颅内动脉瘤术前手术时机选择及术中电生理监测初探
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摘要
第一部分前循环破裂动脉瘤手术时机分析
目的:探讨前循环破裂动脉瘤的手术适宜时机。
方法:回顾性分析82例前循环破裂动脉瘤患者,按入院时Hunt-Hess分级,分为低分级组(Ⅰ~Ⅲ级,n=64)和高分级组(Ⅳ~Ⅴ级,n=18);按手术时机分为早期手术组(≤3d,n=45)、中期手术组(4～10d,n=20)、晚期手术组(≥11d,n=12),5例因再出血未手术。用格拉斯哥转归量表(Glasgow Outcome Scale,GOS)评价转归。
结果:低分级病人中,早期手术组的转归良好(GOS 4~5分)率显著高于中、晚期手术组(96.3%对75%,P=0.031),而术后主要并发症发生率显著低于中、晚期手术组(22.2%对46.9%,P=0.049);中期手术组转归良好率显著高于晚期手术组(85.5%对41.7%,P=0.004),术后主要并发症发生率显著低于晚期手术组(30.0%对75.0%,P=0.027)。高分级患者均为早期手术,其转归良好率为55.6%。
结论:对不同分级的前循环破裂动脉瘤患者宜早期手术。
第二部分颅内动脉瘤术中电生理监测初探
目的:探讨颅内动脉瘤手术中躯体感觉诱发电位(Somatosensory Evoked Potential, SEP)、脑干听觉诱发电位(Brainstem Auditory Evoked potential, BAEP)、运动诱发电位(Motor Evoked Potential, MEP)和脑电图(Electroencephalography, EEG)4项电生理指标的临床应用价值。
方法:在16例动脉瘤手术中,常规开展SEP监测,另根据病情需要,试验性加做头皮EEG监测6例、BAEP监测3例、MEP监测2例,观察术中电生理信号改变与术后神经功能状态的关系。
结果:11例患者术中未出现明显电生理信号异常改变,术后亦未出现新发神经功能障碍。5例患者术中出现明显异常的电生理信号改变:1例有MEP异常,4例有SEP异常(1例伴有BAEP异常)。其中,电生理信号恢复正常的1例患者术后未出现神经功能障碍,而其他4例电生理信号未恢复正常者术后均出现新发神经功能障碍。
结论:对于颅内动脉瘤手术,SEP监测是重要的也是必要的,而头皮EEG的监测价值则较为有限。在前循环动脉瘤手术中联合使用SEP、MEP监测,在后循环动脉瘤手术中联合使用SEP、BAEP监测,可实时了解术中有无脑缺血所致的神经功能障碍,对于指导手术以及评估预后均有重要意义。
PartⅠAnalysis on surgical timing for ruptured anterior circulation aneurysms
Objective:To investigate the appropriate timing of surgery for ruptured anterior circulation aneurysms.
Methods: Eighty-two patients with ruptured anterior circulation aneurysms were analyzed retrospectively. They were divided into one low-grade group (GradeⅠtoⅢ, n=64) and one high-grade group (GradeⅣtoⅤ, n=18) according to the Hunt-Hess Scale on admission. Then they were also divided into early (≤3d, n=45),intermediate (4-10d, n=20) and late (≥11d, n=12) surgery groups according to their timing of surgery. Operations were not performed in 5 patients for rebleeding. The outcome was scored according to the Glasgow Outcome Scale (GOS).
Results: In the low-grade group, the rate of good outcome (GOS 4-5) in the early surgery group was significantly higher than that in the intermediate and late surgery groups (96.3% vs. 75.0%, P=0.031), and the incidence of the major postoperative complications was significantly lower than that in the intermediate and late surgery groups (22.2% vs. 46.9%, P=0.049). Moreover, the rate of good outcome in the intermediate surgery group was significantly higher than that in the late surgery group (85.5% vs. 41.7%, P=0.004), and the incidence of the major postoperative complications was significantly lower than that in the late surgery group (30.0% vs. 75.0%, P=0.027). The patients in the high-grade group were all operated early, and their rate of good outcome was 55.6%.
Conclusion: Early operation is advocated in patients with ruptured anterior circulation aneurysm of different grades.
PartⅡPreliminary research on neuroelectrophysiological monitoring during intracranial aneurysm surgery
Objective : To explore the application of various intraoperative neuroelectro- physiological monitoring on somatosensory evoked potentials (SEPs), brainstem auditory evoked potentials (BAEPs), motor evoked potentials (MEPs) and electroencephalography (EEG) during intracranial aneurysm surgery.
