动脉瘤颈被拉长。数学上讲，瘤颈的原宽度(W)等于这个圆的直径。因为动脉瘤颈的壁是相对着的，所以夹闭后动脉瘤颈的周长(W × π)被压扁为两个相对的等长的线。因此，夹闭后瘤颈的新的宽度(Wc)等于周长的一半[Wc = (W × π)/2 = 1.5 × W]。换句话说，夹闭后的瘤颈宽度(Wc)比未夹闭的瘤颈宽度长50%。由于颈部椭圆化，夹闭时动脉瘤组织被向前推移，有时超出了动脉瘤夹的尖端。这种未安全夹闭的瘤颈可以通过向前调整瘤夹来解决，或代之以更长的瘤夹。
Aneurysms that continue to filldespite well-placed clips that pass beyond the distal neck may not becompletely closed at the tips. The weakest part of a straight clip is its tip.In addition, aneurysm tissue between the proximal blades can splay the distalblades, in the same way that a foot in the doorway on the hinge side opens thedoor wider than a foot in the doorway on the knob side. Splaying is difficult to appreciate visually because the problemis often due to atherosclerosis, calcifications, thrombus, or otherintraluminal irregularities. Tandem clipping fixes this problem. A fenestratedclip encircles tissue at the near neck that might splay the tips, and itmaintains high closing forces at the blades’ tips. After securing the distalneck, the proximal neck is closed with additional clips.
尽管放置良好的动脉瘤夹尖端已经超过瘤颈的远端，但是它仍然可以有血流灌注，原因可能是由于瘤夹的尖端闭合不全。直夹尖端的力量最弱。此外，两叶片近端间的动脉瘤组织可以撑开远端的叶片，就像在门的铰链侧移动一寸打开的门要比在把手侧移动一寸打开的门更宽一样。瘤夹叶片张开的情况很难肉眼观察到，因为问题往往是由于动脉粥样硬化/钙化/血栓或其他管腔内的异常引起。串联夹闭可以解决这个问题。一个带窗的动脉瘤夹绕过可能撑开瘤夹尖端的瘤颈近端，开窗夹能够在尖端保持大的闭合力。在获得瘤颈远端的安全闭合后，近端瘤颈再以另外的动脉瘤夹夹闭。
Persistent aneurysm filling canresult from incomplete occlusion of the proximal neck with a fenestrated clip.Simple fenestrated clipping is used when an efferent artery lies between theneurosurgeon and the near neck. There isa delicate balance between completely closing the proximal neck with the heelof the blades and compromising the caliber of the artery in the fenestration. This spot can be difficult to see, andimperfections in the clip application might allow aneurysm filling. A simple straight clip might be stackedacross this opening, working on either side of theefferent artery. Alternatively, a stacked fenestrated clip with the heelof the blades pulled back will close the leak in the proximal neck, with thefenestrations forming a tube that transmits the efferent artery. This antegradefenestration tube is useful with adherent arteries that cannot be freed fromthe aneurysm wall, sparing the neurosurgeon dangerous dissection along afragile aneurysm wall and difficult repairs when this wall is torn.
持续的动脉瘤充盈可以是因为开窗动脉瘤夹导致的近端瘤颈夹闭不完全。当流出动脉位于术者和近端瘤颈之间时，可以使用简单的带窗动脉瘤夹。在瘤夹叶片跟部完全夹闭近端瘤颈和维持窗内动脉口径之间，有一个精细的平衡。这个平衡很难察觉，如果动脉瘤夹放置不完美，就可能会导致动脉瘤充盈。再用一个简单的直夹，从流出动脉任何一侧进入均可，叠放在此开口处以夹闭完整。或者，再用一个开窗动脉瘤夹叶片跟部回撤，以闭合近端瘤颈的漏口，两个窗形成一个管，容纳流出动脉通过。这种顺行开窗形成管路的方法在动脉粘连于动脉瘤壁无法分离开的情况下是有用的，这可以避免术者沿脆弱的动脉瘤壁进行危险的分离，同样避免了瘤壁撕裂后艰难的修补。
The booster clip is an additionalclip stacked above the initial clip that reinforces the neck closure at a siteof persistent filling. It is often a fenestrated clip that closes strongly atits tips, frequently at the distal neck when the initial clip cannot beadvanced. Booster clips can be applied at the interface between two adjacentclips to overlap a site of persistent filling.
