| Objective: To study the spatial relationship between the aneurysms at the beginning(1 / 3 of the proximal part)of A1 segment of anterior cerebral artery and the main trunk of A1 segment,and to make clinical classification according to the relationship between the two,and to propose targeted treatment strategies for different clinical types of aneurysms;at the same time,toanalyze the clinical characteristics,imaging manifestations,treatment methods and methods of 47 patients with A1 segment of anterior cerebral artery The prognosis of neurological function and other indicators of patients were analyzed.Methods: From May 2014 to January 2020,47 patients with A1 segment(whole segment)aneurysms of anterior cerebral artery in neurosurgery of the secondhospital of Hebei Medical University were analyzed retrospectively.The basic information,imaging manifestations,clinical symptoms,treatment methods,postoperative complications and postoperative neurological prognosis of the patients were collected,and the imaging and clinical follow up of the patients were conducted for 3 months and 6 months.Based on the review of literature and case analysis,the treatment and prognosis were compared,and the factor of influencing the prognosis and death were analyzed.At the same time,according to the relationship between the spatial configuration of the aneurysm at the beginning of A1 and the parent artery,the aneurysm at this site was clinically classified.Results: 1.There were 47 patients with aneurysms of A1 segment(whole segment)of anterior cerebral artery.42 cases(89.4%)were treated by operation,19 cases(40.4%)by intravascular intervention,23 cases(48.9%)by microsurgical clipping,and 5 cases(10.6%)by conservative treatment.The average age was 54.1 ± 13.4 years old.There were 26 women(55.3%),21 men(44.7%),24 patients(51.1%)with hypertension,5 patients(10.6%)with type 2 diabetes,7 patients(14.9%)with coronary heart disease and 13 patients(27.7%)with multiple intracranial aneurysms.SAH was found in 33 cases(70.2%)and in 31 cases(65.9%)the rupture of A 1 segment aneurysm occurred.There were 2 cases of Hunt-Hess grade ?(4.3%),22 cases of grade ?(46.8%),5 cases of grade ?(10.6%),and 4 cases of grade ?(10.6%).The average diameter of aneurysms in A1 segment(whole segment)was 4.3 ± 4.5mm,the average diameter of aneurysm neck was 3.0 ± 1.1mm,the average diameter of ruptured aneurysms was 3.6mm,the average diameter of unruptured aneurysms was 5.7mm,and 4(8.5%)aneurysms with diameter > 7mm.The average angle between the beginning of A1 and the end of the internal carotid artery was 88.4o;the average angle between the beginning of A1 and the middle cerebral artery was 121.9o;the average distance between the aneurysm and the end of the internal carotid artery was about 2.1mm.The aneurysms of A1 segment(whole segment)were located in 22 cases(46.8%)on the left and 25 cases(53.2%)on the right.There were 13 cases(27.6%)of aneurysms with vascular abnormalities,among which 6 cases(46.2%)of contralateral A1 were absent,1 case was accompanied with anterior communicating window malformation,4 cases(30.8%)of contralateral A1 hypoplasia,1 case(7.7%)of distal end hypoplasia,1 case(7.7%)of severe stenosis near the end of aneurysms,and 1 case(7.7%)of arterial bifurcation variation of A1 segment with initial occlusion of ipsilateral middle cerebral artery.13 cases(27.7%)had aneurysms in other parts of the brain,8 cases had multiple aneurysms treated in one stage,5 cases only treated the responsible aneurysms.2.According to the spatial relationship between the aneurysm neck and the parent artery at the beginning of A1,there are five different types.Type I:the aneurysm neck is located in the posterior wall of the parent artery,the projecttion of the aneurysm to the rear,which is the most numerous type among all types.According to the projection direction of the aneurysm,it can be divided into two subtypes: type ?a: the projection of the aneurysm to the lower back;type ?b: the projection of the aneurysm to the upper back.Type ?: the aneury-smal neck is located in the superior wall of the parent artery,with the tumor projecting upward.Type ?: the aneurysmal neck is located in the anterior wall of the parent artery,with the tumor projecting to the front.Type ?: the aneurysmal neck is located in the inferior wall of the parent artery,with the tumor projecting downward.Type ?: spindle or large aneurysm.The cross section of the artery involved in the tumor neck is more than two quadrants.According to the prognosis of the patients,we think that endovascular treatment and microsurgical clipping can be used for type ? and type ? aneurysms.Endovascular treatment is recommended for type ? and microsurgical clipping is recommended for types IV and V.3.A1 shape can be divided into three types: type ?: anti horizontal "s" type;type ?: upper arc type("?" type);type ?: included angle type("?" type)or near linear type;Type ?A: acute angle type;type ?B: obtuse angle type;type ?c: flat angle type.The order of the ratio was ?B > ?> ? > ?A > ?c.All 24 aneurysms were located at or near the angle of the vessel.For type ? and type ?B,the projection direction of aneurysm is mainly backward,downward and upward;for type ?,all projections are backward,downward,backward,upward and downward;for Type ?A,all projections are upward;for type ?c,all projections are backward,upward and forward.4.Three months after discharge,the good prognosis rate was 85.1%(40 cases)and the mortality rate was 6.4%(3 cases).Compared with the neurological function at discharge,80.9%(38 cases)had no change,and 4.3%(2 cases)had improved neurological function.At 6 months after discharge,85.1%(40 cases)had no significant change compared with 3 months after operation,and the mortality rate was still 6.4%(3 cases).5.Six patients(12.8%)had poor prognosis of neurological function,and 41 patients(87.2%)had no change or benefit in neurological function.Single factor Logistic regression analysis showed that the patients with Hunt-Hess grade ?-?,IVH before operation,new hematoma after operation and hydrocephalus after operation were high risk factors for poor prognosis of neuro-logical function.Conclusions: A1 segment aneurysm of anterior cerebral artery is a rare aneurysm with low incidence,but it has its unique clinical characteristics.According to the spatial relationship between the aneurysm at the beginning of A1 and the parent artery,this paper divides them into five main clinical types.According to each clinical type,the treatment plan and strategy are also different.The relationship between aneurysm and carrier artery can be evaluated according to imaging before operation,so as to provide a more ideal treatment strategy for A1 segment initial aneurysm,reduce the occurrence of postoperative complications and improve the prognosis of patients. |
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