Methods: SEPs were monitored routinely during operations on 16 patients with intracranial aneurysms. Moreover, among these patients, scalp EEG, BAEPs and MEPs were monitored experimentally on 6, 3 and 2 cases, respectively. The relationship between the intraoperative changes of electrophysiological signals and the postoperative outcome of neurological deficits was valuated.
Results:11 patients without abnormal intraoperative electrophysiological signal changes had no new neurological deficits after surgery. However, in the left 5 patients, abnormal changes of intraoperative electrophysiological signals were detected, including abnormal SEPs in 4 patients (1 also with abnormal BAEPs) and abnormal MEPs in 1 patient. Among these 5 patients, 1 with recovered electrophysiological signals had no neurological deficits, while 4 with abnormal electrophysiological signals which were not recovered intraoperatively demonstrated new developed functional deficits immediately after operation.
Conclusion:During intracranial aneurysm surgery, SEP monitoring is important and necessary, while the value of scalp EEG monitoring is relatively limited. The combination of SEP and MEP monitoring in operations on anterior circulation aneurysms and the combination of SEP and BAEP monitoring in operations on posterior circulation aneurysms are very beneficial, not only to timely detect neurological functional deficits resulted from intraoperative cerebral ischemia, but also to properly guide surgical manipulation, and to reliably predict postoperative outcome as well.
目的:探讨前循环破裂动脉瘤的手术适宜时机。
方法:回顾性分析82例前循环破裂动脉瘤患者,按入院时Hunt-Hess分级,分为低分级组(Ⅰ~Ⅲ级,n=64)和高分级组(Ⅳ~Ⅴ级,n=18);按手术时机分为早期手术组(≤3d,n=45)、中期手术组(4～10d,n=20)、晚期手术组(≥11d,n=12),5例因再出血未手术。用格拉斯哥转归量表(Glasgow Outcome Scale,GOS)评价转归。
结果:低分级病人中,早期手术组的转归良好(GOS 4~5分)率显著高于中、晚期手术组(96.3%对75%,P=0.031),而术后主要并发症发生率显著低于中、晚期手术组(22.2%对46.9%,P=0.049);中期手术组转归良好率显著高于晚期手术组(85.5%对41.7%,P=0.004),术后主要并发症发生率显著低于晚期手术组(30.0%对75.0%,P=0.027)。高分级患者均为早期手术,其转归良好率为55.6%。
结论:对不同分级的前循环破裂动脉瘤患者宜早期手术。
第二部分颅内动脉瘤术中电生理监测初探
目的:探讨颅内动脉瘤手术中躯体感觉诱发电位(Somatosensory Evoked Potential, SEP)、脑干听觉诱发电位(Brainstem Auditory Evoked potential, BAEP)、运动诱发电位(Motor Evoked Potential, MEP)和脑电图(Electroencephalography, EEG)4项电生理指标的临床应用价值。
方法:在16例动脉瘤手术中,常规开展SEP监测,另根据病情需要,试验性加做头皮EEG监测6例、BAEP监测3例、MEP监测2例,观察术中电生理信号改变与术后神经功能状态的关系。
结果:11例患者术中未出现明显电生理信号异常改变,术后亦未出现新发神经功能障碍。5例患者术中出现明显异常的电生理信号改变:1例有MEP异常,4例有SEP异常(1例伴有BAEP异常)。其中,电生理信号恢复正常的1例患者术后未出现神经功能障碍,而其他4例电生理信号未恢复正常者术后均出现新发神经功能障碍。
结论:对于颅内动脉瘤手术,SEP监测是重要的也是必要的,而头皮EEG的监测价值则较为有限。在前循环动脉瘤手术中联合使用SEP、MEP监测,在后循环动脉瘤手术中联合使用SEP、BAEP监测,可实时了解术中有无脑缺血所致的神经功能障碍,对于指导手术以及评估预后均有重要意义。
PartⅠAnalysis on surgical timing for ruptured anterior circulation aneurysms
Objective:To investigate the appropriate timing of surgery for ruptured anterior circulation aneurysms.
Methods: Eighty-two patients with ruptured anterior circulation aneurysms were analyzed retrospectively. They were divided into one low-grade group (GradeⅠtoⅢ, n=64) and one high-grade group (GradeⅣtoⅤ, n=18) according to the Hunt-Hess Scale on admission. Then they were also divided into early (≤3d, n=45),intermediate (4-10d, n=20) and late (≥11d, n=12) surgery groups according to their timing of surgery. Operations were not performed in 5 patients for rebleeding. The outcome was scored according to the Glasgow Outcome Scale (GOS).
