Surgical results, the rate of complications in surgery closely related to aneurysm morphology.. In order to improve the quality oftreatment for cerebral artery disease, we conduct the pr
Trang 1Cerebral aneurysm (cerebral artery) is a common pathology ofcerebral artery system Research on bodies shows that cerebralaneurysm accounts for 0.2-7.9% of the population, some studiesshow an aneurysm rate of 5% The fatal complication is usually therupture aneurysm and this is also one of the causes of brain stroke
To date, the world as well as in Vietnam has used the methods oftreating cerebral aneurysms such as: micro-surgery aneurysm,intravascular interventions Each method has its advantages andlimitations, but microsurgical clipping aneurysm still plays animportant role
In the process of micro-surgery an aneurysm, there is a part of theneck that is missing, which is the cause of secondary bleeding andrupture of the aneurysm at 2.5% Clipping aneurysm can clip to thecranial nerves to cause damage Especially can be inserted into obliquearteries, arteries carrying aneurysm causes 9.52% brain anemia inthem
Surgical results, the rate of complications in surgery closely related
to aneurysm morphology The study of the location, shape, size,aneurysm direction as well as related factors through clinical, imaging,observation during surgery helps surgeons have appropriate treatmenttactics and prognosis after surgery In order to improve the quality oftreatment for cerebral artery disease, we conduct the project: " research
in morphology and assessing surgical results treatment of cerebral
aneurysms" with the following objectives:
1 Describe the morphological pattern of cerebral aneurysm surgical indications.
2 Assess the results of cerebral aneurysm surgery
New contributions of the thesis:
The study described aneurysm morphology on CTA and DSAimages The shape of aneurysm is mainly bag shaped, on CTAaccounting for 98.7%, on CTA is 100% The aneurysm site is mainlyfound in the anterior communicating artery, on CTA is 38.3%, onDSA is 35.8% The size of aneurysms ≤5mm is the most popular,
Trang 2accounts for 65.6% on CTA and 57.6% on DSA Along with thedevelopment of intravascular intervention to treat cerebral aneurysm,surgery is still a basic method of choice, with good treatment results
of 76.4%, the percentage of aneurysms clipped completely is 94.4%
Thesis structure
Total 134 pages: 2 - page problem section; Chapter 1: Overview
33 pages; Chapter 2: Subjects and research methods 26pages; Chapter 3: Research results 35 pages; Chapter 4: Discussion
37 pages; Concluding remarks 02 pages, Proposal 01 page The thesishas: 41 tables, 35 pictures and 5 charts, 178 references
CHAPTER 1 OVERVIEW 1.1 Research situation of cerebral aneurysm
1.1.1 Studies over the world:
The cerebral aneurysm was first described in the early 18th centuryand subarachnoid hemorrhage was primarily caused by the aneurysm In
1938, Dandy W.E announced the first successful surgical case to treatcerebral aneurysm with an aneurysm clipping Gallagher J.P (1963)introduced the technique of coagulation aneurysm by inserting animalhairs into aneurysm at high speed using an air gun ("hairpump") Serbinenko F.A occluded the aneurysm with balloon in 1970
In 1989, Guglielmi G., the Italian neurosurgeon, firstly invented themethod of using a metal coil (coil) attached to a wire to pass through awire microcatheter into aneurysm This is then cut off by direct current,which coagulates the aneurysm to remove aneurysm from the brainartery system while preserving the artery called the detachable metalspiral (GDC) In 2003, Reisch R et al reported a 10-year experience ofusing supraorbital craniotomy in surgical aneurysm and base skull Theaverage skull cap size the authors made was 2.5x1.5cm
1.1.2 Researches in our country
The first aneurysm surgery was reported by Nguyen ThuongXuan et al in 1962 In 2006, Nguyen The Hao conducted the firstdoctoral thesis "Research diagnosis and surgical treatment of
Trang 3subarachnoid hemorrhage due to rupture of the internal carotid arteryaneurysm" Nguyen The Hao et al (2015) published the study
"Results of treatment of cerebral aneurysm with minimally invasivesurgery at Bach Mai Hospital" including 48 patients with goodresults 87.5%, without residual aneurysm, nerve damage on eyesocket 10.3%, ciliary muscle 7.7%, temporal muscle 5.1%, aestheticpatient complete satisfaction 76.9% Pham Dinh Dai (2011) hasimplemented the topic: "Study of clinical features, subclinical, results
