Clinical Study Of Microsurgical Treatment Of Intracranial Aneurysms

Intracranial aneurysm is the abnormal outward bulging of intracranial arterial wall,which is the main causes of SAH(subarachnoid hemorrhage).With the upgrade of surgical microscope and microscopic instrument of neurosurgery,as well as the improvement of the concept and technique of treatment,the therapeutic effect of microsurgical clipping of aneurysm has been further improved.However,some patients will develop to chronic shunt dependent hydrocephalus;the therapeutic effects of some relatively rare intracranial aneurysms,such as multiple aneurysms,blood blister-like aneurysm,need further improvement.Based on some problems existing in microsurgical treatment of intracranial aneurysms,1534 intracranial aneurysm patients in this study which was treated by microsurgery clipping operated from October 1996 to December 2015 were retrospective analyzed,which provided diagnosis basis and guidance for future diagnosis and treatment.The study was divided into four parts:PART?:the clinical data of 1534 cases of intracranial aneurysms were analyzed;PART?:discussed the effect of intraoperative fenestration of lamina terminalis combined with effective drainage of cerebrospinal fluid(CSF)on chronic shunt dependent hydrocephalus;PART ?:discussed the advantages and technical feasibility of clipping of the contralateral aneurysm through another side;PART ?:explored the new method of microsurgery in the treatment of blood blister-like aneurysm.PART? Clinical analysis to the clinical data of 1534 cases of intracranial aneurysmsObjective: To summarize the experience of microsurgical treatment of intracranial aneurysms.In this study,we analyzed of the gender,age distribution,aneurysm size,location,clinical manifestations and treatment effect of the patients,investigated the safety and efficacy of microsurgical treatment of intracranial aneurysms,which provided reference for future diagnosis and treatment.Methods: The data of patients with intracranial aneurysms from October 1996 to December 2015 operated in the Affiliated Hospital of Qingdao University were collected.In this study,we analyzed the gender,age,Hunt-Hess classification,size and location ofaneurysm,surgical complications,hospital discharge assessment,imaging and clinical follow-up results.Results: This study consisted of 1534 patients,which including male(n = 42.4%)and female(n = 57.6%),the average age of the male patients was 49.8±10.5years old,and the average age of the female patients was 52.6±11.6.Hunt-Hess classification: grade0: 75 cases(4.9%),grade?: 42 cases(2.7%),grade?:742 cases(48.4%),grade III : 493 cases(32.1%),grade IV: 161 cases(10.5%),grade V : 21 cases(1.4%).Among the 1534 responsible aneurysms,the anterior communicating artery,posterior communicating artery and middle cerebral artery were the most common sites of aneurysms,accounting for 36.6%,27.7% and 19.7%,respectively.898 cases underwent surgery less than 3 days after the attack,accounting for 58.5%;488 cases underwent surgery within 3~14 days after the attack,accounting for 31.8%;148 cases underwent surgery more than 2 weeks after the attack,accounting for 9.6%.In this 1755 cases of aneurysms,the successful operation of the microsurgical clipping occurred in 1698 cases;muscle wrapped occurred in the 23 cases;the early or late embolization of the 6 cases;in the operation of isolated surgery,occlusion of the internal carotid artery in 4 cases,clipping in other hospitals in 1 case,while unclipping in 23 cases.Intraoperative rupture rate was 16.6%.At the time of discharge,according to the Glasgow outcome score(GOS),the cure(GOS 5): 1345 cases(87.7%),self-care(GOS 4): 98 cases(6.4%),vegetative state(GOS 3~2): 21 cases(1.4%),death(GOS 1): 70 cases(4.6%).Conclusion: This large series of intracranial aneurysms have their own characteristics.Microsurgical treatment is a safe and effective method to intracranial aneurysms,good prognosis can be achieved.PART? The effect of intraoperative fenestration of lamina terminalis(FLT)with effective cerebrospinal fluid(CSF)drainage on chronic shunt dependent hydrocephalusObjective: There are many reasons for chronic shunt dependent hydrocephalus.The effectiveness of different technical skills on preventing chronic shunt dependent hydrocephalus is controversial.Fenestration of lamina terminalis is one of the hottest topics.The purpose of this part is to study the effect of FLT and the effective drainage of cerebrospinal fluid on the occurrence of chronic shunt dependent hydrocephalus,which may help us to find the more effective methods.Methods: The data of 1534 patients with intracranial aneurysms referred to in the firstpart of this paper were retrospectively analyzed.The patients with Hunt-Hess grade III~IV were selected.The cases were divided into four groups according to different treatment methods: group 1,conventional drainage;group 2,effective CSF drainage;group 3,FLT+ conven-tional drainage;group4,FLT+ effective CSF drainage.Drainage volume of CSF and incidence of chronic shunt dependent hydrocephalus in each group were compared.Collected data were analysed using