Results: In the low-grade group, the rate of good outcome (GOS 4-5) in the early surgery group was significantly higher than that in the intermediate and late surgery groups (96.3% vs. 75.0%, P=0.031), and the incidence of the major postoperative complications was significantly lower than that in the intermediate and late surgery groups (22.2% vs. 46.9%, P=0.049). Moreover, the rate of good outcome in the intermediate surgery group was significantly higher than that in the late surgery group (85.5% vs. 41.7%, P=0.004), and the incidence of the major postoperative complications was significantly lower than that in the late surgery group (30.0% vs. 75.0%, P=0.027). The patients in the high-grade group were all operated early, and their rate of good outcome was 55.6%.
Conclusion: Early operation is advocated in patients with ruptured anterior circulation aneurysm of different grades.
PartⅡPreliminary research on neuroelectrophysiological monitoring during intracranial aneurysm surgery
Objective : To explore the application of various intraoperative neuroelectro- physiological monitoring on somatosensory evoked potentials (SEPs), brainstem auditory evoked potentials (BAEPs), motor evoked potentials (MEPs) and electroencephalography (EEG) during intracranial aneurysm surgery.
Methods: SEPs were monitored routinely during operations on 16 patients with intracranial aneurysms. Moreover, among these patients, scalp EEG, BAEPs and MEPs were monitored experimentally on 6, 3 and 2 cases, respectively. The relationship between the intraoperative changes of electrophysiological signals and the postoperative outcome of neurological deficits was valuated.
Results:11 patients without abnormal intraoperative electrophysiological signal changes had no new neurological deficits after surgery. However, in the left 5 patients, abnormal changes of intraoperative electrophysiological signals were detected, including abnormal SEPs in 4 patients (1 also with abnormal BAEPs) and abnormal MEPs in 1 patient. Among these 5 patients, 1 with recovered electrophysiological signals had no neurological deficits, while 4 with abnormal electrophysiological signals which were not recovered intraoperatively demonstrated new developed functional deficits immediately after operation.
Conclusion:During intracranial aneurysm surgery, SEP monitoring is important and necessary, while the value of scalp EEG monitoring is relatively limited. The combination of SEP and MEP monitoring in operations on anterior circulation aneurysms and the combination of SEP and BAEP monitoring in operations on posterior circulation aneurysms are very beneficial, not only to timely detect neurological functional deficits resulted from intraoperative cerebral ischemia, but also to properly guide surgical manipulation, and to reliably predict postoperative outcome as well.
引文
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[4] Roos YB, Beenen LF, Groen RJ, et al. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. Journal of Neurology, Neurosurgery and Psychiatry, 1997,63: 490-493.
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[35]菅凤增, ASantoro G P Cantore,凌锋.脑血流临时阻断中脑电图连续监测的临床意义及局限性.中国脑血管病杂志,2004,1(6):244-247.
[36] Smara SK, Vanderzant CW, Domer PA, et al. Differential effects of Isoflurane on human median nerve somatosensory evoked potentials. Anesthesilogy 1987,66:29-35.
[37] Pelerson DO, Drummond JC, Todd MM. Effects of halothanc and nitrous oxide on somatosensory evoked potentials in humans. Anesthesilogy 1986,65:35-40.
[38] Banoub M, Tedaff JE, Schubert A. Pharmacologic and physiologic influences affecting sensory evoked potentials. Anesthesiology, 2003,99:716-737.
[1]周琪琪,张小锋.神经监测技术在临床手术中的应用.北京:中国社会出版社,2005,1.
[2]乔慧,王忠诚,张亚卓,等.脑干及其附近手术诱发电位术中监护的研究.中华神经外科杂志,2000,16(5):301-304.
[3] Minahan RE. Intraoperative neuromonitoring. Neurologist, 2002, 8:209-226.
[4] Lesnick JE, Michele JJ, Simeone FA, et al. Alteration of somatosensory evoked potentials in response to global ischemia. Neurosurg, 1984,60:490-494.
[5]乔慧,王忠诚,张亚卓,等.神经电生理在术中监护的应用.临床电生理学杂志, 2000, 3:201-218.
[6] Morawetz RB, DeGirolami U, Ojemann RG, et al. Cerebral blood ?ow determined by hydrogen clearance during middle cerebral artery occlusion in unanesthetised monkeys. Stroke,1978,9:143–149.
[7] Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. Neurosurg, 1981,54:773–82.
