Anatomical And Clinical Study Of Anterior Communicating Artery Aneurysms Clipped By Frontolateral Micro-bone Window Approach

Anterior communicating artery aneurysm(ACA)is a common intracranial aneurysm with a high incidence,once rupture and hemorrhage which seriously threatens the safety of patients.Clipping aneurysm neck by craniotomy is the main method to treat anterior communicating aneurysm.How to reduce the injury caused by craniotomy and seek a more suitable surgical approach has become a hot spot for anterior communicating aneurysm treatment,which is of great significance for the treatment of the disease.Purpose: Anatomical and clinical studies on the clipping of anterior communicating artery aneurysms by frontolateral micro-bone window approach include: related anatomical studies of frontolateral micro-bone window approach;thin-layer CT imaging anatomy of frontal sinus and clinical application of precise clipping of anterior communicating artery aneurysms with the assistance of 3D-Slicer software.To provide a theoretical basis for the appropriate approach and the development of treatment methods for anterior communicating artery aneurysms.Method:1.The anatomical micro structures of the frontolateral micro-bone window approach were studied and analyzed.The characteristics of the frontolateral micro-bone window approach were analyzed by comparing the anatomical characteristics of the pterion approach,the supraorbital micro-bone window approach and the three different approaches of the frontolateral micro-bone window approach.2.Thin-layer CT imaging anatomy of frontal sinus,through the study of 100 cases of image data screened in PACS system of hospital image,the structure characteristics of frontal sinus and frontal sinus gasification grading were analyzed,the relationship between frontal sinus gasification grading and gender was investigated,and the anatomical characteristics of frontal sinus were summarized.3.Combined with anterior communicating artery aneurysms anatomical characteristics of aneurysms were studied.Clinical application of precise clipping of anterior communicating artery aneurysms with the aid of 3D-Slicer software was analyzed.Sixty patients with raptured anterior communicating artery aneurysms treated in our hospital from January 2018 to June 2019 were selected as the researchobjects.These aneurysms can be clipped by both pterion approach and frontolateral micro-bone window approach,as determined by senior neurosurgeons.They were randomly divided into pterion approach group and frontolateral micro-bone window approach according to the serial number of hospitalization.There were 30 cases in each group.In the pterion approach group,3D-Slicer software was used to assist the pterion approach,while in frontolateral micro-bone window approach group,3D-Slicer software was used to assist the frontolateral micro-bone window approach.The basic information,operation time,intraoperative bleeding volume,treatment cost,hospitalization time,treatment effect,complications and prognosis of the two groups were analyzed and compared.Results: 1.Study and analysis of the anatomical structure of the frontolateral micro-bone window approach(1)The cadaver head was well perfused and the specimen model was constructed.(2)The frontolateral micro-bone window approach does not need to remove the sphenoid ridge,and the degree of detachment of temporal muscle is small,the length of incision is short,and the injury to tissue and nerve is small.The location of the approach will not cause frontal sinus opening basically.(3)The pterion approach,the supraorbital micro-bone window approach and the frontolateral micro-bone window approach can well expose the sellar region and the sellar region peripheral structure;(4)There were some differences in the length of vessels exposed by three different approaches.The exposure of the intracranial segment of internal carotid artery: Pterion approach > frontolateral micro-bone window approach > supraorbital micro-bone window approach,and the difference was statistically significant(P < 0.05);Anterior cerebral artery A1: frontolateral micro-bone window approach > supraorbital micro-window approach > Pterion approach,There were not statistical differences(P > 0.05);Anterior cerebral artery A2: supraorbital micro-bone window approach > pterion approach > frontolateral micro-bone window approach,the difference was statistically significant(P < 0.05);Middle cerebral artery M1: pterion approach > frontolateral micro-bone window approach > supraorbital micro-window approach,the difference was not statistically significant(P > 0.05);Middle cerebral artery M2: pterion approach > frontolateral micro-bone window approach > supraorbital micro-window approach,the difference was not statistically significant(P > 0.05);Anterior cerebral artery A1 + Middle cerebral artery M1: frontolateral micro-bone window approach > pterion approach > supraorbital micro-bone window approach,the difference was not statistically significant(P > 0.05).(5)There were some differences in the degree of exposure.There were 9 cases with more than 3 points in pterion approach,8 cases with more than 3 points in supraorbital micro-bone window approach and 9 cases with more than 3 points in frontolateral micro-bone window approach.2.Anatomical study of frontal sinus on thin layer CT(1)Size of frontal sinus: Left frontal sinus is(1.42 ±0.36)cm in length and(0.92 ±0.23)cm in width,while right frontal sinus is(1.44 ±0.31)cm in length and(0.95 ±0.29)cm in width.