| Objective:1.To investigate the efficacy and safety of surgical treatment for anterior circulatory cerebral aneurysms;2.To investigate the safe time limit of temporary occlusion of parent artery during microclipping of internal carotid aneurysm;3.To explore the application value of intraoperative neuroelectrophysiological monitoring in cerebral aneurysm clipping.Methods:1.Part Ⅰ: The clinical data of 136 cases of anterior circulation cerebral aneurysm treated by neurosurgery department of Shiyan People’s Hospital from January2013 to August 2020 were retrospectively analyzed and compared.Collected variables associated with clinical outcomes,including age,sex,hypertension,smoking,ruptured aneurysms with unruptured aneurysms,single aneurysm with multiple aneurysms,and the size of the aneurysm,the location of the aneurysm patients admitted to hospital with Hunt-Hess classification(HH),Fisher classification on patients admitted to hospital,and whether to use neural electrophysiological monitoring,etc.Among them,the Endeavor CR neuroelectrophysiological monitoring system was used for intraoperative monitoring.SEP and MEP were monitored respectively.The scalp electrode placement followed the principles of EEG 10-20.Clinical outcomes,treatment outcomes,and mortality were assessed after treatment by the same surgical and nursing teams.Clinical outcomes were assessed using the modified Rankin Scale(m RS).Treatment outcomes included postoperative DSA or CTA review,whether the patient’s aneurysm was completely clipped,and whether radiographic or clinical ischemic events occurred.2.Part Ⅱ: The clinical data of 36 patients with internal cervical system aneurysm who underwent surgical treatment in the Department of Neurosurgery of Shiyan People’s Hospital from September 2018 to August 2020 were retrospectively analyzed and compared.Temporary occlusion of the internal carotid artery and electrophysiological onitoring were performed in all the included cases.The time,mode and location of temporary occlusion of the tumor carrier artery during the operation were recorded in detail,as well as the amplitude and latency changes of the electrophysiological monitoring waveform.Patients were divided into two groups according to the location of tumor parent artery occlusion:proximal parent artery occlusion group and proximal and distal parent artery occlusion group.According to the way of occlusion,patients were divided into two groups:continuous occlusion group and intermittent occlusion group.Clinical outcomes included reexamination of the brain with CT on the 7th day after surgery to observe the occurrence of delayed cerebral ischemia,and a modified m RS scale to assess the patient’s prognosis.The therapeutic effect was mainly DSA or CTA review after surgery to observe the effect of aneurysm neck clipping.Results:1.Comprehensive analysis showed that 103 patients(75.7%)had good prognosis after operation.83(72.2%)patients with ruptured aneurysm and 20(95.2%)patients with unruptured aneurysm(P<0.05).Imaging ischemia or clinical ischemia events occurred in 47 patients(34.6%),which had a statistically significant impact on the long-term prognosis of patients(P=0.001).At the same time,advanced age,larger aneurysm diameter and simultaneous clipping of multiple aneurysm were also risk factors for poor prognosis(P<0.05).2.Postoperatively,90 patients underwent DSA or CTA,of which 80 patients(88.9%)presented complete occlusion of the aneurysm and 10 patients(11.1%)presented residual aneurysm.The only statistically significant factor associated with complete clipping of aneurysm was aneurysm size(P=0.001).3.For patients with unruptured aneurysms,none of the factors had a statistically significant effect on poor outcome.For patients with ruptured aneurysms,aneurysm diameter at admission,HH grade,and Fisher grade were significantly associated with study outcomes in univariate analysis.Multivariate analysis showed that only HH grade and Fisher grade on admission were independent influencing factors for poor prognosis.4.There was no statistically significant difference in mortality between the two groups.The postoperative mortality of large-diameter aneurysms was higher than that of small-diameter aneurysms,and the difference was statistically significant(P=0.004).5.Among the 59 patients in the intraoperative neuroelectrophysiological monitoring group,1 special case of unruptured aneurysm death was excluded,with a mortality rate of 5.2%(3 patients),and 77 patients in the non-monitoring group,with a mortality rate of 16.9%(13 patients),the difference being statistically significant(P<0.05).There was also a reduction in the incidence of poor outcomes in the intraoperative monitoring group(28.6% vs 17.2%),but this difference was not statistically significant.In the monitoring group,16 cases(27.1%)had abnormal SEP,of which 12 cases(20.3%)recovered the waveforms during or after operation,and 4 cases(6.8%)did not recover the waveforms until the end of operation.Abnormal MEP occurred in 6 cases(10.2%),and none of them recovered after operation.No patients with both abnormalities were found.Finally,10 patients(16.9%)had cerebral ischemia events after surgery,and the prognosis was poor at discharge(m RS≥3),the difference was statistically significant(P<0.05).6.The intraoperative occlusion time of tumor parent artery was 2-18 min,with an average of(7.6±3.5)min.Thirty-four patients(94.4%)had aneurysm neck completely clipped,and 30 patients(83.3%)had good prognosis after surgery.The only factor that was statistically significant with or without complete clipping of the aneurysm neck was aneurysm size(P=0.005).7.There were 10 patients(27.8%)with abnormal electrophysiological signals of internal carotid artery temporarily occlusion during operation,and the duration of occlusion was all greater than 8min.There were 7 cases(70.0%)with abnormal SEP,4cases(40.0%)with abnormal SEP returned to normal after temporary occlusion,and the remaining 3 cases(30.0%)still did not recover until the end of operation.3 cases(30.0%)had abnormal MEP and did not recover after operation.Finally,6 patients(60.0%)developed delayed cerebral ischemia,and 5 patients(50.0%)had poor prognosis after discharge(m RS≥3),the difference was statistically significant(P<0.05).8.The time of temporary occlusion of internal carotid artery is closely related to delayed cerebral ischemia and poor prognosis after surgery.The time of temporary occlusion of internal carotid artery less than 8min can guarantee the safety of surgery.Different internal carotid artery occlusion sites and methods have no statistical difference in the occurrence of delayed cerebral ischemia after operation.Conclusion:1.Surgical treatment of anterior circulatory cerebral aneurysms is safe and effective.Ruptured aneurysms have a worse prognosis than unruptured aneurysms,and the only factor associated with complete clipping of the aneurysm is aneurysm size.None of the factors studied predicted poor outcomes for unruptured aneurysms.High HH grade and high Fisher grade on admission were independent risk factors for poor prognosis of ruptured aneurysms.2.Temporary occlusion of the internal carotid artery was beneficial to complete clipping of the aneurysm neck.The time of temporary occlusion is closely related to the occurrence of delayed cerebral ischemia and poor prognosis after surgery.The time of temporary occlusion is less than 8min,which can guarantee the safety of surgery.There was no statistical difference in the delayed cerebral ischemia in patients with different blocking sites and methods.3.Neuroelectrophysiological monitoring in intracranial aneurysm microclipping can reduce the incidence of delayed cerebral ischemia,improve the prognosis of patients,and provide an effective reference for the safe time limit of intraoperative temporary occlusion of tumor parent artery.Among them,combined intraoperative monitoring of SEP and MEP and irreversible abnormal MEP waveforms are more effective in predicting poor prognosis. |
PDF Full Text Request