of treatment after intravascular intervention in patients with strokedue to cerebral aneurysm rupture"
1.2 Diagnostic image of cerebral aneurysm
1.2.1 Computerized tomographic without injection of contrast material
With the new generation com machines for accurate diagnosis ≥95% of cases of subarachnoid hemorrhage in the first 48 hours Withimages of increasing the proportion of blood in the subarachnoid in thebase of the skull (pituitary apoplexy, pontine cistern), Sylvius fissure,inter hemispherical fissures, cerebellum tent, even brain cortex
1.2.2 Computerized tomography angiography
Computerized tomography angiography (CTA) results indiagnosing aneurysms up to 97% with the advantage of being a safe,effective method that can be used to diagnose both unruptured andruptured aneurysms CTA for 3D images helps to identify the obliqueveins separated from the aneurysm, as well as the anatomicalconnection between the aneurysm and the base of skull, which isimportant in the development of the surgery plan CTA is alsovaluable in diagnosing vasospasm
1.2.3 Magnetic resonance imaging and magnetic resonance angiography
Magnetic resonance imaging (MRI) in the diagnosis ofsubarachnoid hemorrhage is not sensitive within the first 24-48 hours(due to too little met-Hb) especially with thin blood layers MRIgives the best results within 4-7 days (positive results are in a semi-acute period of 10-20 days) Imaging on the Flair pulse provides the
Trang 4highest sensitivity to subarachnoid hemorrhage with increased signalimaging in the brain sulcus An MRI can detect a dilated aneurysm,the image of aneurysm without a blood clot in the upper T2W isusually regular, relatively clear, no signal, hollow flow, continuouswith a blood vessel.
Magnetic resonance angiography (MRA) diagnosesaneurysmswith 87% sensitivity, 92% specificity, but difficult todiagnose aneurysm smaller than 3 mm
1.2.4 Digital subtraction angiography
This is the gold standard for determining theaneurysm active brain circuits DSA found 80-85% of cases ofruptured cerebral aneurysms causing subarachnoid hemorrhage (therest are unexplained subarachnoid hemorrhage)
1.3 Micro surgical treatment of cerebral aneurysm
1.3.1 Surgical approaches of aneurysm
+ Frontotemporosphenoidal approach: also known as the pterionalapproach is indicated for cases of aneurysm of the anterior cerebralcirculation: the internal carotid arteries of aneurysm, the middle cerebralartery, the anterior cerebral artery; or basilar tip aneurysm
+ Subfrontal approach: is indicated for anterior communicatingartery aneurysm with an aneurysm upwards, especially in caseswhere intracerebral hemorrhage large
+ Anterior interhemispheric approach: is indicated for anteriorcommunicating artery aneurysm, with the advantage of a small brain lift.+ Transcallosal approach: indicative for vesicular aneurysm.+ The superior temporal gyrus approach: is indicated for theaneurysm of the middle cerebral artery, with little advantage of thebrain, can reduce the risk of vasospam
+ Suboccipital approach: indicative of the aneurysm of thebasilar vertebral artery complex
+ Subtemporal approach: designates the basilar aneurysm at thesame height as the superior cerebellar artery
+ Orbitozygomatic approach: Some authors use to access thebasilar aneurysm
Trang 52.1 Research subjects
Including 156 patients who were diagnosed and treated formicrosurrgical clipping at Department of Neurosurgery - Viet DucHospital from January 2011 to December 2013
2.1.1 Criteria for selecting a patient
+ Patients diagnosed with cerebral aneurysms disease identifiedby: DSA and or CTA
+ Patients underwent surgery at the Department of Neurosurgery
- Viet Duc Hospital with clear surgical records, image on injected brain CT scan, CTA, DSA cerebrovascular clearly, withsufficient reliability
2.3 Formula to calculate sample size
+ Select a sample: Select a probability sample, using aconvenient sampling method Select all patients diagnosed withcoronary aneurysm and received microsurgical surgical treatment forneck aneurysm during the study
Trang 6+ Sampling selection: Probability sampling, using convenientsampling methods Select all patients diagnosed with coronaryaneurysms and treated for micro-aneurysms during the study period.