助压夹闭是在第一个动脉瘤夹上方另加一个动脉瘤夹，在持续充盈的漏口加强瘤颈的闭合。通常当第一个动脉瘤夹不能继续闭合时，应用尖端夹闭力强的带窗动脉瘤夹放在远侧的瘤颈。助压瘤夹也可以放在两个相邻瘤夹的交界面，在导致持续充盈的漏口处重叠。
■ Branch Occlusions--分支闭塞
Unintended branch arteryocclusions can cause devastating strokes. Clips should ride high on the neckand generously reconstruct the efferent arteries, particularly withatherosclerotic aneurysms and those with aberrant branch angles. Theseaneurysms have thickened walls and branches that appear to be patent afterclipping when viewed externally, but may be narrowed internally withcompromised blood flow. ICG videoangiography is particularly useful with theseaneurysms.
意外的分支动脉闭塞可导致严重卒中。瘤夹应该骑在瘤颈上并使重建的流出动脉通畅，尤其对于粥样硬化性动脉瘤和分支角度异常的动脉瘤更应如此。由于这些动脉瘤的瘤壁厚，所以虽然夹闭后分支外径完好，但其内径可能是狭窄的，同时血流受限。ICG荧光造影对于这些动脉瘤手术特别有用。
Clips applied to broad-based,dolichoectatic, and giant aneurysms can slide down the neck and occlude parentand branch arteries. Intraluminal thrombus and coils can hold aneurysm wallsapart and transform the neck into a dangerous wedge than can also slide clipsdown the neck and occlude arteries. A poorly placed clip or one that hasmigrated can be used as a “tentative clip.” The natural reaction to a poorlyapplied clip occluding the parent artery is to remove it immediately. However,by leaving it on, it can serve as a scaffold that guides the stacking ofpermanent clips above it, keeping them off the parent artery. After thesepermanent clips are secured, the tentative clip is removed and the parentartery reopens. A tentative clip can beused for vascular control when the usual proximal or distal control isinaccessible and the aneurysm needs to be deflated or mobilized. If brancharteries remain occluded, permanent clips should retreat progressively from theneck until patency of the trunks is restored. Aneurysms that continue to slide permanent clips down the neck mayrequire suction decompression, thrombectomy, coil mobilization, or transection to simplify the neck for stable clipping.
对于宽颈、迂曲扩张和巨型动脉瘤，瘤夹会沿着瘤颈向下滑动，闭塞载瘤动脉和分支动脉。动脉瘤管腔内的血栓、弹簧圈使动脉瘤壁不能闭合，将动脉瘤颈部变形为一个危险的楔形，从而也可使动脉瘤夹下滑而闭塞动脉。放置不当或放置后滑动移位的瘤夹可被用作“临时支撑夹”。对于放置不当闭塞载瘤动脉的动脉瘤夹，自然反应就是立即去除它。但是，将它留置原处，可以作为一个支撑，引导术者在它上面叠加永久动脉瘤夹，从而使其不影响载瘤动脉。安全放置永久动脉瘤夹后，将“临时支撑夹”取下，载瘤动脉重新恢复通畅。当近端或远端控制难以进行而动脉瘤又需要减张或推移时，可以用“临时支撑夹”控制血管。如果夹闭后分支动脉闭塞，应该从动脉瘤颈部逐步后撤永久夹直到分支血流恢复通畅。如果这样处理永久夹仍继续沿瘤颈下滑，就需要抽吸减压、去除血栓、取出弹簧圈或瘤颈切开塑形以达到稳定夹闭。
编译者：九江市第一人民医院，神经外科，杨枫，主任医师。
审校：九江市第一人民医院，神经外科，胡炜，主任医师，医学博士。
终审：河南省人民医院，神经外科，张长远。
【Seven Aneurysms】往期回顾
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