[8] Ducati A, Landi A, Cenzato M, et al. Monitoring of brain function by means of evoked potentials in cerebral aneurysm surgery. Acta Neurochir Suppl (Wien),1988, 42:8–13.
[9] Penchet G, ArnéP, Cuny E, et al. Use of intraoperative monitoring of somatosensory evoked potentials to prevent ischaemic stroke after surgical exclusion of middle cerebral artery aneurysms. Acta Neurochir (Wien), 2007, 149: 357-364 .
[10] Lopéz JR, Chang SD, Steinberg GK. The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms. Neurosurg, 1999,66(2):189-196.
[11] Friedman WA, Chadwick GM, Verhoeven FJ, et al. Monitoring of somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery,1991,29(1): 83-88.
[12] Mizoi K, Yoshimoto T. Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery, 1993,33:434-440.
[13] Schramm J, Zentner J, Pechstein U. Intraoperative SEP monitoring in aneurysm surgery. Neurol Res, 1994,16:20-22.
[14] Lopez JR. The use of evoked potentials in intraoperative neurophysiologic monitoring. Phys Med Rchabil Clin N Am, 2004,15: 63- 84.
[15] Wiedemayer H,San dalcioglu IE,Armbruster W,et a1. False negative findings in intraoperative SEP monitoring: analysis of 658 consecutive neurosurgical cases and review of published reports. Neurol Psychiatry, 2004,75(2):280-286.
[16] Kang DZ, Wu ZY, Lan Q, et al .Combined monitoring of evoked potentials during microsurgery for lesions adjacent to the brainstem and intracranial during aneurysms. ChinMed J ( Engl) , 2007, 120: 1567-1573.
[17] Little JR, Lesser RP, Luders H. Electrophysiological monitoring during basilar aneurysm operation. Neurosurgery, 1987, 20:421-427.
[18] Neuloh G, Schramm J. Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. Neurosurg, 2004,100(3):389-399.
[19] Branstoanston NM, Ladds A, Symon L, et al. Comparison of the effect of ischaemia on early components of the somatosensory evoked potential in brainstem, thalamus, and cerebral cortex. Cereb Blood Flow Metab, 1984, 4: 68–81.
[20] Manninen PH, Patterson S, Lam AM, et al. Evoked potential monitoring during posterior fossa aneurysm surgery: a comparison of two modalities. Can J Anaesth, 1994, 41: 92–97.
[21] Sasaki T, Kodama N, Matsumoto M, et al. Blood flow disturbance in perforating arteries attributable to aneurysm surgery. Neurosurg, 2007, 107: 60- 67.
[22] SzelényiA, LangerD, Kothbauer K, et al. Monitoring of muscle motor evokedpotentials during cerebral aneurysm surgery: intraoperative changes and post operative outcome. Neurosurg, 2006, 105: 675- 681.
[23] Szelényi A, Langer D, Beck J, et al. Transcranial and direct cortical stimulation for motor evoked potential monitoring in intracerebral aneurysm surgery. Neurophysiol Clin, 2007, 37: 391- 398.
[24] Sloan T. Monitoring the brain and spinal cord. Int Anesthesiology, 2004, 42(2): 1-23.
[25] Taylor CL, Selman WR, Kiefer SP, et al. Temporary vessel occlusion during intracranial aneurysm repair. Neurosurgery, 1996,39:893-906.
[26] Arnold M, Sturzenegger M, Schaffler L, et al. Continuous intraoperative monitoring of middle cerebral artery blood flow velocity and electroencephalography during carotid endarterectomy: A comparison of the two methods to detect cerebral ischemia. Stroke, 1997, 28:1345-1350.
[27]菅凤增, ASantoro G P Cantore,凌锋.脑血流临时阻断中脑电图连续监测的临床意义及局限性.中国脑血管病杂志, 2004,1(6):244-247.
[28] Young WL, Solomon RA, Pedley TA, et al. Direct cortical EEG monitoring during temporary vascular occlusion for cerebral vascular surgery. Anesthesiology, 1989, 71:794-799.
[29]宋志俊,田蕾,史继新,等.皮质脑电图与头皮脑电图同时监测在前循环颅内动脉瘤术中的应用. 2009,17(4):292-296.
[30] Jones TH, Chiappa KH, Young RR, et al. EEG monitoring for induced hypotension for surgery of intracranial aneurysms. Stroke, 1979,10: 292-294.
[31] DehdashtiAR, Pralong E, Debatisse D, et al. Multilobar electrocorticography monitoring during intracranial aneurysm surgery. Neurocrit Care, 2006, 4: 215- 222.
