Clinical Study Of Surgical Treatment Of Small Intracranial Aneurysms

PART Ⅰ: SMALL RUPTURED INTRACRANIAL ANEURYSMS: THE RISK OF HEMORRHAGE SEVERITY AND REBLEEDINGObjective: The risk of hemorrhagic events in patients with small ruptured aneurysms remains unclear.Due to less arterial wall,small ruptured aneurysms may be correlated with massive bleeding and rebleeding.Therefore,it may contribute to clinical treatment to evaluate the risk of hemorrhagic events in patients with small ruptured aneurysms.Methods: From February 2013 to December 2017,we conducted a retrospective study on all continuous patients with ruptured intracranial aneurysms.According to the 3D-CTA measurement of the maximum diameter of the ruptured intracranial aneurysm,ruptured intracranial aneurysms were divided into small RIAs(≤ 5 mm)group and large RIAs(> 5 mm)group.The difference of bleeding amount,rebleeding and clinical outcomes were analyzed between the two groups.Results: A total of 738 patients with aneurysmal subarachnoid hemorrhage(SAH)were included in this study and small ruptured aneurysms accounted for 49.2% of all ruptured aneurysms.Univariate analysis demonstrated that the amount of bleeding(14.5 vs.14.4;P =0.867),rebleeding(8.3% vs.10.9%;P = 0.261)and poor outcome(29.6%vs.23.1%;P = 0.055)were similar between the small RIAs and large RIAs groups.Multivariable analysis showed that hypertension was obviously associated with the amount of bleeding(adjusted odds ratio(a OR),3.25[1.81–4.69];P < 0.001)and rebleeding(a OR,3.31 [1.10–9.99];P = 0.034)in small ruptured aneurysms,and its effect on rebleeding of small ruptured aneurysms is greater than that of large ruptured aneurysms.Conclusions: The older patients with small ruptured aneurysms or hypertensive patients with small ruptured aneurysms are more prone to severe SAH,and hypertensive patients with small ruptured aneurysms are at an increased risk of rebleeding.PART Ⅱ: SMALL RUPTURED INTRACRANIALANEURYSMS: TREATMENT OUTCOMES AND RISKFACTORS RELATED POOR OUTCOMESObjective: Small ruptured intracranial aneurysms(≤ 5mm)accounted for a majority of aneurysmal SAH,and its clinical management remains a challenge.The aim of this study was to identify the treatment outcomes of patients with small ruptured aneurysms patients and the effect of age-related complications on the outcomes of patients.Methods: A retrospective review was performed in small ruptured aneurysms patients who underwent microsurgical clipping or endovascular coiling from September 2012 to December 2018.Patients were divided into the elderly group and the non-elderly group according to the age.The differences in baseline characteristics,clinical complications,and outcomes of the two groups were analyzed.Multivariate logistic regression was used to analyze the risk factors independently associated with poor prognosis in elderly patients.Result: The rate of good outcomes(GOS 4-5)in patients with small small ruptured aneurysms was 88.1%.Among them,the poor outcomes rate of old patients was significantly higher than that of non-old patients(20.3%vs 8.2%;P = 0.001).Compared with the non-elderly group,the incidence of neurological complications with neurologic deficit(P = 0.006),ischemic complications(P = 0.046),cardiopulmonary complications(P = 0.031)and pulmonary infection(P = 0.008)were obviously higher in the elderly group.In multivariate analysis,irregular aneurysms(P = 0.045)and ischemic complications(P < 0.001)were independent risk factors correlated with poor outcomes in elderly patients.Conclusion: Non-elderly patients with small ruptured aneurysms have better treatment outcomes,but the elderly patients have poor treatment outcomes,and higher morbidity and mortality.Preoperative irregular shape of small ruptured aneurysms or postoperative ischemic events should be paid attention as the higher risk of poor outcome in elderly patients.PART Ⅲ: SMALL UNRUPTURED INTRACRANIALANEURYSMS: TREATMENT OUTCOMES AND RISKFACTORS RELATED POOR OUTCOMESObjective: An increasing number of unruptured intracranial aneurysms were treated by aggressive opertation,and the size of aneurysm was a significant factor for decision-making in the treatment of unruptured aneurysms.The purpose of the study was to investigate the treatment outcomes of patients between small unruptured aneurysms and medium-large unruptured aneurysms as well as the effect of age on the outcomes.Methods: A retrospective review was performed in small unruptured aneurysms patients who underwent microsurgical clipping or endovascular coiling from May 2011 to January 2019.According to the 3D-CTA measurement of the maximum diameter of the unruptured intracranial aneurysm,patients were divided into small UCAs(≤ 5 mm)group and large UCAs aneurysm(> 5 mm)group.The differences in clinical complications and outcomes of two groups were analyzed,and a multivariate logistic regression was used to analyze the risk factors independently associated with poor prognosis in all patients.Result: There was no significant difference in the outcomes between the small unruptured aneurysm group and the medium-large unruptured aneurysm group after operative treatment(P = 0.104).Multivariate analysis demonstrated that largest aneurysm size(P = 0.014)and age(P = 0.009)were independently risk factors associated with poor outcome of unruptured aneurysm patients.Further subgroup analysis showed that in the small unruptured aneurysm,elderly and non-elderly patients had a higher rate of good outcome,with no significant difference(97.6% vs.98.4%;P=1.000);in 6-10 mm medium-large unruptured aneurysm,the poor outcome rate of elderly patients was significantly higher than that of non-elderly patients(9.4% vs.0%;P=0.007);in > 10 mm medium-large unruptured aneurysm,the rate of poor outcome was high in both the elderly and non-elderly patients(14.7% vs.7.5%;P=0.458).Conclusion: Operative treatment of small unruptured aneurysm is safe and effective,but elderly patients with medium-large unruptured aneurysm are at high risk of poor outcome and the treatment indications of these patients should be more cautious.