(2)Gasification degree of frontal sinus: in left frontal sinus: 0 cases(0.0%),21 cases(21.0%)of grade I frontal sinus,49 cases(49.0%)of grade II frontal sinus and 30 cases(30.0%)of grade III frontal sinus.In right frontal sinus: 0 cases(0.0%)of undeveloped frontal sinus,47 cases(47.0%)of grade I frontal sinus,45 cases(45.0%)of grade II frontal sinus and 8 cases(8.0%)of grade III frontal sinus.(3)Frontal sinus gasification volume: the left frontal sinus volume of male was(4.52 ±2.08)ml,the right frontal sinus volume was(4.13±1.96)ml,the left frontal sinus volume of female was(2.68±1.76)ml,and the right frontal sinus volume was(2.52 ±1.82)ml.The difference was not statistically significant(P > 0.05).(4)Frontal sinus is the most susceptible cavity of nasal sinus to variation.The types of variation are complex and varied.The absence of frontal sinus and excessive frontal sinus are all abnormal frontal sinus development.There are some differences in frontal sinus structure and morphology among different individuals,and there are also some differences in frontal sinus on different sides of the same body.(5)The anatomical structure of frontal sinus image can accurately reflect the position,size,shape and variation of frontal sinus.By observing the image anatomy of frontal sinus and designing the surgical approach for anterior communicating artery aneurysm,the frontal sinus and surrounding tissues should be avoided as far as possible so as to reduce the complications of frontal sinus opening after operation.3.3D-Slicer software assisted precise clipping of anterior communicating artery aneurysms via frontolateral micro-bone window approach(1)There was no significant difference in basic information(age,sex ratio,aneurysmal diameter,aneurysmal orientation,etc.)(P > 0.05).(2)The operation time of aneurysmal the pterion approach group was(95.23±2.05)min,and that of the frontolateral micro-bone window approach was(55.18±3.12)min.The operation time of the frontolateral micro-bone window approach group was significantly shorter than that of the pterion approach group,with statistical significance(P < 0.05).(3)The amount of bleeding in the pterion group was(170.12±5.12)ml,while that in the frontolateral micro-bone window group was(61.81±4.28)ml,with statistical difference(P < 0.05).(4)The treatment cost of the patients in the pterion group was(6.28±1.15)million yuan,and that of the frontolateral micro-bone window group was(6.22±1.23)million yuan.There was no significant difference in the treatment cost between the two groups(P > 0.05).(5)The hospitalization time of the patients in the pterion group was(16.12 ±3.42)days,and that of the frontolateral micro-bone window group was(14.19 ±3.28).The hospitalization time of the frontolateral micro-bone window group was slightly shorter than that of the pterion group,and the difference was statistically significant(P < 0.05).(6)The frontal branch of the facial nerve injury occurred in 2 patients in the pterion group(6.6%)and 1 patient in the frontolateral micro-bone window group(3.3%).(7)Temporal muscle atrophy occurred in 1 patient in the pterion group,accounting for 3.3%.There was no temporal muscle atrophy in the frontolateral micro-bone window group.(8)There was no cerebrospinal fluid leakage in both groups.(9)The anterior communicating artery aneurysms of the two groups were successfully clipped,among them,one patient in the pterion group had intraoperative ruptured,and the operation was successfully completed after timely treatment;there was no aneurysm rupture in the frontolateral micro-bone window group,and the operation process was smoothly.(10)In the pterion group,there were 11 cases of postoperative complications,accounting for 36.7%.In the frontolateral micro-bone window group,there were 5 cases of postoperative complications,accounting for 16.7%.The incidence of complications in the frontolateral micro-bone window group was significantly lower than that in the pterion group,and the difference was significant(P < 0.05).(11)The incidence of complications in patients with Fisher grade III was significantly higher than that in patients with Fisher grade I/II,and the difference was significant(P < 0.05).(12)The overall good prognosis rate was 86.7% in the pterion group and 96.7% in the frontolateral micro-bone window group.The prognostic effect of the frontolateral micro-bone window group was significantly higher than that of the pterion group,and the difference was statistically significant(P < 0.05).Conclusion: The anatomic structure of anterior communicating artery aneurysm is complex,with deep location,multiple peripheral nerves and vessels.Clipped the aneurysm is difficult and has more complications,which serious threaten the patient't life.Frontolateral micro-bone window approach is a good approach with good anatomical exposure and less injury to the body.3D-Slicer is a powerful medical image processing software.By collecting CT data of anterior communicating artery aneurysm patients,a three-dimensional model of the complex of frontal sinus,sphenoid ridge and anterior communicating aneurysm complex can be reconstructed before operation.During the operation,the frontal sinus and important nerve vessels can be avoided effectively.It makes the intraoperative trauma less,the operation time shorter and the aneurysm clipping more accurate,which has higher clinical value.