[32] Smara SK, Vanderzant CW, Domer PA, et al. Differential effects of Isoflurane on human median nerve somatosensory evoked potentials. Anesthesilogy, 1987,66:29-35.
[33] Pelerson DO, Drummond JC, Todd MM. Effects of halothane and nitrous oxide on somatosensory evoked potentials in humans. Anesthesilogy, 1986,65:35-40.
[34]郑静,游潮,万衡.电生理监测在颅内动脉瘤夹闭术中的应用及临床意义.中国脑血管病杂志, 2005, 2(10):441-444.
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[37] Banoub M, Tedaff JE, Schubert A. Pharmacologic and physiologic influences affecting sensory evoked potentials. Anesthesilogy, 2003, 99:716-737.
[2] Mack WJ, Mocco J, Hoh DJ, et al. Outcome prediction with serum intracellular adhesion molecule-1 levels after aneurismal subarachnoid hemorrhage. Neurosurg, 2002, 96: 71–75.
[3] Bunc G, Ravnik J, Seruga T. Treatment of ruptured intracranial aneurysms: report from a low-volume center. Wiener Klinische Wochenschrift, 2006,118 Suppl 2:6-11.
[4] Ross N, Hutchinson PJ, Seely H, et al. Timing of surgery for supratentorial aneurismal subarachnoid haemorrhage: report of a prospective study. Neurol Neurosurg Psychiatry, 2002, 72: 480-484.
[5] Roos YB, Beenen LF, Groen RJ, et al. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. Journal of Neurology, Neurosurgery and Psychiatry, 1997,63: 490-493.
[6] Laidlaw JD, Siu KH. Ultra-early surgery for aneurismal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. Neurosurg ,2002,97(2): 250–258
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[15] Qing Lan, Zhigang Gong, Dezhi Kang, et al. Microsurgical experience with keyhole operations on intracranial aneurysms. Surg Neurolo, 2006,66[Suppl 1]:S2–S9.
[16]顾宇翔,毛颖,宋冬雷,等.脑前循环动脉瘤破裂早中期的显微外科手术治疗.中华外科杂志, 2006,44(6): 412-415.
[17] Fridriksson S, Saveland H, Jakobsson KE, et al. Intraoperative complications in aneurysm surgery: a prospective national study. Neurosurg, 2002,96(3):515-522.
[18] Stendel R, Pietila T, Al Hassan AA, et al. Intraoperative microvascular Doppler ultrasonography in cerebral aneurysm surgery. Neurol Neurosurg Psychiatry, 2000, 68(1):29-352.
[19] Sala F, Krzan MJ, Deletis V. Intraoperative neurophysiological monitoring in pediatric neurosurgery: why, when, how? Childs Nerv Syst, 2002, 18:264-287.
[1] Mack WJ, Mocco J, Hoh DJ, et al. Outcome prediction with serum intracellular adhesion molecule-1 levels after aneurismal subarachnoid hemorrhage. Neurosurg, 2002,96: 71–75
[2] Bunc G, Ravnik J, Seruga T. Treatment of ruptured intracranial aneurysms: report from a low-volume center. Wiener Klinische Wochenschrift, 2006,118 Suppl 2:6-11.
[3] Ross N, Hutchinson PJ, Seely H, et al. Timing of surgery for supratentorial aneurismal subarachnoid haemorrhage: report of a prospective study. Neurol Neurosurg Psychiatry, 2002, 72: 480-484.
[4] Roos YB, Beenen LF, Groen RJ, et al. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. Journal of Neurology, Neurosurgery and Psychiatry, 1997,63: 490-493.
[5] Laidlaw JD, Siu KH. Ultra-early surgery for aneurismal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. Neurosurg ,2002,97(2): 250–258
[6] de Gans K, Nieuwkamp DJ , Rinkel GJ , et al. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature. Neurosurgery, 2002, 50: 336-340.
[7] Nieuwkamp DJ, de Gans K, Algra A, et al. Timing of aneurysm surgery in subarachnoid haemorrhage an observational study in The Netherlands. Acta Neurochirurgica, 2005,147(8):815-821.
[8] Yasargil MG.显微神经外科学:ⅢA .凌锋,译.北京:中国科学技术出版社,2002:7-25.
[9] Maira G, Anile C, Mangiola A, et al. Pure surgical treatment of 109 aneurysms. Neurosurg Sci, 2005, 49(2): 31-38.
[10]陆永建,李明昌,何伟文,等.早期显微手术夹闭瘤颈治疗脑动脉瘤破裂出血.中华显微外科杂志, 2006, 29:152-154.
