The Surgical Treatment Of Middle Cerebral Artery Aneurysm Ruptured With Intracrainal Hematoma And Prognosis

Objective:1.To investigate the surgical management of ruptured middle cerebral artery aneurysms(MACCs) associated with intracrainal hematoma and prognosis.2. To discuss the effect of hematoma evacuation rate and decompressive craniectomy etc on prognosis.3.To discuss some key points in the treatment of emergency operation.Methods:The clinical features of 42 cases of ruptured middle cerebral artery aneurysms in our department(Department of Neurosurgery, Shanxi Provincial People’s Hospital) from January 2012 to July 2015 were analyzed retrospectively,including gender, age,symptoms, signs, onset to surgery time, CT,CTA or DSA, operation time in the vascular area,blood pressure during operation postoperative cranial CT, prognosis,etc. According to Glasgow Outcome Scale, good prognosis(5 points), moderate disability(4 points),severe disabilities(3 points), plant status(2 points), and 1 deaths(1 points), we evaluated the prognosis. we used logistic regression analysis to statistics the reasons,including intraoperative blood pressure, hematoma clearance rate, removal of bone flap,intraoperative vascular operation time, postoperative rehabilitation. All analyses were performed using SPSS Statistics version 17.0.All the statistical analyses were two-sided,and P < 0.05 had statistical significance in establishing the hypothesis.Results:There were 42 cases,16 cases were mail,26 cases were femail.The mean age was53.4 years.There were 44 middle cerebral artery aneurysm and 1 internal carotid posterior communicating artery aneurysm among 42 cases. The associated hematoma was ranged from 30 to 65 ml and mean clot volume was 52.0 ml.There were 41 patients who were taken emergently into the operating room and treated with a modification of the pterional craniotomy for hematoma evacuation and aneurysm clipping,decompressive craniectomy was performed in 29 patients. Onset to surgical treatment of average time is23.9 hours, operation time in the vascular area(including the removal of the hematoma and the separation of free aneurysms, clipping of aneurysm and other operations of the total time), the average time is 51.05 minutes,intraoperative aneurysm ruptured again in5 cases. The mean value of blood pressure was 113 / 75 mmHg.Patients were followed up for 6-48 months after discharge. 2 patients were lost to follow-up.The final patient outcome was good prognosis(5 points) in 15 patients, 13 patients with moderate disability(4 points), 5 patients with severe disability(points), 1patients with plant status(2 points), and deaths(1 point) in 8 patients.Single factor Logistic analysis showed that increasing the age, increasing the amount of hematoma, increasing the preoperative Hunt-Hess classification, postoperative pulmonary infection, reducing blood pressure, increasing the operation time of the vascular area can be used as a factor of poor prognosis and postoperative rehabilitation treatment is a good prognostic factor(P<0.05). Multi factor Logistic analysis showed that the reduction of the operation time and postoperative rehabilitation treatment was a significant factor in the prognosis of the patients. The single factor Logistic regression analysis shows to decompressive craniectomy with the prognosis of patients with little correlation(P>0.05), but I think that the patients of large amount of hematoma, high preoperative hunt Hess grade should take decompressive craniectomy that can reduce postoperative intracranial pressure, but the clearance rate of hematoma is not related to the prognosis of the patients(P>0.05). I think that the prognosis of the patients mainly related with Fisher score and volume of hematoma superposition, onset to emergency surgery time, postoperative pulmonary infection, and is also associated with the doctor’sskill, and also a factor may have a great relationship with the postoperative rehabilitation of the normal(P<0.05). Meanwhile, we must access to each of the blood pressure in patients undergoing surgery(P>0.05), is very important, prognosis and blood pressure,especially if the surgical procedure, especially during induction of anesthesia was significantly associated hypotension may be positively correlated with postoperative hypertension.Conclusion:The prognosis of patients with middle cerebral artery aneurysm with large hematoma usually is poor and is required emergency surgery. The right emergency treatment and surgical principle can effectively improve the survival of patients, reducing intraoperative vascular zone operation time should be minimized to reduce the area of vascular harassment. For the high grade of Hunt-Hess, the large amount of hematoma and edema of brain tissue need to be decompressive craniectomy, the blood pressure level should be maintained at a relatively high level during anesthesia. Preoperative cerebral hernia or hernia were required to remove large bone flap, early rehabilitation therapy can be beneficial for the prognosis of patients after operation.