| Cerebral hernia induced by aneurysmal intracranial hematoma is a severe disease, which is associated with high mortality rates. However, not everyone has the change to get imaging diagnosis, and preoperative angiography in some cases may be a waste of time. In such critical clinical condition, urgent surgical treatment is required. Currently, the treatment of these patients has not yet formed a unified understanding, then surgical strategies including hematoma evacuation, decompressive craniectomy and intracranial aneurysm clipping is undoubtedly a feasible approach. However, without the guidance of preoperative vascular imaging, this strategy requires clinicians build a more solid foundation anatomy. In addition, there was no study pointed out which strategy is better for such patients.In this study, we dissected cadaveric head to become more familiar with microscopic anatomy of the cerebral arteries, and to provide the theoretical basis for clinical surgery. Then, We developed a retrospective review and analyzed the clinical date from microsurgical course, curative effects and prognosis of17cases with cerebral hernia induced by intracranial hematoma due to ruptured intracranial aneurysms. In order to decide which of these strategies is better for such patients, the therapeutic effects of different treatment strategies were compared. What’s more, for the purpose of providing preliminary reference for both clinicians and the relatives of patients for making treatment decisions, the patients’ clinical characteristics were collected from their hospital records, and their prognosis-related risk factors were examined using univariate analysis, respectively, followed by multiple logistic regression analysis.Part1(Paper1and2). The basic anatomical study of cerebral arteriesObjective To become more familiar with microscopic anatomy of the cerebral arteries, and to provide the theoretical basis for clinical neurosurgery by research the microsurgical anatomy of the cerebral arteries.Methods On12sides of6adult cadaveric heads specimens, classic pterional craniot-omy was performed, with the help of surgical microscope, we dissected and observed the Willis circle and middle cerebral artery(MCA) and their mainly branch, and its relationships with surrounding important anatomical structures. Results1.The microsurgical anatomy of the MCAThe medial group of lenticulostriate artery mainly originated from the paries posterior/superior/posterior-superior of the M1segment of the MCA, less than10mm from the origin of MCA. The lateral group of lenticulostriate artery mainly originated from the paries posterior/superior of the Ml segment of the MCA, other than10mm from the proximal Ml segment, near the bifurcation of MCA. The cortical branch of the M1segment mainly originated from the proximal segments of the MCA bifurcation, and the knee of MCA was mainly located in the insular (8/12), where the MCA turned sharply posterosuperiorly at a curve and divided into two arterial branches (83.3%), only2sides were three arterial branches (16.7%). The origin of M2segment was at the knee of MCA. According to the diameter of the two arterial branches of M2segment, it could be divided into three categories:(1) equal trunks type (40%);(2) superior trunk predominant type (30%);(3) inferior trunk predominant type (30%).2. The microsurgical anatomy of Willis circle2.1A1segment of anterior cerebral artery(ACA)The A1segment of ACA, together with the lateral edge of the optic chiasm and optic nerve, and the medial margin of clinoid segment of the internal carotid artery, constituted the optic nerve-internal carotid artery gap, in which there were small branches of the internal carotid artery. The left A1segments of ACA often had larger diameter and shorter than the right one (50%), in a few cases, both of them were equal (33.3%). The perforating arteries mainly originated from the paries superior/posterior-superior of the outside1/3of A1segment, a few of which originated from the paries superior/anterior-superior of the inside1/3of Al segment.2.2Anterior communicating artery (ACoA)Single trunk and double trunk were the most common types of ACoA. The perforating arteries of ACoA mainly originated from its paries superior, followed by the paries posterior and paries inferior, distributed in the optic chiasm, endplate, hypothalamus, fornix, corpus callosum and so on.2.3Heubner’s recurrent artery (RAH)The common types of RAH was single trunk (9/12), and its origin was at the ACoA, and Al and A2segment of ACA, less than2-3mm from the ACoA (12/15),4of which originated from Al segment of ACA,5cases originated from A2segment of ACA, and the rest originated from the ACoA. The RAH entered into precribrum in front of or above the beginning part of the MCA, and its branches mainly distributed in the optic nerve, optic chiasm, and part of frontal cortex and olfactory nerve.2.4Posterior communicating artery (PCoA)PCoA mainly originated from the paries posterior-lateralis (58.3%) and paries posterior (33.3%) of the internal carotid artery, traveling in the interpeduncular cistern. The perforating branches originated within5mm from the beginning of the PCoA (9/12), and distributed in the optic chiasm, optic tract, tuber cinereum and mammillary bodies, and so on.2.5Posterior cerebral artery (PCA)PCA originated from the end of the basilar artery, traveling in the interpeduncular cistern. The average length of the left and right P1segment of PCA were7.5±2.1mm and6.9±2.3mm respectively. There were1-12perforating branches originated from the P1segment, and distributed in the tuber cinereum, mammillary bodies, cerebral peduncle and mesencephalon. Thalamic perforating artery was the main artery branches of P1segment.Conclusions