| Objective Anterior circulation aneurysms are the most common intracranial aneurysms.Microsurgical clipping is one of the main treatment methods for anterior circulation aneurysms.The rationality of surgical approach is the basis for successful surgery.At present,the commonly used microsurgery approaches for anterior circulation aneurysms include the classical pterional approach(PT),the modified pterional approach(MPT),the supraorbital extra lateral approach(LSOC),and the supraorbital keyhole approach(SOC),which are developing towards precision,minimally invasive,and individualized.This study analyzed the clinical and follow-up data of patients with anterior circulation aneurysms treated by PT,MPT,LSOC and SOC,summarized and analyzed the characteristics of each approach and its influencing factors,and provided scientific basis for individualized approach selection.At the same time,the anatomy of the cistern and the release of cerebrospinal fluid is a crucial process for the minimally invasive and individualized development of various surgical approaches for anterior circulation aneurysms.During microsurgery of ruptured aneurysms,we found a new abnormality of cerebrospinal fluid flow,that is,there was no hydrocephalus sign on the patient’s brain CT before surgery,but when dissecting the arachnoid membranes of the lateral fissure cistern,carotid cistern,chiasmatic cistern and other cisterns,no or only a small amount of the CSF released,so it is named as the cistern cerebrospinal fluid circulation disorder.By analyzing the factors that cause the cistern cerebrospinal fluid circulation disorder during operation,this study provides a new basis for formulating a more reasonable surgical strategy before operation.In addition,it is necessary to place wound drainage in the microsurgery of anterior circulation aneurysms,which is an important part of the implementation of minimally invasive surgery.In this study,by comparing the difference between the two groups of patients with and without wound drainage during the operation and the outcome of follow-up,we conducted a study on the necessity of wound drainage during anterior circulation aneurysm microsurgery,and provided new cognition for the comprehensive,accurate and minimally invasive individualized treatment of anterior circulation aneurysms.Methods Retrospective collection and analysis of the clinical and follow-up data of236 patients with anterior circulation aneurysms who met the inclusion criteria from January 2019 to December 2019 in our center were divided into PT group,MPT group,LSOC group and SOC group according to different surgical approaches.Based on the statistical analysis of the basic data characteristics,preoperative clinical characteristics,intraoperative characteristics and postoperative effects of the four groups of patients,the characteristics,relevant influencing factors and surgical effects of various surgical approaches were summarized and analyzed.According to whether there is cerebrospinal fluid circulation disorder in the cistern during operation,236 patients were divided into normal cerebrospinal fluid circulation group and obstacle group.Through statistical analysis of the basic data,preoperative clinical characteristics,intraoperative endplate fistula rate,ventricular drainage rate,postoperative effects,etc.of the two groups,the related influencing factors,treatment methods and prognosis evaluation of cerebrospinal fluid circulation disorder were determined.236 patients were divided into drainage group and non-drainage group according to whether to place wound drainage during micro clipping operation.The necessity of placing wound drainage under modern craniotomy technology was clarified by analyzing the differences between the two groups of patients in terms of basic information,incidence of postoperative epidural hematoma,rate of postoperative intracranial infection,length of postoperative hospital stays,and surgical effect(at discharge and at 6-month follow-up).Results(1)The results of different surgical approaches showed that there were 95 cases in PT group,56 cases in MPT group,52 cases in LSOC group and 33 cases in SOC group in 236 patients.There is no significant difference in the basic characteristics of patients before operation between different surgical approaches,but there are differences in the location,rupture,and clinical characteristics(GCS score,Hunt Hess grade,and mFisher grade)of aneurysms between different groups.The results of multivariate logistic regression analysis show that the location,rupture,GCS score Hunt Hess(H-H)classification and mFisher classification are independent factors in the selection of surgical approaches,but the selection of specific surgical approaches may be affected by different factors.At the same time,the patients in the four surgical approaches groups showed different intraoperative signs.The patients in the different surgical approaches groups had statistical differences in the length of surgical incision,bone window area,intraoperative blood loss,operation duration,the incidence of intraoperative cerebrospinal fluid circulation disorders in the cistern,and whether to perform end plate fistula,ventricular drainage,and placement of drainage wounds during the operation.There was no statistical difference in the rate of intraoperative aneurysm rupture,However,it shows a trend of difference.The results showed that there were differences in postoperative complications(superficial temporal artery injury,postoperative infection,and frontal sinus opening),length of hospital stay after surgery,and sense of surgical experience(temporal muscle atrophy and poor facial recovery)among patients with different surgical approaches.In the analysis of surgical outcomes,there were differences in m RS scores between patients in different surgical access groups at discharge and 6 months after surgery.However,when we excluded H-H4 patients,there was no statistical difference in m RS scores between patients in different surgical access groups at discharge and 6 months after surgery,suggesting that H-H4 patients had a higher adverse rate of surgical outcomes.