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》著作第五期。本期主要内容为 临时夹闭，《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.检测；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》著作系列回顾：
第一期：神外医师基本功-- 在显微镜下操作技巧----Seven Aneurysms系列
第二期：神外医师基本功--蛛网膜下腔的解剖---Seven Aneurysms系列
第三期：神外医师基本功--脑牵拉---Seven Aneurysms系列
第四期：神外医师基本功--血管控制---Seven Aneurysms系列第四期
第五期：Temporary Clipping--临时夹闭
■ Final Dissection 最后的解剖
Temporary clips are used occasionally to control an intraoperative aneurysm rupture, but more often to finish aneurysm dissection and prepare it for permanent clipping. Aneurysm dissection proceeds in an orderly sequence from controlling afferent arteries, finding efferent arteries, and
dissecting the neck. Inevitably, this orderly progression is disrupted by the aneurysm dome. A dome that blocks the line of sight will conceal critical aneurysm anatomy in a surgical blind spot. Most of the dissection is performed in open surgical corridors with visible aneurysm anatomy; final dissection is performed in surgical blind spots after all visible anatomy has been prepared. Seeing into a surgical blind spot typically requires mobilizing the aneurysm. Pushing on the aneurysm’s base adheres to the policy of dome avoidance, but can avulse a fragile, tethered dome or dislodge a clot at the rupture site. Alternatively, the policy of dome avoidance
can be ignored during final dissection, de-tethering and mobilizing the dome to see around it. A turgid, pulsatile aneurysm moves only with great force, whereas a softened aneurysm moves easily. Therefore, temporary clipping enables the neurosurgeon to manipulate the aneurysm aggressively and visualize hidden anatomy.
临时夹闭偶尔用于术中控制动脉瘤破裂，但是更多时候用于完成动脉瘤的最后解剖，为永久夹闭做准备。动脉瘤的解剖遵循固定的步骤：先控制流入动脉，然后找到流出动脉，最后解剖瘤颈。这个过程会不可避免地受瘤顶的干扰。瘤顶对视线的阻挡会在动脉瘤关键的解剖部位形成手术盲区。绝大多数的动脉瘤解剖是在一个开放的手术通路、能够看清楚动脉瘤解剖的情况下完成的。所有能够看清楚的解剖完成后，在手术盲区完成最后的解剖。向手术盲区看时常需推移动脉瘤。这时要遵循的操作原则是尽量避免骚扰动脉瘤顶，而是在动脉瘤的基底部推移动脉瘤，但是有撕裂动脉瘤脆弱的、受束缚的顶部或者造成破裂处血凝块脱落的风险。所以有时候，在最后解剖时，可以不拘泥于避开动脉瘤顶的操作原则，而是解除瘤顶的蛛网膜束缚、移动瘤顶，看清其周围解剖。高张力、搏动明显的动脉瘤需要用力推动，而变软的动脉瘤则容易推移。所以，临时夹闭可以让医生对动脉瘤进行进一步的操作，以便看到隐藏的解剖结构。
Temporary clipping is also used for potentially dangerous moves that have nothing to do with surgical blind spots or dome manipulation. An efferent artery stuck to the side of an aneurysm may be completely visible, but peeling this artery off the side wall and developing this cleavage plane may tear into a thin aneurysm wall. These risky maneuvers are deliberately saved for the final dissection. Similarly, delicate perforators stuck to the back of an aneurysm must allow passage of a clip blade. The cleavage plane is developed best with gentle traction on a softened aneurysm, pulling it away from the adherent perforator. Aneurysm traction widens
the plane and adhesions are cut under tension. Aneurysm traction relieves a deflected perforator, rather than distorting it further. Temporary clipping and aneurysm softening give the neurosurgeon confidence for these risky moves.
