| BackgroundAn intracranial aneurysm is a weakness in the wall of an artery that causes bulging or outpouching of an intracranial blood vessel wall. It is the leading cause of subarachnoid hemorrhage (SAH) and the third etiological factor in cerebral vascular disease (CVD). Both estimated initial mortality and disable rate after aneurysmal rupture varies from22%-25%and shows a rising tendency. It is demonstrated that15%-20%of patients with ruptured aneurysms died at the first bleeding. The mortality would rise up to75%-85%in case of inappropriate treatment or delay. Half of the patients may be disabled with different extent. Patients with unruptured intracranial aneurysms often have no symptoms and some present with focal symptoms such as oculomotor nerve paresis (ONP).With the continuous development of interventional material and technology, endovascular treatment has become the first treatment method of intracranial aneurysms. Because of minimal invasion, endovascular treatment has been accepted by more and more neurosurgeons and patients with intracranial aneurysms. With the performance improvement of radiological device, microcatheter, guide wire and coil and development of embolization technique, the safety of endovascular treatment has been enhanced very much. However, the risk is not evitabled for interventional treatment of intracranial aneurysms. The total complication rate is8%-10%and some patients were disabled or dead. It is still an important issue to enhance the efficacy and safety of endovascular treatment of intracranial aneurysms.Intraoperative rupture of aneurysms and thromboembolic events are two severe complications of coiling of intracranial aneurysms, which have high rate of disability and death. Thus, active prevention and management is crucial. Risk factors of the two complications have been reported in previous literature, but the results were different. It is important to clarify further risk factors and enhance capability of prevention of complications.Studies reported that the recurring rate of intracranial aneurysms is relatively high after embolization, and that aneurysmal recanalization is related to aneurysmal embolization degree, the lower degree, the more recanalization. It is necessary to enhance the degree of aneurysm embolization in order to improve long-term efficacy of intracranial aneurysms. Understanding effect factors related to the degree of aneurysm occlusion and proper assessment before coiling are important. However, the knowledge about effect factors related to the degree of aneurysm occlusion is limited at present, and larger studies are required to adequately assess the outcome.Oculomotor nerve paresis (ONP) is one of the clinical presentations associated with posterior communicating artery (PcomA) aneurysms. Direct mechanical compression or irritation by the aneurysms may result in partial or complete dysfunction of oculomotor nerve. Endovascular embolization is a minimal invasive treatment of intracranial aneurysms, and the efficacy has been reported in some literature. However, the number of patients included in each series reported in the literature was limited, and the results were also different. Larger series is still needed for further evaluation about the efficacy and effect factors of endovascular treatment of aneurysm-induced oculomotor nerve paresis. Based on the problems mentioned above, and also to provide evidence and guidance for future treatment, the cases with intracranial aneurysms which were treated with endovascular treatment in our department in recent8years were analyzed. The study includes4sections:Efficacy evaluation of endovascular treatment of intracranial aneurysms (Section I); Clinical analysis of complications related to endovascular treatment of ruptured intracranial aneurysms (Section II); Analysis of effect factors of immediate angiographic results after embolization of intracranial aneurysms (Section III); Efficacy analysis of endovascular treatment of posterior communicating artery aneurysm-induced oculomotor nerve paresis (Section Ⅳ).Section I Efficacy evaluation of endovascular treatment of intracranial aneurysmsObjective The purpose of this section was to summarize our experience with endovascular treatment of intracranial aneurysms, to analyze clinical and radiological outcome, the rate of complications related to endovascular treatment and aneurysmal recurring