Willis覆膜支架治疗神经内窥镜下肿瘤切除术中颈内动脉损伤1例

2018-03-14 佚名 中华神经外科疾病研究杂志

患者女,51岁,头痛1年,加重伴视力下降1月,2015年6月入院。

【一般资料】

患者女,51岁

【主诉】

头痛1年,加重伴视力下降1月,2015年6月入院。

【现病史】

头痛1年,加重伴视力下降1月,2015年6月入院。

【体格检查】

神志清楚,问答切题,双侧瞳孔等大等圆,直径3.0mm,对光反射灵敏,左眼视力下降,20cm处指数,右眼视力正常,伸舌居中,四肢活动自如,余神经系统无明显阳性体征。

【辅助检查】

MRI鞍区肿瘤,颅咽管瘤。

【治疗】

我们给她安排实施经鼻蝶神经内窥镜下肿瘤切除术。不幸的是术中发生颈内动脉损伤,并大量出血(图1A)。立即给予输血,维持血压,并进行鼻腔填塞止血治疗(图1B)。转移至血管造影室由神经介入治疗组行颈内动脉造影,造影发现左侧颈内动脉海绵窦段破裂,并可见造影剂外渗(图2A)。确认无其他可疑血管破裂后,行Willis覆膜支架植入术。我们选用3.5mm×16mmWillis覆膜支架,使用polit-50微导丝,将Willis支架输送导管送入左侧颈内动脉海绵窦段,调整支架位置,使用等渗造影剂充盈支架球囊,同时释放支架(图2B),释放后造影可见原颈动脉破损修补完成,造影剂未再发生外渗(图2C)。肿瘤组医师继续行肿瘤切除术,并完全切除肿瘤。术后患者恢复良好,随访1年未再发生出血性事件。



【讨论】

经蝶入路切除肿瘤可导致颈内动脉损伤。血管破裂,往往导致紧急血管结构变化,产生严重并发症,并导致轻微和重大的缺血性中风。有文献报道使用Jostent支架治疗医源性颈动脉损伤。Willis支架是由上海第六人民医院和微创公司共同研发的新型覆膜支架。2007年Li等报道了一种用于治疗颈内动脉颅内段创伤性动脉瘤的新型支架,Willis支架。Willis覆膜支架由3部分组成:裸支架,可膨胀聚四氟乙烯和球囊导管。裸支架钻铬合金经激光镂刻而成(直径0.06mm),具有分段的、开放式的网状结构。Wllis覆膜支架被用于颅内动脉瘤和颈内动脉海绵窦瘘的治疗,并取得良好效果。Willis支架的良好通过性、高的到位率,内漏发生率低,故我们使用它治疗神经内镜术中颈动脉破裂。在该病例报道中,Willis支架迅速到达颈动脉破裂处,并覆盖损失部位,取得良好效果。Willis支架为医源性颈内动脉损伤提供了一种及时有效的治疗手段。

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