[11] Dizdarevi? K, Iblizovi? N, Kadi? N. Early and urgent (micro)surgery of single and multiple intracranial aneurysms of anterior and posterior circulation and total mortality rate after operative and conservative treatment. Med Arh, 2004,58(5): 301-305.
[12] Komotar RJ, Zacharia BE, Mocco J, et al. Controversies in the surgical treatment of ruptured intracranial aneurysms: the First Annual J. Lawrence Pool Memorial Research Symposium--controversies in the management of cerebral aneurysms. Neurosurgery , 2008,62:396–407.
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[14] Suzuki S, Jahan R, Duckwiler GR, et al. Contribution of endovascular therapy to the management of poor-grade aneurysmal subarachnoid hemorrhage: Clinical and angiographic outcomes. Neurosurg, 2006,105(5):664-670.
[15]徐小川,黄开华. Hunt-Hess IV～V级前交通动脉瘤急诊手术成功五例.中华神经外科杂志, 1993 ,9:26.
[16] Nowak G, Schwachenwald R ,Amold H. Early management in poor grade aneurysm patients. Acta Neurochir(Wien), 1994, 126:33.
[17] Kassell NF, Torner JC, Jane JA, et al. The international cooperative study on the timing of aneurysm surgery. Part 2: surgical results. Neurosurg, 1990,73: 37-47.
[18] Qing Lan, Zhigang Gong, Dezhi Kang, et al. Microsurgical experience with keyhole operations on intracranial aneurysms. Surg Neurolo, 2006,66[Suppl 1]:S2–S9.
[19]顾宇翔,毛颖,宋冬雷,等.脑前循环动脉瘤破裂早中期的显微外科手术治疗.中华外科杂志, 2006,44(6): 412-415.
[20]韩如泉,王保国,李树人,等.持续输注尼莫地平对颅内动脉瘤夹闭术中脑血管痉挛的影响.中华外科杂志, 2004, 42(24): 1489-1492.
[21]王中,周岱,鲍耀东.免疫抑制剂环孢菌素-治疗脑血管痉挛的实验研究.中华神经外科杂志, 2003 , 4 (2) : 252– 254 .
[1] Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysm: a randomized trial. Lancet, 2002,360(9342): 1267.
[2] Nanda A, Vannemreddy P. Management of intracranial aneurysms: factors that influence clinical grade and surgical outcome. South Med J, 2003,96:259–263.
[3] Schulz MK, Wang LP, Tange M, et al. Cerebral microdialysis monitoring: determination of normal and ischemic cerebral metabolisms in patients with aneurismal subarachnoid hemorrhage. Neurosurg, 2000,93(5): 808-814.
[4] Fridriksson S, Saveland H, Jakobsson KE, et al. Intraoperative complications in aneurysm surgery: a prospective national study. Neurosurg, 2002,96(3):515-522.
[5] Sim,J.H., Elseviver BV. Surgical experiences of intracranial aneurysms (2500 cases) Developments in Neuroscience. Proceedings of the 3rd International Mt. Bandai Symposium for Neuroscience and the 4rd Pan-pacific Neurosurgery Congress International Congress Series, 2004, Feb(1259) 163-168.
[6] McLaughlin N, Boianowski MW. Early surgery-related complications after aneurysm clip placement: after an analysis of causes and patient outcomes. Neurosurg. 2004,101(4): 600-606.
[7] Stendel R, Pietila T, Al Hassan AA, et al. Intraoperative microvascular Doppler ultrasonography in cerebral aneurysm surgery. Neurol Neurosurg Psychiatry, 2000, 68(1):29-352.
[8] Sala F, Krzan MJ, Deletis V. Intraoperative neurophysiological monitoring in pediatric neurosurgery: why, when, how? Childs Nerv Syst, 2002, 18:264- 287.
[9]乔慧,王忠诚,张亚卓,等.脑干及其附近手术诱发电位术中监护的研究.中华神经外科杂志,2000,16(5):301-304.
[10] Minahan RE. Intraoperative neuromonitoring. Neurologist, 2002, 8: 209-226.
[11] Lopez JR. The use of evoked potentials in intraoperative neurophysiologic monitoring. Phys Med Rchabil Clin N Am, 2004,15: 63- 84.
[12] Wiedemayer H, San dalcioglu IE, Armbruster W, et a1. False negative findings in intraoperative SEP monitoring:analysis of 658 consecutive neurosurgical cases and review of published reports. Neurol Psychiatry, 2004,75(2):280-286.