rate, and to investigate the efficacy and safety of endovascular treatment of intracranial aneurysms.Methods We retrospectively analyzed the records of patients with intracranial aneurysms treated with endovascular treatment in Neurosurgical Department of Southern Medical University Zhujiang Hospital between January2003and December2010. Following data were recorded:gender, age, history of hypertention, history of diabetes, history of smoking, atherosclerosis of intracranial artery, Hunt-Hess grade, aneurysm size, aneurysm location, feature of aneurysmal neck, vasospasm, complications (intraoperative rupture of aneurysms, thromboembolic events, device-related problems), the degree of aneurysm occlusion, clinical evaluation at discharge, radiological and clinical outcome at follow up. The records above were made into SPSS data which were summarized and analyzed to evaluate the total efficacy. Radiological outcomes at follow up were also compared according to different immediate radiological outcome after aneurysmal embolization. Statistical analysis was performed with the SPSS statistical package (SPSS13.0). A value<0.05was considered statistical significant.Results A total of720patients were included in this study. Of them,409(56.8%) were women and311(43.2%) were men. The mean age of the patients was51.2±8.4years. Hunt-Hess grade on admission was as follow:0108cases (15.0%), Ⅰ-Ⅲ576cases (80.0%), Ⅳ-Ⅴ36cases (5.0%). A total of752aneurysms were treated, and670aneurysms (89.1%) were located in the anterior circulation and82(10.9%) in the posterior circulation. According to aneurysm size, the aneurysms were classified as: tiny aneurysms57(7.6%), small617(82.0%), large72(9.6%), giant6(0.8%). Intraoperative rupture of aneurysms occurred in25patients (3.5%), thromboembolic events in35patients (4.9%), and device-related problems in22patients (3.1%). Evaluation of the postoperative radiological results indicated complete occlusion in364aneurysms (48.4%), neck remnant in223aneurysms (29.7%), and aneurysm remnant in165aneurysms (21.9%). Clinical evaluation at discharge indicated good (MRS,0-2) in640patients (88.9%), bad (MRS,3-6) in80patients (11.1%), and death (MRS,6) in33patients (4.6%). Follow-up angiograms (mean,10months; range,6months to5years) were obtained in502aneurysms (70.5%). Of them,369aneurysms (73.5%) demonstrated stablility,84aneurysms (16.7%) demonstrated recanalization,49aneurysms (9.8%) demonstrated progressive thrombosis. The degree of aneurysm occlusion was associated with aneurysmal recanalization (χ2=92.224, P=0.000), and complete occlusion was less subjected to recanalization. Clinical follow-up outcome (mean,18months; range,1months to5years) was as follow:good in500patients (74.3%), bad in35patients (6.5%), and death in6 patients (0.8%).Conclusions Endovascular treatment of intracranial aneurysms was safe and effective. Aneurysms treated with embolization remained a certain rate of recanalization. The degree of aneurysm occlusion was associated with aneurysmal recanalization, and complete occlusion was less subjected to recanalization.Section II Clinical analysis of complications related to endovascular treatment of intracranial aneurysmsObjective Intraoperative rupture of aneurysms and thromboembolic events are two severe complications of coiling of intracranial aneurysms, which have high rate of disability and death. The purpose of this section was to analyze risk factors of the two complications, to explore techniques for prevention and treatment of the complications, so as to guide clinical treatment of intracranial aneurysms.Methods We retrospectively analyzed the records of patients with ruptured intracranial aneurysms treated with coiling in Neurosurgical Department of Southern Medical University Zhujiang Hospital between January2003and December2010. Following data were recorded:gender, age, history of hypertention, history of diabetes, history of smoking, atherosclerosis of intracranial artery, Hunt-Hess grade, aneurysm size, aneurysm location, feature of aneurysmal neck, vasospasm, the timing of endovascular treatment after SAH, modality of treatment, the degree of aneurysm occlusion, and complications (intraoperative rupture of aneurysms, thromboembolic events). The data above were investigated in univariate analysis and multivariate logistic regression model to determine whether they were associated with complications of aneurysmal