In this study we performed 156 patients
2.4 Research content
2.4.1 Study clinical characteristics
+ Age of patients at the time of diagnosis to determine: averageage, minimum age, maximum age, divided into 3 groups: 13-20, 21-
55, 56-57
+ Gender: determining the incidence between men and women.+ Medical history: t antennas blood pressure, headache, CTSN,cerebral stroke, polycystic kidney, alcoholism, smoking
+ Clinical characteristics:
- Patients with unruptured aneurysm: headache, nausea,epilepsy, cranial nerve damage Clinically assessed on a Glasgowscale, modified Hunt-Hess grading and modified WFNS grading
- Patients with ruptured aneurysms: determine the time fromthe onset to the time of admission, determine the time from theonset to the time of surgery Judged by a Glasgow coma scale,modified Hunt-Hess grading and modified WFNS Determinewhether an aneurysm has ruptured before surgery and the number
of ruptures
2.4.2 Study morphological characteristics of aneurysm
2.4.2.1 Computerized tomography without contrast
Trang 7accuracy in detecting subarachnoid hemorrhage, degree of subarachnoidhemorrhage and predicting vasospasm according to Fisher.
Trang 82.4.2.2 Digital subtraction angiography (DSA)
Digital subtraction angiography was performed on GE Advantxmachine at the diagnostic imaging department of Bach Mai Hospital, thediagnostic imaging department at Viet Duc Friendship Hospital Selectivescan of the internal carotid artery and vertebral artery Take upright,sloping, and 3/4 poses and special positions depending on the direction ofthe SEG The evaluation criteria are divided into two groups (unrupturedaneurysms ruptured aneurysm), including:
* Number of aneurysm: 1 aneurysm, 2 aneurysms, 3 aneurysms, 4aneurysms
* Aneurysmposition: right, left
+ Anterior cerebral circulation:
- Superior hypophyseal artery
- Ophthalmic artery
- Posterior communicating artery
- Internal carotid artery bifurcation
- Internal carotid artery
- Middle cerebral artery
- Middle cerebral artery bifurcation
- Anterior cerebral artery
- Pericallosal artery
- Anterior communicating artery
+ Posterior circulatory system:
- Vertebral artery
- Posteroinferior cerebellar artery
- Basilar tip aneurysm
* Shape aneurysms: shaped, rhombus
* The size of the aneurysm: the neck of the aneurysm, the body
of the aneurysm, the depth of the aneurysm
* Some characteristics: uneven or irregular aneurysm, calcifiedneck of an aneurysm, aneurysm with one or multiple lobes, obliquebranches coming from aneurysm, abnormalities of coronary artery(aplasia, deformities )
Trang 9* On the DSA image, determine the degree of vasospasm onGeorge's scale.
2.4.2.3 Computerized tomography angiography
Used computerized 64-layer tomography machine Somatomasensations of Siemens (Germany) Contrast type Xenetic 300(Guerbet) used 50ml, injected at a rate of 5ml / s, then injected Bolus40ml 0.9% physiological saline (Volume of drug used = X-rayemission time of injection speed) Time delay depends BolusTest Spiral cutting 0.3 s / rev, 1.25 mm cutting layer thickness, 0.75
mm hops, 0.8 mm image reproduction Voltage of 120 KV, 240
mA The height of the box cuts from the horizontal C4 level to theend of the skull The image is 3-5-10mm thick, the maximum densityprojection ( MIP ), the multi-plane volume reconstruction (MPR ),the volume processing technique (VRT) Research targets :
+ Number of aneurysms
+ Aneurysm location
+ Shape of an aneurysm: a bag, a rhomb
+ Aneurysm are regular or uneven
+ Calcium neck aneurysm
+ An aneurysm has one or more lobes
+ Oblique branches come out of the aneurysm
+ The abnormalities of cerebral artery (aplasia, deformities)
+ Aneurysms size: neck, body, aneurysm depth
2.4.3 The approach
* Frontotemporosphenoidal approach (pterional approach) : theaneurysm in the anterior cerebral circulation, basilar tip aneurysm
* Suboccipital approach: the vascular aneurysm follow
* Supraorbital keyhole: aneurysm informed in advance
* Anterior interhemispheic approach : anterior communicatingartery, pericallosal artery
2.4.4 Evaluation of morphology of aneurysm during surgery
+ Studying morphological characteristics of an aneurysm: number,position, shape, calcification of an aneurysm, clot in an aneurysm, ananomalous or irregular aneurysm, an aneurysm with a single or
Trang 10multiple lobes, oblique vessels, abnormalities of coronary system(malformation, hypoplastic).
