The Treatment Of Intracranial Ruptured Microaneurysms

Objective:This study aims to investigate the times of treatment, therapeutic methodsand prognostic factors of intracranial ruptured microaneurysms through aretrospective analysis of clinical cases, which would provide reference andbasis for future clinical treatment.Methods:1Case sources: From February,2013to February,2014,156patientswith aneurismal subarachnoid hemorrhage were analyzed in the east branch ofthe Second Hospital of Hebei Medical University, including35microaneurysms patients, and a total of44aneurysms patients,4microaneurysm patients without undergoing treatment during hospitalizationas well as six microaneurysms. For the rest31cases, data and informationwere collected on admission in terms of gender, age, location, neck width,GCS score, aneurysm size, Hunt-Hess grade and fisher classification. Besides,this study also investigated whether these patients have a history ofhypertension and coronary heart disease, accompanied with vascular stenosis,had an aneurysm treatment, timing of surgery and perioperative complications,GOS score and radiographic follow-up. All data were registered one by one tocreate an Access database.2The criteria of case inclusion:①The medical history, imaging data orreceived lumbar puncture confirmed that these patients have spontaneoussubarachnoid hemorrhage on admission.②Cranial CTA or3D-DSAconfirmed that SAH was caused by ruptured aneurysm after admission,instead of reasons such as traumatic subarachnoid hemorrhage, pseudoaneurysm, arteriovenous malformation, Moyamoya disease or Moyamoyasyndrome, arteriovenous fistula, etc.③Imaging data showed that the diameterof aneurysms should be3mm or less, patients with either single or multiple aneurysms, may be accompanied with other types of aneurysm or stenosisapart from microanerurysm.④Treatment of microaneurysms should includemicroscopic clipping or interventional embolization. Whoever met the criteriaabove can be diagnosed as small-ruptured intracranial aneurysms, thus couldbe included in the study.3Data descriptions and statistics: The results were expressed asmean±standard deviation (±s); count data was showed as constituent ratio orrate by adopting the chi-square test or Fisher’s exact test, and the relationshipbetween various factors and prognosis was obtained by the bivariatecorrelation analysis. The above clinical data were statistically analyzed bySPSS13.0software, in which the size of test was0.05.Results:1Age and genderThe ages of the31patients ruptured intracranial small aneurysms rangefrom31to77(mean55.19±9.81). Among them,18cases, more than half ofwhich (58.06%), are aged between40to60years. Thus it is possible that thisage group has the high risk of suffering from microaneurysms. With regard togender, there were9male cases (29.03%) and22females (70.97%),15ofwhich are over the age of50. It indicates that changes in hormone levels may,to a certain extent, affect the formation of the microaneurysms. There was nostatistical significance between two groups of patients in terms of age andgender (P>0.05).2Conditions of aneurysm and its concomitant diseasesThere are33cases with internal carotid artery (86.84%),5cases withvertebral-basilar artery (13.16%); The average diameter of aneurysms is2.31±0.67mm, the average width of the aneurysm neck2.06±0.82mm, thenumber of wide-necked aneurysms29(76.32%);16cases with hypertension(51.61%),4cases with diabetes mellitus (12.90%),2cases with coronary heartdisease (6.45%),7cases with pernicious habits of smoking, drinking and so on(22.58%). There was no statistical significance between two groups in termsof locations, diameters, neck ratio of aneurysms, and the history of concomitant diseases (P>0.05).3Preoperative fisher and Hunt-Hess gradeAccording to preoperative fisher,14cases were graded I~II Class(45.16%),17cases III~IV (54.84%); According to Hunt-Hess Category,26cases got1to2scores (80.65%),5cases3to5scores (19.35%).18caseswere treated with endovascular embolization (embolization group),13caseswith microsurgical clipping (clipping group). There was no statisticalsignificance between preoperative fisher classification and the Hunt-Hessgrade in the two groups (P>0.05).4Timing of treatment, perioperative