Clinical Study On Prognosis And Influential Factor Of Multiple Intracranial Aneurysms In Subarachnoid Hemorrhage

Section one Clinical data analysis of93patients with a diagnosis of MIA in SAHBackground Multiple intracranial aneurysms(MIA) is a special type of intracranial aneurysms. Two or more than two Intracranial aneurysms exist simultaneously. The proportion is8.1%-34%in the intracranial aneurysms. Within the patients who occur SAH,the incidence rate of multiple aneurysms aneurysm is around30%. Cerebral arterial wall partial congenital defect and cavity pressure are the main cause of intracranial aneurysms.Hypertention, cerebral arteriosclerosis, vasculitis are relevant to the occurrence and development of aneurysm. Intracranial aneurysm is one of the main reasons for the cerebral hemorrhage, accounting for subarachnoid hemorrhage causes of more than70%, with high mortality and morbidity. Subarachnoid hemorrhage (SAH) is caused by a variety of causes the base of the brain and spinal cord or brain surface vascular rupture of acute hemorrhagic cerebrovascular disease, the blood directly inflows subarachnoid. Before a larger aneurysm ruptures, the individual may experience such symptoms as a sudden and unusually severe headache, nausea, vision impairment, vomiting, and loss of consciousness, or the individual may be asymptomatic, experiencing no symptoms at all. If an aneurysm ruptures, it leaks blood into the space around the brain. This is called a "subarachnoid hemorrhage." Depending on the amount of blood, it can produce:a sudden severe headache that can last from several hours to days,nausea and vomiting,drowsiness and/or coma.The ruptured aneurism (hemorrhage) may also damage the brain directly, usually formes a big hematoma,. This can lead to: weakness or paralysis of an arm or leg,trouble speaking or understanding language,vision problems,seizures.. and the disease more dramatically worse, appear even cerebral hernia.Unruptured aneurysm may also display to local mass effect, such as epilepsy, oculomotorius paralysis, etc. Unruptured aneurysm burst the risk of bleeding every year between1%2%.The ruptured aneurysm has a higher rate of rebleeding than unruptured aneurysm.The cerebral angiogram is the most exactly diagnostic method. In recent years the progress of medical image technology improves the diagnosis of aneurysms greatly. For different conditions of aneurysms, the treatment protocols are different. Because of existing ruptured aneurysms and unruptured aneurysm in MIA patients, it needs more carefully to discriminate and treat than a single aneurysm. There are two main therapeutic methods for intracranial aneurysms:neurosurgical clipping and endovascular coiling. Although some treatment experience of the multiple intracranial aneurysms have been made at home and abroad, but explicit diagnosis and treatment procedure does not reach a consensus. The study summarized clinical experience of the treatment of93multiple aneurysms in SAH from January2000to January2011,and the influencing factors of prognosis were retrospectively analyzed, in order to make a diagnosis and treatment guideline of multiple aneurysm patients in SAH.Objective The purpose of this part was to summarize the demographic distribution, the clinical symptoms, the Hunt-Hess classification, aneurysms quantity, aneurysm site, regional classification and influence factors such as hypertention. This section of study was the basic of section two study.Methods We reviewed and collected the data of93MIA patients with complete past history and cerebral angiograms treated in our hospital from January2000to January2011. As to the clinical presentation, we recorded and analysed the basic clinical elements of each patient such as gender, age, the clinical symptoms, the Hunt-Hess classification and hypertention history, carefully analyzed each patient’s angioarchitectural features, including the number of aneurysm, aneurysm site, regional aneurysm classification. The data were synthesized and processed with SPSS13.0. All data were analyzed using nonparametric tests, P<0.05was considered to be of statistical significance.Results(1)This group included93MIA patients aging from21to78, with an average age at diagnosis of47.6, among them,21(22.58%)were male and72(77.42%)were female, and26(27.96%)patients with hypertension history.(2) All patients were admitted to hospital in subarachnoid hemorrhage. According to Hunt-Hess classification, patients can be divided into:level Ⅰ11cases, level Ⅱ44cases, level Ⅲ26cases, levelⅣ12cases.(3) There were totally210aneurysms of all patients, and suffering from two aneurysms in74patients, three aneurysms in15patients, above three aneurysms in4patients.(4) According to the site of the aneurysm,30aneurysms were located in anterior cerebral artery(ACA)&anterior communicating artery (AcoA), and116in internal carotid artery (ICA)&posterior communicating artery (PcoA),38in middle cerebral artery (MCA),26in vertebro-basilar artery(V-B A).(5) According to LingFeng’ regional aneurysm classification,36cases were in first level,49cases were in second level,6cases were in third level and2cases were in forth level.Conclusions (1) In this group, the Hunt-Hess classification of MIA patients in defferent gender and age stages had no obvious difference.