+ Evaluation of difficult factors in surgery: cerebral edema,intracerebral hemorrhage, thin vault arch, vasospasm, calcification of theneck of the vesicle, the lateral vascular, the difficult aneurysm position.+ Statistics of surgical complications: rupture of the aneurysmduring surgery (before surgery, when the neck is anatomy, whenclipping the neck of the aneurysm), vascular lesions, cranial nervedamage, aneurysm failure or incomplete clips
2.4.5 Techniques for managing aneurysm
+ Clip merely
+ Clip combination to taking hematoma
+ Clip and bypass
+ Clip and aneurysm wrap
+ Wrap the balloon bag
+ Clip the proximal and distal end clips with aneurysm
2.4.6 Additional tachniques during surgery
Taking hematoma, craniectomy, ventricular drainage, revealing theinternal carotid artery and outside the skull, cutting the anterior clinoidprocess, cutting a straight back, supporting endoscopy
2.4.7 Evaluation of clinical results of microsurgical treatment
+ Assess the clinical results of patients on discharge according toGlasgow outcome scale, mRankin
+ Evaluate far results: based on clinical condition of patients based
on mRankin scale
2.4.8 Evaluate the image diagnosis result after surgery.
2.4.8.1 Computerized tomographic without injection of contrast material
+ Identify images of cerebral hemorrhage
+ Identify images of ischemic brain
+ Identify images of hydrocephalus (new appearance, old, improved).+ Identify images of contusion brain
2.4.8.2 Digital subtraction angiography after surgery
+ Completely out of aneurysm: there is no more aneurysm and neck
Trang 11+ Remaining balloon bag.
+ Whether the artery carrying aneurysm is narrow or not
+ Rebleeding, ruptured aneurysm during surgery
+ The degree of vasospasm according to George
+ Aneurysms location
+ Size of aneurysms
2.5 Data processing methods
The study was processed according to STATA 13.0 software + Calculate the rate, mean value and standard deviation of theindex in the research group
+ Testing of average ratios and indicators by the method ofmedical statistics through the processing of T-test tables, χ ²
+ Sensitivity (Se): the percentage (%) correctly diagnosed as havingdisease in the total number of people diagnosed with the disease
+ Specificity (Sp): the rate (%) correctly diagnosed that there is nodisease in the total number of people diagnosed with no diseases
+ Positive predictive value (PPV): the ratio (%) is correct whenthe disease is forecasted
+ Negative predictive value (NPV): the ratio (%) is correct whenthe prediction is disease or no disease
+ Accuracy: the percentage (%) of correct diagnosis is a diseaseamong the total number of people diagnosed with the disease
+ Comparing the difference: p <0.05 is statistically significant, p
<0.01 is statistically significant, p> 0.05 is not statistically significant
2.6 Research ethics: compliance regulations on medical ethics in the
research process
Trang 12CHAPTER 3 RESEARCH RESULTS 3.1 General characteristics of the study object
Table 3.1 Patient distribution by age and gender
Rati
o %
Amount
21
0.002
56
0.001
0
0.004
´
X±
SD 49.6 ± 11.8 55.0 ± 12.0 52.4 ± 12.1
0.001Comment:
The average age of study subjects was 52.4 ± 12.1 (from 13 to 77years old) In particular, the age group 21-55 accounts for the highestrate of 55.1% The incidence of men is higher than women in the agegroup 21-55 (p = 0.002) In contrast, the incidence of women wassignificantly higher than men in the 56 -77 age group (p = 0.001)
Ruptured
Patient(n=18)
Aneurysm(n=20)
Patients(n=125)
Aneurysm(n=135)
Patients(n=143)
Aneurysm(n = 154)