complications and the time inhospital19cases underwent surgery within24hours (61.29%),21cases within3days (67.74%),10cases more than3days (32.26%). As for perioperativecomplications,4cases suffered bleeding (12.90%),5cases were ischemic(16.13%),8cases had a delayed cerebral vasospasm (25.81%),1patientMODS (3.23%),1case suffered intracranial infection (3.23%),15cases hadlung infection (48.39%),19cases hypoalbuminemia (61.29%), and2casesseizures (6.45%). There was no statistical significance between the two groupsin terms of timing of treatments and incidence rates of complications(P>0.05).Neither was there any statistical significance about the average time inhospital between the intervention groups (12.94±10.51) and the clipping group(21.38±18.31)(P>0.05).5Prognosis and follow-upsTaking1.5mm microaneurysms as a standard, patients were divided intotwo groups: the diameter of <1.5mm group and the diameter of1.5~3mmgroup. Their rates of favorable prognosis (GOS4~5scores on discharge) were0%and76.92%respectively, and P<0.05. The prognosis resulted in twogroups had statistical significances. Following the standard of the aneurysmneck/tumor diameter of0.5, patients were divided into two groups: one withwide-necked aneurysms (neck/tumor>1/2) and the other with narrow-neckedaneurysms (neck/tumor<1/2). Their rates of favorable prognosis (GOS4~5 scores on discharge) were59.09%and66.67%respectively, and theirprognosis results in two groups had no statistical difference (P>0.05). Formicroaneurysm patients with narrow or embryonic posterior cerebral artery,their prognosis also had no statistical significance (P>0.05). The rates offavorable prognosis (GOS4~5points on discharge) in the Stent-assistedinterventional embolization group and the general embolization group were71.43%and81.82%respectively, which has no significant difference (P>0.05).The Embolization group and Clipping group immediately got postoperativeGOS score and their rates of favorable prognosis (GOS4~5) were72.22%and23.08%respectively, and they had a statistical significance (P<0.05). Ondischarge, the rates of favorable prognosis of the Embolization group and theClipping group (GOS4~5scores) were77.78%and23.08%, and they had astatistical significance (P<0.05). Patients were followed up for2to24months,19of which were followed up after three months. Their rates of favorableprognosis (GOS4~5scores) were respectively80.00%and55.56%, and theyhad no statistical significance (P>0.05). Six cases were followed up byimaging, CTA and DSA tests showed no evidence of recurred and enlargedaneurysm, and head CT tests indicate that subarachnoid hemorrhage wasabsorbed completely.6Related factors of prognosisPreoperative Hunt-Hess grade were correlated with GOS score negatively,Rs1=-0.500, P1<0.01. The higher preoperative Hunt-Hess grade was, thelower GOS score was, and the worse the prognosis was; fisher grading wasnegatively correlated with GOS score, Rs2=-0.539, P2<0.01, which meansthat the higher Preoperative fisher grade was, the lower GOS score was, theworse the prognosis was. In contrast, preoperative GCS score was positivelycorrelated with GOS score, Rs3=0.505, P3<0.01, the higher preoperativeGCS score was, the higher GOS score was, and the better the prognosis was.Age and timing of surgery were not significantly correlated with postoperativeGOS score (P>0.05). Conclusion:The age group of40to60years may be a high-risk stage when peoplemay suffer microaneurysms. To a certain extent, changes in hormone levelswould affect the formation of the microaneurysms. Furthermore, prognosis hasno shown connection with the width of aneurysm neck, whether patients areaccompanied with stenosis and fetal PCA or not, whether apply stents tointraoperative or whether it is multiple or single. Patients with diameter ofaneurysm between1.5~3.0mm have better prognosis than those withdiameter<1.5mm. If interventional embolization and microsurgical clippingsurgery are appropriate, embolization is recommended because its prognosis isbetter in the near future. Moreover, the preoperative fisher classification andHunt-Hess grade have a negative correlation with the prognosis, whereas thehigher the preoperative GCS score and the prognosis are correlated positively.