(2) The ratio of men and women were0.292:1in this group. Most patients were female, probably because of the lack of estrogen of estrogen in postmenopausal women;(3) The data showed that Hunt-Hess classification was relatively higher in patients with higher blood pressure. hypertension and Hunt-Hess classification have relevance(P=0.021);(4) In parent arteries, the arteries of ICA&PcoA system were the most, followed by MCA bifurcate department, this phenomenon may related to hemodynamic changes, there were no relevance in aneurysm quantity and Hunt-Hess classification(P=0.161);(5) The regional aneurysm and H-H classification had no significant association(P=0.853),but posterior circulation aneurysms and Hunt-Hess classification had relevance(P=0.043). The Hunt-Hess classification is higher in patients with vertebral-basilar artery aneurysm. Section twoClinical study on prognosis and influential factor of multiple intracranial aneurysms in subarachnoid hemorrhageobjective By comparing the Glasgow Outcome Scale (GOS) and the influence factors of such as age, sex, aneurysms quantity, Hunt-Hess classification, the operation timing, whether treatment, treatment protocols, staging operation, hypertention. To explore related factors of MIA patients in SAH for clinical treatment, so as to accumulate clinical experience for the treatment protocols of MIA patients, enhanced multiple intracranial aneurysms therapy levels and effectiveness.Methods We reviewed and collected Review and conclusion of the93treated MIA patients, and more than six months follow-up were made. Select the GOS score after treatment for6months as prognosis standards, we defaulted the GOS score to1meaning survival time less than6months.Inclusion criteria:1, multiple intracranial aneurysms were manifested by angiography;2, all or part of the aneurysms were treated by Endovascular Treatment, operation or combination.3, multiple intracranial aneurysms took conservative treatment.Exclusion criteria:1, multiple intracranial aneurysms with AVM;2,intracranial spindle aneurysm or sandwich aneurysm3, the aneurysms treated by simply occludding the parent arteries.4, patients in Hunt-Hess classification level V, or unable to endure surgery, or serious cardiac, pulmonary, renal insufficiency.The data were synthesized and processed with SPSS13.0. All data were analyzed using multiple linear regression and nonparametric tests, P<0.05was considered to be of statistical significance.Results All multiple intracranial aneurysms patients were confirmed by DSA, in which surgery treatment in12cases, endovascular embolization in51cases, combination in5cases, and conservative treatment in25patients; Timing of treatment (time interval from onset to treatment):23cases<3d,48cases between3d-3weeks,22cases>3weeks.In this group, the GOS score of male patients group were16cases in score5,4cases in score4and1case in score1; with39cases in GOS score5,13cases in score4,6cases in score3,4cases in score2and10cases in GOS score1of female patients group, nonparametric test showed that men after surgery to score more than women GOS(P=0.043). hypertension patients had lowwer GOS score than the patients without hypertension(P=0.042).Hemorrhagic cerebrospinal fluid were drainaged by lumbar puncture or continuous lumbar cisterna drainage in all patients treated their ruptured aneurysm. By Glasgow Outcome Scale (GOS) score after treatment for6months as prognosis standards, there were55cases in GOS score5,17cases in score4,6patients in score3,4cases in score2and11patients in score1. In conservative group of25patients, there were4cases in GOS score5,6cases in score4,4cases in score3,1cases in score2and10cases in score1. There were38cases in GOS score5,7cases in score4,2cases in score3,3cases in score2and only1case in score1in embolization therapy group of51patients. In the surgical treatment group, There were10cases in GOS score5,2cases in GOS score4.While there were3cases in score5,2cases in score4in combination therapy group.By single factor analysis, sex, preoperative Hunt-Hess classification, treatment or not, hypertension have relevance to GOS score (P<0.05). While by linear multivariate analysis, only the preoperative Hunt-Hess classification treatment or not had statistically significant influence of the GOS score (P<0.05), the linear regression equation is Y=8.272-0.598X1-1.688X2(X1:preoperative Hunt-Hess classification; X2:treatment or not).In this group, total of142aneurysms were treated in68patients.36patients treated all74aneurysms, in which27cases treated all55aneurysms for the first time, another9patients only treated9ruptured aneurysm in first treatment, then10unruptured aneurysm in retreatment; and the other all74aneurysms in32patients only treated33ruptured aneurysm, and follow-up other41aneurysms.68aneurysms m25patients only received conservative treatment.In GOS score<3group, there were2cases of32patients only dealing with ruptured aneurysm,also there were4cases of36patients dealing with unruptured aneurysm. Under the precondition of judging and dealing with ruptured aneurysm, wheter treating the unruptured aneurysm or not had no obvious difference to MIA patients’ outcome (P=0.270). Conclusions (1) nonparametric test showed that women and hypertension patients had lowwer GOS score, but these relevances to GOS score were not found in linear multivariate analysis.(2) preoperative Hunt-Hess classification had obvious influence of the prognosis of MIA patients in SAH, with effective treatment most H-H grading1-3levels of patients got favourable prognosis. But patients of Hunt-Hess classification grade4always got poor prognosis.(3) With the progress of the surgical operation and endovascular treatment, GOS score was not significantly associated with regional aneurysm classification.(4)Both of the surgical operation and endovascular treatment are effective protocols in MIA treatment, two kinds of protocols or combination were better than conservative treatment.(5) Early treating ruptured aneurysms would led to favorable prognosis of MIA patients in SAH.(6) in the same area of the multiple aneurysms, use stents for treatment can have a positive effect.(7) Under the precondition of judging and dealing with ruptured aneurysm, wheter treating the unruptured aneurysm or not had no obvious difference to MIA patients’ outcome.