[13] Kang DZ, Wu ZY, Lan Q, et al. Combined monitoring of evoked potentials during microsurgery for lesions adjacent to the brainstem and intracranial during aneurysms. Chin Med J ( Engl) , 2007, 120: 1567-1573.
[14] Sasaki T, Kodama N, Matsumoto M, et al. Blood flow disturbance in perforating arteries attributable to aneurysm surgery. Neurosurg, 2007, 107: 60- 67.
[15]周琪琪,张小锋.神经监测技术在临床手术中的应用.北京:中国社会出版社, 2005,1.
[16] Lesnick JE, Michele JJ, Simeone FA, et al. Alteration of somatosensory evoked potentials in response to global ischemia. Neurosurg, 1984,60:490-494.
[17]乔慧,王忠诚,张亚卓,等.神经电生理在术中监护的应用.临床电生理学杂志, 2000, 3:201-218.
[18] Morawetz RB, DeGirolami U, Ojemann RG, et al. Cerebral blood ?ow determined by hydrogen clearance during middle cerebral artery occlusion in unanesthetised monkeys. Stroke 1978, 9:143–149.
[19] Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. Neurosurg 1981, 54:773–82.
[20] Ducati A, Landi A, Cenzato M, et al. Monitoring of brain function by means of evoked potentials in cerebral aneurysm surgery. Acta Neurochir Suppl (Wien) 1988, 42:8–13.
[21] Penchet G, ArnéP, Cuny E, et al. Use of intraoperative monitoring of somatosensory evoked potentials to prevent ischaemic stroke after surgical exclusion of middle cerebral artery aneurysms. Acta Neurochir (Wien), 2007, 149: 357-364.
[22] Lopéz JR, Chang SD, Steinberg GK. The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms. Neurosurg, 1999,66(2): 189-196.
[23] Friedman WA, Chadwick GM, Verhoeven FJ, et al. Monitoring of somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery, 1991, 29(1): 83-88.
[24] Mizoi K, Yoshimoto T. Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery,1993,33:434-440.
[25] Schramm J, Zentner J, Pechstein U. Intraoperative SEP monitoring in aneurysm surgery. Neurol Res, 1994,16:20-22.
[26] Branstoanston NM, Ladds A, Symon L, et al. Comparison of the effect of ischaemia on early components of the somatosensory evoked potential in brainstem, thalamus, and cerebral cortex. Cereb Blood Flow Metab 1984, 4:68–81.
[27] Manninen PH, Patterson S, Lam AM, et al. Evoked potential monitoring during posterior fossa aneurysm surgery: a comparison of two modalities. Can J Anaesth, 1994, 41:92–97.
[28] Little JR, Lesser RP, Luders H. Electrophysiological monitoring during basilar aneurysm operation. Neurosurgery, 1987, 20:421-427.
[29] Neuloh G, Schramm J. Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. Neurosurg, 2004,100(3):389-399.
[30] Horiuchi K,Suzuki K, Sasaki T, et a1.Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. Neurosurg, 2005, 103:275-283.
[31] Sakuma J, Suzuki K, Sasaki T, et al. Monitoring and preventing blood flow insufficiency due to clip rotation after the treatment of internal carotid artery aneurysms. Neurosurg, 2004,100:960-96.
[32]宋志俊,田蕾,史继新,等.皮质脑电图与头皮脑电图同时监测在前循环颅内动脉瘤术中的应用. 2009,17(4):292-296
[33] Young WL, Solomon RA, Pedley TA, et a1. Direct cortical EEG monitoring during temporary vascular occlusion for cerebral aneurysm surgery.Anesthesiology,l 989,71:794-799.
[34] Nuwer MR.Intraoperative electroencephalography. Clin Neurophysiol. 1993,10:437-444.
[35]菅凤增, ASantoro G P Cantore,凌锋.脑血流临时阻断中脑电图连续监测的临床意义及局限性.中国脑血管病杂志,2004,1(6):244-247.
[36] Smara SK, Vanderzant CW, Domer PA, et al. Differential effects of Isoflurane on human median nerve somatosensory evoked potentials. Anesthesilogy 1987,66:29-35.
[37] Pelerson DO, Drummond JC, Todd MM. Effects of halothanc and nitrous oxide on somatosensory evoked potentials in humans. Anesthesilogy 1986,65:35-40.
[38] Banoub M, Tedaff JE, Schubert A. Pharmacologic and physiologic influences affecting sensory evoked potentials. Anesthesiology, 2003,99:716-737.
[1]周琪琪,张小锋.神经监测技术在临床手术中的应用.北京:中国社会出版社,2005,1.