There are many variations in the morphology and structure of cerebral arteries, and the variations also exist in the origins and numbers of artery branches. Becoming more familiar with microscopic anatomy of the cerebral arteries, will help us to reduce the impact of various unfavorable factors, which is playing an important role in improving the surgical techniques. Part2. Emergent Surgical Strategy for Cerebral Hernia induced by Aneurysmal Intracerebral HematomaPaper3. Emergent Surgical Treatment for Cerebral Hernia induced by Aneurysmal Intracerebral HematomaObjective This study aims at discussion of the treatment principle of cerebral hernia caused by Intracranial Hematoma due to Ruptured Intracranial Aneurysms.Methods During an3-year period,17patients of cerebral hernia induced by aneurysmal ICH were treated microsurgically in our department. For serious clinical conditions, all patients received emergent surgical without preoperative angiography.Results The intracranial aneurysm clipping was successfully completed in17cases, direct clipping of the aneurysmal necks was achieved in8patients, while reconstructive clipping was performed in9patients.4cases with Hunt-Hess grade VI-V died after operation,13cases were survived,3of which had communicating hydrocephalus and were cured by ventriculo-peritoneal shunt. At follow-up,6of13survivors had favorable outcome (ADL grade Ⅰ3; ADL grade Ⅱ3),5patients had mild disability (ADL grade Ⅲ), and the rest had severe disability (ADL grade Ⅳ).Conclusions In patients with poor neurological grade at admission, whose consciousness rapidly deteriorated, because of aneurysmal ICH, urgent ICH removal and aneurysm clipping without the delay for diagnostic angiography may be life saving and a satisfactory outcome can be accomplished. Paper4. Clinical efficacies of different surgical treatment strategies of cerebral hernia induced by aneurysmal intracerebral hematomaObjective To compare the clinical efficacies of three different surgical treatment strategies of cerebral hernia induced by aneurysmal intracerebral hematoma (ICH), which incldued1. The craniotomy was done to remove the hematoma firstly, then the aneurysms were diagnosed by CT angiography (CTA) or Digital subtraction angiography (DSA),(Delayed imaging group);2. Emergent surgery without cerebral vascular imaging, including hematoma evacuation, intracranial aneurysm clipping and decompressive craniectomy,(Emergency exploration group);3. Conservative treatment,(Conservative treatment group).Methods A total of43patients of cerebral hernia induced by aneurysmal ICH who were hospitalized during last6-years, were enrolled in this study and divided into delayed imaging group, emergency exploration group, and conservative treatment group. Then the clinical efficacies were observed and compared between the three groups, and all of the statistical analyses were performed with SPSS version20.0for Windows.Results The prognosis of patients in emergency exploration group was was significantly better than that of patients in the other two groups, and the former’s mortality was significantly lower (P<0.05). Compared with the conservative treatment group, delayed imaging group had better prognosis, and the difference was statistically significant (P<0.05). On the other hand, in the delayed imaging group, the percentage of patients with good prognosis in early surgery group after the diagnosis was higher than in the late surgery group, and the percentage of patients with poor prognosis in early surgery group after the diagnosis was lower than in the late surgery group, however, both of the differences between the two groups was not statistically significant (P>0.05), and the mortality of both groups were the same.Conclusions In patients with cerebral hernia induced by aneurysmal ICH, if the diagnosis could not be performed in time for the neurosurgeons, emergency surgical exploration therapy, including urgent hematoma evacuation, intracranial aneurysm clipping and decompressive craniectomy, can effectively save the lives of patients and improve the patient outcomes. Paper5. Risk factors affecting the prognosis of emergency exploratory surgery in patients with cerebral hernia induced by aneurysmal ICHObjective To analyze the risk factors affecting the prognosis of emergency exploratory surgery in patients with cerebral hernia induced by aneurysmal ICH, so as to provide preliminary reference for both clinicians and the relatives of patients for making treatment decisions.Methods This was a prospective study. The patients’ clinical characteristics were collected from their hospital records, and the risk factors affecting the prognosis of emergency exploratory surgery in patients with cerebral hernia induced by aneurysmal ICH were examined using univariate analysis, respectively, followed by multiple logistic regression analysis.Results Of the17patients,11had good prognosis (64.7%), and the rest had poor prognosis (35.3%). Univariate analysis shows that The prognosis of patients was correlated with age, preoperative hematoma volume, preoperative Hunt-Hess grade (P<0.05). Multivariate logistic regression analysis indicated that preoperative Hunt-Hess grade was the independent risk factors affecting the prognosis of emergency exploratory surgery in patients with cerebral hernia induced by aneurysmal ICH (P<0.05).Conclusions Preoperative Hunt-Hess grade was closely correlated with the prognosis of the patients. It was the independent risk factors affecting the prognosis of emergency exploratory surgery in patients with cerebral hernia induced by aneurysmal ICH, and could be used as preliminary reference for both clinicians and the relatives of patients for making treatment decisions. |
