Clinical Study Of Surgical Treatment Of Intracranial Anterior Circulation Aneurysms

BackgroundIntracranial aneurysms is a limitated protuberance of cerebral arteries formed by abnormally enlarged cerebral wall,which is the primary factor of spontaneous intracranial subarachnoid hemorrhage.About 20%of the patients died from the first bleeding because of no treat in time.Microsurgical and interventional surgery are the two main ways of clinical treatment of ruptured aneurysms.Aneurysm clipping is the "gold standard" in the treatment of aneurysms in the past and has 60 years of history.How to make the aneurysm clipping operation more minimally invasive is a challenge for craniotomy surgeon.In recent years,interventional therapy developed rapidly and has become an important means for the treatment of intracranial aneurysms.Usually for anterior circulation aneurysms,two kinds of treatment efficacy,but postoperative recurrence rate is low by microsurgery.For aneurysms of posterior circulation,due to the deep location,intervention treatment usually preferred.For elderly patients,interventional embolization is also priority given.The literature reported that there was still a high recurrence rate after embolization of aneurysms.The study showed that the recurrence of aneurysms was related to the density of the embolization,and the more dense the embolism was,the lower the recurrence rate was.Aneurysms in different parts of the different characteristics.Individualized treatment of aneurysms,we need to explore.Anterior communicating artery aneurysms in intracranial aneurysms accounted for the highest proportion.Due to the deep location,usually choose interventional embolization.The study on individualized treatment of anterior communicating artery aneurysms were sumimarized and analyzed.In addition,wide neck,irregular aneurysms currently used stent assisted embolization,but in acute cerebral hemorrhage,stent application still exist certain risks,including thromboembolic events after surgery and the risk of bleeding,and the application of double catheter technique can avoid stent application.Based on this,this study also made a retrospective analysis of the application of double micro catheter technique in the treatment of intracranial complex irregular aneurysms.Oculomotor nerve palsy is a typical clinical manifestation of posterior communicating artery aneurysms.Interventional embolization and craniotomy clipping are also some helpful to the recovery of oculomotor nerve paralysis.However,there is no definite conclusion about which treatment is more beneficial to the recovery of oculomotor nerve palsy.In the past literature reports,the results were different because of limited number of cases.In this study,we retrospectively analyzed the cases of posterior communicating artery aneurysms with oculomotor nerve palsy in single center.It is found that the recovery rate of oculomotor nerve paralysis is higher in patients undergoing craniotomy clipping.In view of the above problems in the surgical treatment of intracranial aneurysms,a retrospective study of the clinical data of Anhui Provincial Hospital over the past four years was conducted to provide the basis for the surgical treatment of intracranial aneurysms.The research is divided into four parts:Comparison of the efficacy of surgical clipping and embolization for oculomotor nervepalsy due to aposterior communicating artery aneurysm(the first part).Lateral supraorbital approach microsurgical clipping of intracranial anterior circulation aneurysms(part second).Individualized interventional embolization treatment of ruptured anterior communicating artery aneurysms(Part third).Fndovascular treatment of irregular and complicated intracranial aneurysms with coils by double microcatheter technique(Part fourth).Section ? Comparison of the efficacy of surgical clipping and embolization for oculomotor nervepalsy due to aposterior communicating artery aneurysmObjective To aim at the efficacies of surgical clipping and endovascular embolization for oculomotor nerve palsy(ONP)as treatments for posterior communicating artery aneurysm(PcoAA),and the comparison and various influencing factors of the treatments.Methods A retrospective analysis of the clinical data of 52 enrolled PcoAA patients with ONP who had treatment in the Department of Neurosurgery in Anhui provincial Hospital from January 2011 to June 2015 was conducted.There were 23 patients among a total underwent surgical clippings and others 29 patients received endovascular embolization treatment.Then,the age,gender,aneurysm size and rupture status,onset duration,preoperative ONP severity and postoperative recovery degree of ONP of patients in the two groups were compared.The factors affecting the degree of recovery from ONP were analyzed using multivariate logisticregression.Results The final ONP outcomes of the 52 PcoAA patients consisted of 27 full recovery patients(51.9%),21 partial recovery patients(40.4%),and 4 no recovery patients(7.7%).