coiling. Statistical analysis was performed with the SPSS statistical package (SPSS13.0). A value<0.05was considered statistical significant. Results A total of578patients with578ruptured aneurysms were included in this study. Of them,326(56.4%) were women and252(43.6%) were men. The mean age of the patients was51.4±8.6years. Hunt-Hess grade on admission was as follow:Ⅰ-Ⅲ543cases (93.9%), IV-V35cases (6.1%). A total of578ruptured aneurysms were coiled, and518aneurysms (89.6%) were located in the anterior circulation and60(10.4%) in the posterior circulation. According to aneurysm size, the aneurysms were classified as:tiny aneurysms42(7.3%), small477(82.5%), large59(10.2%). Intraoperative rupture of aneurysms occurred in20patients (3.5%), thromboembolic events in30patients (5.2%). Univariate analysis indicated that atherosclerosis (P=0.008), aneurysm size (χ2=16.009, P=0.000), vasospasm (P=0.004) were effect factors of intraoperative rupture of aneurysms. Multivariate logistic regression analysis indicated that atherosclerosis (OR,3.789;95%CI,1.288-11.146; P=0.016), tiny aneurysm (OR,6.852;95%CI,1.176-39.923; P=0.032), vasospasm (OR,3.293;95%CI,1.257-8.628; P=0.015) were independent risk factors of intraoperative rupture of aneurysms. Univariate analysis indicated that history of smoking (x2=6.386, P=0.011), aneurysm size (x2=9.673, P=0.008), feature of aneurysmal neck (x2=18.728, P=0.000), vasospasm (x2=7.285, P=0.007), modality of treatment (x2=34.139, P=0.000) were effect factors of thromboembolic events. Multivariate logistic regression analysis indicated that history of smoking (OR,5.134;95%CI,1.789-14.734; P=0.002), wide-neck aneurysm (OR,3.440;95%CI,1.189-9.948; P=0.023), vasospasm (OR,2.711;95%CI,1.176-6.251; P=0.019), balloon-assisted embolization (OR,5.743;95%CI,1.424-23.156; P=0.014) were independent risk factors of thromboembolic events.Conclusions Atherosclerosis, tiny aneurysm, vasospasm were independent risk factors of intraoperative rupture of aneurysms. Once intraoperative rupture of aneurysms happened, it was crucial to reverse immediately heparin anticoagulation with protamine sulfate and complete aneurysmal coiling quickly and accurately. The history of smoking, wide-neck aneurysm, vasospasm, balloon-assisted embolization were independent risk factors of thromboembolic events. Careful observation was necessary during and after coiling, and it was important to apply actively thrombolytic and anticoagulation therapy once thromboembolic events happened.Section HI Analysis of effect factors of immediate angiographic results after embolization of intracranial aneurysmsObjective Aneurysmal recanalization is related to aneurysmal occlusion degree, and total occlusion may decrease the rate of aneurysmal recurrence after treatment. The purpose of this section was to analyze effect factors associated with immediate angiographic results of intracranial aneurysms after endovascular coiling, so as to provide theoretical evidence and guidance for clinical treatment.Methods We retrospectively analyzed the records of patients with intracranial aneurysms treated with coiling in Neurosurgical Department of Southern Medical University Zhujiang Hospital between January2003and December2010. Each aneurysm was analyzed as an independent unit. Following data were recorded:gender, age, history of hypertention, history of diabetes, history of smoking, atherosclerosis of intracranial artery, aneurysm rupture status, aneurysm size, aneurysm location, feature of aneurysmal neck, aneurysm shape, vasospasm, modality of treatment, degree of aneurysm occlusion (complete occlusion and incomplete occlusion). The data above were investigated in univariate analysis and multivariate logistic regression model to determine whether they were associated with the degree of aneurysm occlusion. Statistical analysis was performed with the SPSS statistical package (SPSS13.0). A value<0.05was considered statistical significant.Results A total of712cases were included in this study. Of them,411(57.7%) were women and301(42.3%) were men. The mean age of the patients was51.2±8.5years. Six hundred and thirty-four aneurysms (89.0%) were located in the anterior circulation and78(11.0%) in the posterior circulation. According to aneurysm size, the aneurysms were classified as:tiny aneurysms50(7.0%), small595(83.6%), large67(9.4%). There were453narrow-neck aneurysms (63.6%) and259wide-neck