SPSS,Ver.16.p<0.05 was considered significant.Resuls: 512 complete cases with complete information were selected according to the inclusion criteria.There are 192 in group 1,108 in group 2,120 in group 3,92 in group 4.More volume and longer time of CSF drainage in effective CSF drainage group than conventional drainage group were observed respectively(t=92.5,P < 0.001 and t=39.4,P<0.001;respectively).The possibility of chronic shunt hydrocephalus decreased as fellows: group 1>group 2>group 3>group 4(Trend chi square test,p=0.004).Conclusion: Intraoperative FLT with effective drainage of CSF may reduce the incidence of chronic shunt dependent hydrocephalus for the Hunt-Hess grade III~IV patients.PART? Study on the advantage and feasibility of microsurgical operation for contralateral aneurysm clipping through unilateral pterional approachObjective:Multiple intracranial aneurysms(MIAs)are associated with higher risk of rupture and mortality than single intracranial aneurysm.Clipping bilateral aneurysms through unilateral pterional approach in one stage often needs a higher technical requirement.The purpose of this section is to explore the advantage and feasibility of microsurgical operation for contralateral aneurysm clipping through unilateral pterional approach.Methods: We retrospectively analyzed the clinic data of 1534 cases of intracranial aneurysms mentioned in the first section of this study,and cases of anterior circulation multiple aneurysms was selected for the further study.Patients were divided into three groups: clipping MIAs through bilateral pterional approach in two stages(group 1);clipping MIAs through bilateral pterional approach in one stage(group 2);clipping MIAs through unilateral pterional approach in one stage(group 3).Comparison of the operation time,bleeding volume and hospitalization days in different groups wereanalyzed,as well as the range of exposure to the contralateral aneurysm by unilateral approach.All statistical data were analyzed by SPSS version 16 software.A p-value of <0.05 was considered statistically significant.Results: A total of 149 cases were enrolled in the study.52 patients were divided into group 1,34 patients were divided into group 2,and 63 patients were divided into group 3.The analysis of variance showed that there was significant difference in operation time among the groups(p<0.05),and the multiple comparisons showed that the operation time in three groups: group 3< group 2< group 1.The difference of bleeding volume among the three groups was statistically significant(p<0.05),Further multiple comparisons showed that the bleeding volume in group 3 was significantly lower than that in group 2,but there was no significant difference between group 2 and group 1.There was significant difference in the length of hospital stay among the groups(p<0.05).The multiple comparisons showed that the number of days of hospitalization in group 1 was significantly longer than that in group 2 and group 3,and there was no significant difference between group 2 and group 3.Conclusion: It is safe and feasible to clip MIAs through unilateral pterional approach by one-stage microsurgery,although the procedures may need a higher technical requirement.The majority of contralateral aneurysms between the ophthalmic artery and middle cerebral artery bifurcation could be clipped via unilateral pterional approach.PART ? Microsurgery treatment blood blister like aneurysmsObjective: Blood blister like aneurysms(BBA)are rare aneurysm at the non-branching sites of the supraclinoid internal carotid artery anterior or superior wall.No matter what kind of treatment,the outcome is still poor.This part retrospectively analyzed the characteristic and microsurgery treatment of blood blister like aneurysms,in order to guide future treatment and improve the therapeutic effects.Methods: A retrospective analysis of 11 patients of BBA with complete data,which mentioned in the first part,analyzed the clinical manifestations and treatments of microsurgery technique,summarizes its therapeutic effect,meanwhile,inspected the pathological changes of autologous dura mater.Results: 11 individuals met the criteria for inclusion,4 male(36.4%)and 7 female(63.6%)patients.The age of patients was 40-59 years old.Hunt-Hess grade at admission: 0 case was in grade 0 and grade I,3 cases in grade II(27.3%),4 cases in grade III(36.4%),3 cases in grade IV(27.3%),1 case in grade V(9.1%).All the 11 patients were treated bypterional microsurgery.1 cases(9.1%)was treated with directly clipping,4 cases accepted isolated treatment(36.4%),6 cases were treated with wrapping(54.6%),1 case was wrapped with cotton fiber,and the rest were wrapped by autologous dura mater.10 cases were ruptured before cliping,and the rupture rate was 90.9%.According to the Glasgow outcome score(GOS),5 patients were cured,4 cases were indepandent(36.4%)and 1 case was dead(9.1 %).Conclusion: BBA clipping could achieve good performance;wrapping with autologous dura mater assists with clip aneurysm needs more technical skills,and the method could improvethe effect of surgical treatment.Autologous dura mater is an ideal material for clipping BBA.