临时夹闭除用于动脉瘤顶部或手术盲区的操作，还用于有潜在风险动脉瘤的推移。例如，与动脉瘤壁粘连紧密的流出动脉，虽然手术可看清楚，但是将其从动脉瘤剥离有可能会撕裂薄的动脉瘤壁。最后分离的过程中要尽量避免这种有风险的操作。同样，（不必过度游离）粘连在动脉瘤背侧易损伤的穿支血管，只需要能够通过动脉瘤夹的叶片即可。轻柔牵拉变软的动脉瘤，将其和粘附的穿支分离，可以很好地形成分离裂隙。牵引动脉瘤可以拓宽分离的解剖间隙，在牵引下锐性分离其与周围组织的粘连。牵拉动脉瘤应该减轻穿支的扭曲，而不是加重其扭曲。临时夹闭和使动脉瘤变软可以让医生有信心进行这些有风险的操作。
■ Extent of Temporary Clipping 临时夹闭的程度
One temporary clip proximally is often all that is needed for the final dissection. Aneurysms with only one afferent artery, such as middle cerebral artery (MCA) and basilar bifurcation aneurysms, soften dramatically with a single temporary clip. Aneurysms with contrast jetting into it on preoperative angiography also soften dramatically with a single temporary clip. Aneurysms with several afferent arteries do not slacken with one temporary clip and require additional clips. Ophthalmic artery aneurysms can backfill from the posterior communicating artery (PCoA) or ophthalmic artery (OphA) despite cervical internal carotid artery (ICA) occlusion; an anterior communicating artery (ACoA) aneurysm can cross-fill from the contralateral A1 segment despite ipsilateral A1 segment occlusion; and basilar bifurcation aneurysms can fill from the contralateral PCoA despite occlusion of basilar trunk. The extent of temporary clipping is individualized according to afferent artery anatomy and how much softening is needed.
最后解剖过程中通常需要一个近端临时阻断夹就够用了。只有一个流入动脉的动脉瘤，如大脑中动脉(MCA)和基底动脉分叉部动脉瘤，用单个临时阻断夹后动脉瘤可以明显地变软。术前造影显示造影剂喷射状进入动脉瘤的，用单个临时阻断夹后动脉瘤同样可以明显地变软。有多个流入动脉的动脉瘤仅临时夹闭一支流入动脉则动脉瘤不会松弛，需要额外的临时夹。眼动脉动脉瘤在颈内动脉(ICA)夹闭后可以通过后交通动脉(PCoA) 或眼动脉(OphA)返流；前交通动脉(ACoA)动脉瘤的同侧A1段虽然阻断，但是从对侧A1段可以灌流；尽管基底动脉主干临时夹闭，但其分叉部动脉瘤可以经对侧PCoA灌流。要根据流入动脉的解剖和需要的松弛程度来个体化地决定临时夹闭的程度。
Distal temporary clips on efferent arteries together with proximal temporary clips on afferent arteries trap the aneurysm and arrest its flow, which may be necessary when final dissection calls for deliberately opening an aneurysm. Thrombotic aneurysms may require thrombectomy to debulk its mass and clip the neck; coiled aneurysms may require removal or mobilization of coils to clip the neck; and giant aneurysms may require suction decompression. Suction decompression takes aneurysm softening one step further, collapsing the aneurysm through an afferent artery outside the cranial field (such as the cervical ICA for an ophthalmic
artery aneurysm), through the aneurysm dome with direct puncture, or endovascularly through a balloon-tipped catheter. Suction decompression quickly removes blind spots and greatly facilitates permanent clipping, but it requires complete aneurysm trapping to keep the aneurysm from re-expanding with blood. The aneurysm must also be soft and collapsible, which may not be the case with elderly patients and atherosclerotic aneurysms.