(2)The analysis of intraoperative cerebrospinal fluid circulation disorder in the cistern showed that there were 33 patients with intraoperative cerebrospinal fluid circulation disorder,the incidence was 14%.There is no significant difference in baseline data characteristics between patients with normal cerebrospinal fluid circulation and patients with cerebrospinal fluid circulation disorder,but there are differences in aneurysm rupture,GCS score,H-H grade and mFisher grade,suggesting that the occurrence of cerebrospinal fluid circulation disorder in the cistern may be related to these factors.These differences will be further included in the multifactor analysis,The results showed that mFisher classification was an independent predictor of cerebrospinal fluid circulation disorders in the cistern(P=0.028,OR 1.977,95% CI1.078-3.626);There were differences between the two groups in the rate of end plate fistula and the rate of external ventricular drainage,suggesting that the patients with cerebrospinal fluid circulation disorder in the cistern need to release cerebrospinal fluid in the ventricle to reduce intracranial pressure;There was a difference in m RS scores between the two groups at discharge and follow-up,indicating that the proportion of poor prognosis in the circulatory disorder group was higher(P=0.001 and P<0.001).(3)The results of wound drainage analysis during operation showed that whether oral anticoagulants were taken before operation,the location of aneurysm,whether aneurysm was ruptured,and whether emergency surgery was used were not related to whether wound drainage was placed(P=0848,P=0.773,P=0.362,P=0.134),and there was no statistical difference between the drainage group and the non drainage group in the incidence of postoperative epidural hematoma(P=0.277),There was a difference in the incidence of intracranial infection between the two groups(P=0.009),and the infection rate of patients in the non drainage group was lower.At the same time,the non drainage group had shorter postoperative hospital stay,9.82 ± 4.50 days,which was statistically different from the drainage group’s 12.83 ± 5.07 days(P=0.007).In addition,there was a statistical difference in m RS scores between the drainage group and the non drainage group at discharge and 6 months after surgery.The patients in the non drainage group showed better surgical outcomes(P=0.006 and P=0.038).Conclusion Micro-clipping is a safe and effective treatment for anterior circulation aneurysms.PT,MPT,LSOC and SOC can effectively expose and treat anterior circulation aneurysms.MPT and SOC are characterized by more minimally invasive,less invasive damage and better cosmetic effect after operation.There is a significant correlation between aneurysm location,preoperative GCS score,H-H grade,mFisher grade and the choice of surgical approach,which requires careful preoperative evaluation and comprehensive evaluation to select appropriate individualized surgical approach.LSOC and SOC are more appropriate in the operation of unruptured ICA and ACA aneurysms or those with H-H grade of 0-2,in which SOC shows the least trauma and the best therapeutic effect.For MCA segment aneurysms,PT and MPT have obvious advantages.For unruptured and H-H grade 0-2 MCA segment aneurysms,MPT should be the first approach,showing less trauma and better postoperative results.PT is applicable to aneurysms at all locations,but has the characteristics with a higher invasive and traumatic.The rate of temporal muscle atrophy and poor aesthetic recovery after surgery is the highest,and patients have a poor sense of surgical experience.However,patients with ruptured aneurysm whose GCS score is below 13 or H-H3 or above or mFisher grade is 3 or above have better applicability in surgery,which is the best for the protection of neural function and is conducive to further rehabilitation of patients.Anatomical separation of cerebral cistern and release of cerebrospinal fluid are important in all surgical approaches of aneurysm,which should be paid special attention.The mFisher classification is an independent related factor for the occurrence of the cistern.cerebrospinal fluid circulatory disorder.The higher the classification,the greater the chance of circulatory disorder.In case of cerebrospinal fluid circulation disorder in the cistern,end plate fistula or ventricular puncture and drainage can effectively reduce intracranial pressure during surgery,which is conducive to the exposure and treatment of aneurysms.At the same time,the study found that the prognosis of patients with the cistern cerebrospinal fluid obstruction was relatively worse,which requires us to select more appropriate PT,and relieve the cistern cerebrospinal fluid circulation disorder by releasing cerebrospinal fluid in the ventricular system in the early stage.The necessity of wound drainage is the last link in the minimally invasive whole process management of the surgical approach for anterior circulation aneurysms.After the placement of drainage,the incidence of intracranial infection is higher and the hospital stay is longer.This requires us to be more careful when placing wound drainage during surgery,and consider the advantages and disadvantages comprehensively. |
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