(1)Within the 23 patients in the surgical clipping group,subarachnoid hemorrhage(SAH)occurred in 16 patients,and no SAH occurrence in the other 7 patients;the final ONP evaluation showed 18 patients fully recovered(78.3%)and 5 patients partially recovered(21.7%).Within the 29 patient's in the endovascular embolization group,SAH occurred in 18 patients,and no SAH occurrence in the other 11 patients;the final ONP evaluation showed 9 patients fully recovered(31%),16 patients partially recovered in 16 patients(55.2%)and 4 no recovery patients(13.8%).(2)The postoperative ONP recovery was analyzed with multi-variate logistic regression,and the treatment method was an independent factor for ONP recovery(OR=0.041,95%CI:0.007-0.261,p<0.01).Conclusions When compared with the endovascular embolization,the surgical clipping showed a better efficacy in the recovery from PcoAA related ONP.Section ? Lateral supraorbital approach microsurgical clipping of intracranial anterior circulation aneurysmsObjective To summarize the experience of microsurgical treatment of intracranial anterior circulation aneurysms with lateral supraorbital approach.Analyze the feasibility,advantages and disadvantages of the lateral supraorbital approach,and to provide a safe and minimally invasive approach for microsurgical treatment of anterior circulation aneurysms.Methods Clinical datas(including aneurysm distribution,complications and prognosis GOS score,etc.)were retrospectively analyzed from January 2013 to June 2014 using the lateral supraorbital approach to treat intracranial anterior circulation aneurysms.Results 62 patients with a total of 72 aneurysms,of which 9 cases multiple aneurysms,all aneurysms were clipped.59 cases recovered well,moderate disability in 1 case,mild disability in 2 cases,no mortality.Conclusions lateral upraorbital approach is more simple and efficient than traditional pterional approach,especially suitable for patients with aneurysms within Hunt-Hess grade ?.Section ? Individualized interventional embolization treatment of ruptured anterior communicating artery aneurysmsObjective To summarize the experience of endovascular embolization for the treatment of ruptured anterior communicating artery aneurysm,and to explore the therapeutic effect of endovascular embolization and the method to reduce the complications.Methods A retrospective study was applied on 126 cases with anterior communicating artery aneurysms which were treated by endovascular embolization in the Department of Neurosurgery of Anhui provincial Hospita from January 2011 to December 2013,The data collected included sex,age,Hunt-Hess classification,aneurysm distribution,treatment time,surgical complications,etc.according to Hunt-Hess classification:grade ?22 cases,grade ? 56 cases,grade ? 35 cases,grade ? 13 cases.Results This group of 126 patients were all treated by endovascular embolization.107 cases treated with single catheter embolization,11 cases treated with stent assisted embolization,4 cases treated with balloon assisted embolization,4 cases treated with double catheter embolization.Successful embolization occurred in 123 cases.According to the classification of Raymond,the embolization degree of the aneurysm was evaluated.Raymond grade I embolization was performed in 98 cases(79.6%),and Raymond ? embolization was performed in 25 cases(20.4%).The patients were followed up for 6 months to 4 years,and 4 cases recurred.3 of them were completely embolized again.1 cases underwent clipping by craniotomy.No rebleeding case.Conclusions Endovascular embolization is an effective method for the treatment of anterior communicating artery aneurysms.Individualized treatment,early embolization,better embolization techniques,and early postoperative drainage of hemorrhagic cerebrospinal fluid can reduce complications.Section IV Endovascular treatment of irregular and complicated intracranial aneurysms with coils by double microcatheter techniqueObjective To summarize preliminary experience in the endovascular treatment of irregular and complicated intracranial aneurysm with coils by double micro catheter technique,and to evaluate its feasibility and advantage.Methods A retrospective study was applied on 37 cases with irregular and complicated intracranial aneurysms which were treated by using double microcatheter method from July 2013 to May 2015.Follow-up after patients discharged 6 months.The data collected included gender,age,Hunt-Hess classification,aneurysm distribution,treatment time,surgical complications,and so on.Results All aneurysms were successfully embolized with double micro catheter technique.Immediate postemboliz,ation angiography showed no residual contrast filling in 35 cases,and redidual filling in 2 cases.At discharge,according to modified Rankin Scale(mRS),all patients recovered well,no complications and no deaths occurred.Follow-up in 24 cases by DSA after 6 months,no recanalization was found.Conclusions Double Micro-catheter technique for irregular shape intracranial aneurysms has a good effect,simple operation,fewer complications.