aneurysms (36.4%). Five hundred and forty-nine aneurysms (77.1%) were regular and163ones (22.9%) were irregular. There were134unruptured aneurysms (18.8%) and578ruptured aneurysms (81.2%). The modalities of treatment were as follow: embolization with coil only in586aneurysms (82.3%), stent-assisted coil embolization in105aneurysms (14.7%), balloon-assisted coil embolization in21aneurysms (2.9%). Postoperative angiography indicated that complete occlusion were achieved in338aneurysms (47.5%) and incomplete occlusion in374aneurysms (52.5%). Univariate analysis indicated that aneurysm size (x2=18.886, P=0.000), the feature of aneurysmal neck (x2=9.688, P=0.002), aneurysm shape (x2=9.637, P=0.002), aneurysm rupture status (x2=11.146, P=0.001) were effect factors of immediate occlusion results after endovascular treatment. Multivariate logistic regression analysis indicated that ruptured aneurysm (OR,0.514;95%CI,0.345-0.768; P=0.001), tiny aneurysm (OR,4.628;95%CI,1.948-10.996; P=0.001), wide-neck aneurysm (OR,0.346;95%CI,0.221-0.542; P=0.000), regular-shape aneurysm (OR,1.861;95%CI,1.275-2.714; P=0.001), stent-assisted embolization (OR,3.665;95%CI,2.095-6.412; P=0.000), balloon-assisted embolization (OR,3.593;95%CI,1.367-9.438; P=0.009) were independent effect factors of complete occlusion of intracranial aneurysm treated with endovascular treatment.Conclusions Aneurysm rupture status, aneurysm size, the feature of aneurysmal neck, aneurysm shape, modalities of treatment were independent effect factors of immediate angiographic results of intracranial aneurysm after coiling. Unruptred aneurysm, tiny aneurysm, narrow-neck aneurysm, regular-shape aneurysm, stent-assisted coiling, and balloon-assisted coiling were more probable to be occluded completely.Section Ⅳ Efficacy analysis of endovascular treatment of posterior communicating artery aneurysm-induced oculomotor nerve paresisObjective Recovery of aneurysm-induced oculomotor nerve paresis (ONP) after endovascular coiling has not yet been adequately assessed. The aim of this section was to investigate the recovery of ONP and the factors that affect the outcome of ONP after endovascular treatment of posterior communicating artery (PcomA) aneurysms.Methods We retrospectively analyzed the records of patients with ONP due to PcomA aneurysms treated by endovascular coiling in Neurosurgical Department of Southern Medical University Zhujiang Hospital between January2003and December2010. Following data were recorded:gender, age, degree of preoperative ONP (complete and partial), length of ONP before treatment, aneurysm rupture status, aneurysm size, aneurysm location, feature of aneurysmal neck, modality of treatment, degree of aneurysm occlusion, recovery of oculomotor nerve function. The data above were investigated in univariate analysis to determine whether they were associated with recovery of oculomotor nerve function. Statistical analysis was performed with the SPSS statistical package (SPSS13.0). A value<0.05was considered statistical significant.Results A total of36patients with36aneurysms were included in this study. Of them,20(55.6%) were women and16(44.4%) were men. The mean age of the patients was54.3±9.0years. Ruptured aneurysms were present in21cases (58.3%) and unruptured aneurysms in15cases (41.7%). The mean size of the aneurysms was 9.3±3.9mm. ONP was complete in14patients (38.9%) and partial in22patients (61.1%) on admission. The mean time from symptom occurrence to endovascular treatment was38days, ranging between1and147days. The mean time of follow-up was15months, ranging between3and36months. Seventeen patients (47.2%) had complete recovery of oculomotor nerve function,15had incomplete recovery (41.7%), and4(11.1%) remained unchanged after treatment. Factors showing significant association with recovery of oculomotor nerve function were the length and degree of ONP before treatment (P=0.035and P=0.019, respectively).Conclusions Endovascular coiling of PcomA aneurysms in patients with ONP resulted in cure or improvement of oculomotor nerve dysfunction in the majority of patients. The length and degree of preoperative ONP were statistically associated with ONP recovery, and patients with partial paresis of oculomotor nerve dysfunction and short length of preoperative ONP were more probable to obtain complete ONP recovery after treatment. |
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