[2]乔慧,王忠诚,张亚卓,等.脑干及其附近手术诱发电位术中监护的研究.中华神经外科杂志,2000,16(5):301-304.
[3] Minahan RE. Intraoperative neuromonitoring. Neurologist, 2002, 8:209-226.
[4] Lesnick JE, Michele JJ, Simeone FA, et al. Alteration of somatosensory evoked potentials in response to global ischemia. Neurosurg, 1984,60:490-494.
[5]乔慧,王忠诚,张亚卓,等.神经电生理在术中监护的应用.临床电生理学杂志, 2000, 3:201-218.
[6] Morawetz RB, DeGirolami U, Ojemann RG, et al. Cerebral blood ?ow determined by hydrogen clearance during middle cerebral artery occlusion in unanesthetised monkeys. Stroke,1978,9:143–149.
[7] Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. Neurosurg, 1981,54:773–82.
[8] Ducati A, Landi A, Cenzato M, et al. Monitoring of brain function by means of evoked potentials in cerebral aneurysm surgery. Acta Neurochir Suppl (Wien),1988, 42:8–13.
[9] Penchet G, ArnéP, Cuny E, et al. Use of intraoperative monitoring of somatosensory evoked potentials to prevent ischaemic stroke after surgical exclusion of middle cerebral artery aneurysms. Acta Neurochir (Wien), 2007, 149: 357-364 .
[10] Lopéz JR, Chang SD, Steinberg GK. The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms. Neurosurg, 1999,66(2):189-196.
[11] Friedman WA, Chadwick GM, Verhoeven FJ, et al. Monitoring of somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery,1991,29(1): 83-88.
[12] Mizoi K, Yoshimoto T. Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery, 1993,33:434-440.
[13] Schramm J, Zentner J, Pechstein U. Intraoperative SEP monitoring in aneurysm surgery. Neurol Res, 1994,16:20-22.
[14] Lopez JR. The use of evoked potentials in intraoperative neurophysiologic monitoring. Phys Med Rchabil Clin N Am, 2004,15: 63- 84.
[15] Wiedemayer H,San dalcioglu IE,Armbruster W,et a1. False negative findings in intraoperative SEP monitoring: analysis of 658 consecutive neurosurgical cases and review of published reports. Neurol Psychiatry, 2004,75(2):280-286.
[16] Kang DZ, Wu ZY, Lan Q, et al .Combined monitoring of evoked potentials during microsurgery for lesions adjacent to the brainstem and intracranial during aneurysms. ChinMed J ( Engl) , 2007, 120: 1567-1573.
[17] Little JR, Lesser RP, Luders H. Electrophysiological monitoring during basilar aneurysm operation. Neurosurgery, 1987, 20:421-427.
[18] Neuloh G, Schramm J. Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. Neurosurg, 2004,100(3):389-399.
[19] Branstoanston NM, Ladds A, Symon L, et al. Comparison of the effect of ischaemia on early components of the somatosensory evoked potential in brainstem, thalamus, and cerebral cortex. Cereb Blood Flow Metab, 1984, 4: 68–81.
[20] Manninen PH, Patterson S, Lam AM, et al. Evoked potential monitoring during posterior fossa aneurysm surgery: a comparison of two modalities. Can J Anaesth, 1994, 41: 92–97.
[21] Sasaki T, Kodama N, Matsumoto M, et al. Blood flow disturbance in perforating arteries attributable to aneurysm surgery. Neurosurg, 2007, 107: 60- 67.
[22] SzelényiA, LangerD, Kothbauer K, et al. Monitoring of muscle motor evokedpotentials during cerebral aneurysm surgery: intraoperative changes and post operative outcome. Neurosurg, 2006, 105: 675- 681.
[23] Szelényi A, Langer D, Beck J, et al. Transcranial and direct cortical stimulation for motor evoked potential monitoring in intracerebral aneurysm surgery. Neurophysiol Clin, 2007, 37: 391- 398.
[24] Sloan T. Monitoring the brain and spinal cord. Int Anesthesiology, 2004, 42(2): 1-23.
[25] Taylor CL, Selman WR, Kiefer SP, et al. Temporary vessel occlusion during intracranial aneurysm repair. Neurosurgery, 1996,39:893-906.
[26] Arnold M, Sturzenegger M, Schaffler L, et al. Continuous intraoperative monitoring of middle cerebral artery blood flow velocity and electroencephalography during carotid endarterectomy: A comparison of the two methods to detect cerebral ischemia. Stroke, 1997, 28:1345-1350.
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