将动脉瘤远端的的流出动脉和近端的流入动脉一同夹闭，以孤立动脉瘤、使其内部血流停止，这在最后解剖需要有意打开动脉瘤时可能是必要的。血栓性动脉瘤需要清除瘤体内血栓、解除占位效应并夹闭瘤颈；弹簧圈填塞的动脉瘤可能需要去除或移动弹簧圈以便夹闭瘤颈；巨大动脉瘤可能需要抽吸减压。控制颅外段流入动脉(如控制颈部ICA处理眼动脉动脉瘤)后，通过直接在动脉瘤顶穿刺或球囊导管血管内抽吸，仅一步就可以使动脉瘤更变软、塌陷。抽吸减压可以迅速消除手术盲区，极大地方便永久夹闭。但它需要完全孤立动脉瘤，以免动脉瘤血流灌注再扩大。前提是动脉瘤必须是软的和可塌陷的，老年患者以及伴有动脉粥样硬化的动脉瘤可能不是这样。
■ Neurosurgeon Efficiency 神经外科医生的效率
Temporary clipping has disadvantages too. The clip consumes precious space around the aneurysm and can interfere with deep dissection. Interruption of blood flow can cause brain ischemia, depending on the extent of temporary clipping and collateral circulation. Changes in somatosensory or motor evoked potentials may be observed and may elicit warnings from the neurophysiologist. There appears to be a direct relationship between aneurysm softening and
brain ischemia: dramatic softening with temporary clipping is often followed quickly by signs of ischemia.
临时夹闭也有不足。动脉瘤夹占据了动脉瘤周围宝贵的操作空间，影响深部的解剖。血流的中断会导致脑缺血，这取决于临时夹闭的程度和侧枝循环的代偿能力。神经电生理医生可以监测躯体感觉和运动诱发电位的变化，及时提出警告。动脉瘤变软和脑缺血之间有非常直接的关系：临时夹闭后迅速而显著的变软常随之很快出现缺血的迹象。
Unquestionably, temporary clipping adds time pressure and stress to the final dissection. Cerebral protection with barbiturates extends patient tolerance to temporary clipping, and so does raising blood pressure. However, neurosurgeon speed is most important. Technical steps during the final dissection must be clear. Contingency plans must be reviewed in advance. Instruments and permanent clips should be preselected. Preparation translates into surgical efficiency. The precious few minutes of final dissection after the temporary clips are applied are the crux of the operation, when exposure is optimized, the aneurysm is slack, risky moves must be made, and the outcome is determined. An aneurysm’s tolerance to mobilization is never clear, and a bold maneuver that might cause a catastrophe is not natural for surgeons. However, delicacy vanishes as one appreciates the difficulty of seeing an aneurysm’s blind side and the high cost of missing a deep perforator. Intraoperative rupture may be our biggest fear because it causes bleeding and demands an immediate solution. Perforator infarcts may not hurt us in the operating room, but ultimately they have no solution. Performing comfortably under pressure and becoming aggressive with aneurysms is a gradual process. The key to becoming aggressive with aneurysms is the temporary clip. The temporary clip pressures the surgeon to complete the task, but signals the right time to battle the aneurysm.
毫无疑问，临时夹闭时增加了夹闭后操作时间的压力和术者最后解剖时的紧张感。巴比妥类药物的脑保护作用提高了患者临时夹闭的耐受性，升高血压也有同样的作用。不过，对于神经外科医生来说速度是最重要的。最后解剖时的技术步骤必须清楚，提前核查应急计划十分必要。手术器械以及永久性动脉瘤夹型号数量应该预先选好。充分的术前准备可以转化为手术的效率。临时夹闭后最后解剖用的宝贵的有限的几分钟是操作的关键，此时显露充分、动脉瘤松弛、必须进行危险的操作，这决定了手术的效果。动脉瘤能够耐受推移的程度从来就不确定，一个鲁莽的操作，可能会导致一场术者意料之外的灾难。然而，当一个术者屈服于探查动脉瘤盲区的困难时，当他因为遗漏一个深部穿支而造成功能严重损伤时，动脉瘤手术本身应有的精细之处也就消失了。术中破裂可能是术者最大的恐惧，因为它会导致出血，并要求我们立即处理。动脉瘤术中穿支梗塞的发生可能十分隐蔽，甚至在手术室操作的术者不会察觉，但最终这些梗塞造成的损伤也是无法挽救的。能够做到在压力下心态平稳并积极的处理动脉瘤，需要一个循序渐进的过程。积极处理动脉瘤的关键是临时夹闭。临时夹闭迫使外科医生以战斗状态、必须在适当的时间内完成对动脉瘤的操作。
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