Surgical Procedures For Aneurysmal Subarachnoid Hemorrhage And Influential Factors Of Aneurysmal Occlusion:a Retrospective Study Of 434 Cases In A Single-Center

Objective To discuss the different surgical procedures for patients with aneurysmal subarachnoid hemorrhage, compare their prognosis, surgical complications, residual aneurysm and recanalization rate and analyze the influential factors.Methods A retrospective analysis was carried out on consecutive 434 cases of patients with aneurysmal subarachnoid hemorrhage who were treated in Neurosurgery of The First Affiliated Hospital of Guangxi Medical University between January 2008 and December 2013. The patients were divided into aneurysm clipping group (n=178) and endovascular embolization group (n=256) according to the surgical procedures. Analysis was carried out on Hunt-Hess classification, Fisher grades, the size and site of the aneurysm, aneurysmal neck characteristics, vasospasm, surgical complications, the degree of aneurysm occlusion, decompressive craniectomy rate, incidence of hydrocephalus, clinical evaluation at discharge, and radiographic and clinical follow-up results. Multivariate analysis was performed on factors that may influence clipping and embolism effects.Result For patients in clipping group,124 patients (69.66%) had favorable prognosis,54 patients (30.33%) had poor prognosis while 7 patients (3.93%) died at discharge; 45 patients (25.28%) appeared hydrocephalus postoperatively; 10 patients (5.61%) were with residual aneurysm,1 patient (0.74%) recurrent hemorrhage after surgery and 3 patients (2.22%)had aneurysms recurrence. For patients in embolization group,180 patients (70.31%) had good clinical evaluation,76 patients (29.69%) had poor prognosis while 8 patients (3.13%) died; 47 patients (18.35%) had non-dense embolization,79 patients (30.85%) appeared hydrocephalus postoperatively; 10 patients (7.52%) recurrent hemorrhage after operation and 42 patients (31.57%) had aneurysms recurrence. There were no differences between clipping and embolization group in GOS scores (P=0.884). Hunt-Hess grade had significant effects on GOS scores (P=0.000). Postoperative recurrent hemorrhage, residual aneurysm and recanalization rate and incidence of hydrocephalus were lower in aneurysm clipping group than embolization group. A total of 44 patients were undergone decompressive craniectomy. There were statistically significant differences between GOS groups, Hunt-Hess grade groups, and Fisher grade groups in decompressive craniectomy rate.Angiography or CTA after neurosurgical clipping showed in this study that: 168 aneurysms (94.38%) were completely clipped; 135 cases were followed up within 3-6 months after operation; among 10 cases with residual aneurysm,1 case recurrent hemorrhage (died), and 3 cases had recurrence of aneurysm. Univariate analysis showed brain atrophy (P=0.899), the size (P=0.156) and site (P=0.210) of the aneurysm, aneurysm neck characteristics (P=0.971), aneurysm neck perforators (P=0.232), intracranial atherosclerosis (P=0.990), intraoperative rupture (P=0.729), application of multiple permanent aneurysm clip (P=0.577) were not the influence factors for occlusion effects of aneurysm. And multivariate analysis showed Fisher grade (P=0.0091), cerebrospinal fluid drainage (P=0.0103), the application of intraoperative temporary vessel occlusion (P<0.0001) and intraoperative fluorescence angiography (P=0.0363) were the independent influence factors for complete occlusion of aneurysm.Postoperatively immediate radiography showed 217 aneurysms (82.19%) reached dense embolization while 47 aneurysms (17.8%) were with non-dense embolization in endovascular embolization group. One hundred and thirty-three cases were followed up within 3-6 months after embolization. Among 86 cases with dense embolization, no case recurrent hemorrhage. All 47 cases of non-dense embolization were followed up, ten cases (7.52%) recurrent hemorrhage and 8 cases further thrombosis in 39 cases recurred aneurysm. Univariate analysis showed site (P=0.114) of the aneurysm, vascular spasm (P=0.283), intraoperative aneurysm rupture (P=0.664), aneurysm neck characteristics (P=0.835) and Hunt-Hess grade (P=0.106), were not the influence factors for dense embolization. And multivariate analysis showed small aneurysms (P<0.001), saccular artery aneurysms (P=0.0003), and stent assisted embolism (P=0.0046) were independent factors for embolization of intracranial aneurysms.Conclusions 1. Both of the two treatments are effective for intracranial aneurysm. There are no statistically significant differences between the two groups in GOS scores. All the clinical and morphological factors should be considered to design individual-based treatment.2. Postoperative recurrent hemorrhage, residual aneurysm and recanalization rate and incidence of hydrocephalus are lower in aneurysm clipping group than embolization group.2. Patients at Hunt-Hess Ⅰ-Ⅲ have relatively favorable GOS scores, while patients at Hunt-Hess Ⅳ-Ⅴ have poor prognosis. Poor grade of Hunt-Hess is often accompanied with high grade of Fisher. When the patients with poor grade of Hunt-Hess are companied with larger brain hematoma (supratentorial hematoma volume≧30ml, subtentorial hematoma volume≧10ml), decompressive craniectomy single or combined with cerebrospinal fluid drainage is needed.4. Brain atrophy, intracranial atherosclerosis, the size and site of the aneurysm, aneurysm neck characteristics, aneurysm neck perforators, intraoperative rupture are not directly associated with the clipping effects of aneurysm; Fisher grade, cerebrospinal fluid drainage, the application of intraoperative temporary vessel occlusion and intraoperative fluorescence angiography are the independent influence factors for complete occlusion of aneurysm. Hematoma removal, unobstructed cerebrospinal fluid drainage, and intraoperative temporary vessel occlusion are conducive to complete clipping of aneurysm.5. Site of the aneurysm, aneurysm neck characteristics, vascular spasm, intraoperative aneurysm rupture and Hunt-Hess grade are not directly associated with the embolization of aneurysm; while aneurysmal morphology, the size of the aneurysm and embolization treatment methods are independent influence factors of dense embolization of aneurysm. Saccular artery aneurysms, small aneurysms and stent assisted embolism are conducive to dense embolization of aneurysm.