Predictors of postoperative mortality in ruptured aneurysms of internal carotid artery

Background and purposeAn analysis of predictors of mortality in patients with ruptured intracranial aneurysm is an important aspect in the assessment of outcome. The aim of the study was to analyse factors determining mortality risk after the surgical treatment of ruptured internal carotid artery (ICA) aneurysm.Material and methodsThis study comprised 242 patients operated on between 1997 and 2006 in the Neurosurgery Department of the Medical University Hospital in Gdansk, Poland. Multivariate logistic regression, ROC curves (for model assessment as a mortality classifier) and population attributable risk for contribution of individual factor mortality explanation were used to assess factors related to in-hospital mortality.Results14.9% of patients died postoperatively. In univariate analysis, increased risk of death was related to the Glasgow Coma Scale score, WFNS score, Hunt-Hess and Fisher grade, preoperative neurological deficit, delayed cerebral ischaemia (DCI), trapping and bypass operative method. Multivariate analysis revealed two independent predictors of in-hospital mortality: DCI and Hunt-Hess grade. 91% of mortality risk was attributed to grade 4 or 5 in Hunt-Hess scale and DCI. The dominant predictor of survival was the Hunt-Hess scale. Increase by one grade in the Hunt-Hess scale resulted in two-fold increase of in-hospital mortality risk.ConclusionsPostoperative mortality after ICA aneurysm rupture is determined by clinical status at admission and the occurrence of DCI.     

颈内动脉前壁动脉瘤破裂后的血管内治疗

目的总结颈内动脉前壁动脉瘤的影像学特征,评估其血管内治疗的临床疗效。方法回顾性分析12例颈内动脉前壁动脉瘤的病例资料。采用单纯弹簧圈栓塞3例,单纯支架植入3例,支架辅助弹簧圈栓塞4例,载瘤动脉闭塞2例。结果发生术中出血1例,术后再出血3例;出院时预后良好8例（66．7％）,死亡4例（33-3％）。临床随访2～78个月,平均23个月;GOS5分7例,4分1例。结论血管内治疗是颈内动脉前壁动脉瘤的有效治疗方法。动脉瘤段载瘤动脉闭塞是治疗此类动脉瘤最确实的方法．但对于球囊闭塞试验阳性,或动脉瘤颈对侧壁有重要穿支的病人,可考虑行支架辅助弹簧圈栓塞术。     

颈内动脉眼动脉段动脉瘤手术治疗分析

目的 探讨颈内动脉眼动脉段动脉瘤（OSAs）的手术治疗方法及其疗效。方法 回顾性分析2005年8月至2015年12月年收治的88例OSAs的临床资料。88例共109枚动脉瘤。无眼部症状的48例69枚小型动脉瘤中,支架辅助弹簧圈栓塞49枚,单纯弹簧圈栓塞20枚;无眼部症状的17例单发大型或巨大动脉瘤中,球囊辅助栓塞2例,支架辅助栓塞13例,球囊联合支架辅助栓塞2例;合并视力障碍的23例（均为单发动脉瘤,小型动脉瘤12枚,大型或巨大型动脉瘤11枚）,12例栓塞,11例行动脉瘤夹闭术。结果 栓塞治疗的98枚动脉瘤术后即刻造影示,致密栓塞87枚,瘤颈部分显影11枚。88例术后平均随访18个月,术后6个月DSA或CTA随访,致密栓塞的47枚小型动脉瘤中,复发2枚（4.2%）;17例大型或巨大型动脉瘤中,复发5例（29.4%）。合并视力障碍的23例中,术后眼部症状改善13例（栓塞6例,夹闭7例）,未见明显变化6例（栓塞3例,夹闭3例）,加重4例（栓塞3例,夹闭1例）。结论 血管内栓塞治疗OSAs微创、安全、有效,但对改善视力障碍而言,夹闭术可能优于栓塞术。     

Surgical management of aneurysms of the bifurcation of the internal carotid artery

Internal carotid artery (ICA) bifurcation aneurysms are rare and easily bleed in younger patients, but are difficult to treat surgically, due to perforators surrounding and adherent to the aneurysm. A series of 25 patients treated by clipping under the operating microscope are analyzed and compared with previous cases. Twenty-five patients, 11 men and 14 women (mean age 51 years), were treated by the same neurosurgeon. Seventeen patients presented with subarachnoid hemorrhage (Hunt & Kosnik Grade I in three, II in five, III in two, IV in seven), five with unruptured ICA bifurcation aneurysms, and three with unruptured ICA bifurcation aneurysms but another ruptured aneurysm. There were 23 small, one large, and one giant ICA bifurcation aneurysms. The projection was superior in 12, anterior in seven, and posterior in six cases. Pterional approach was employed for all cases. Outcomes were evaluated at discharge with the Glasgow Outcome Scale. Favorable outcomes (good recovery (GR) and moderate disability (MD)) were obtained in ten of 17 patients with ruptured ICA bifurcation aneurysm. Favorable outcomes were significantly greater in Grades I and II (three in I, four in II) than in Grades III and IV (one in III, two in IV; P=0.0498). Seven of eight patients with unruptured ICA bifurcation aneurysm had favorable outcomes. Temporary clipping and projection of the aneurysm did not affect the outcome. Causative factors of unfavorable outcomes were primary brain damage in cases of small and large aneurysms and perforator damage in the case of giant aneurysm. Poor clinical grade and vasospasm are the causative factors of poor outcome in patients with ruptured ICA bifurcation aneurysm. Preservation of perforators is crucial in cases of giant aneurysm. Clipping of unruptured ICA bifurcation aneurysms is recommended since they tend to bleed at a lower age than other aneurysms.     

LVIS支架辅助栓塞颈内动脉床突上段破裂夹层动脉瘤

目的 探讨LVIS支架辅助栓塞治疗颈内动脉床突上段破裂夹层动脉瘤的可行性、有效性。方法 回顾性分析2015年6月到2018年3月采用LVIS支架辅助栓塞治疗的9例颈内动脉床突上段破裂夹层动脉瘤的临床资料。结果 9例均成功实施LVIS支架辅助栓塞治疗,术后即刻造影显示Raymond分级Ⅰ级5例,Ⅱ级4例。术后DSA随访1周~24个月,2例双LVIS支架辅助栓塞术后2周DSA复查显示动脉瘤复发,血栓弹力图示ADP>90%,调整抗血小板方案后半年后复查动脉瘤未显影;其余病人动脉瘤均未显影,载瘤动脉通畅。出院时改良Rankin量表（mRS）评分0分5例,3分2例,4分1例,6分1例;术后90 d mRS评分0分6例,1分1例,3分1例。结论 LVIS支架辅助栓塞颈内动脉床突段破裂夹层动脉瘤是一种安全、有效的方法,调整抗血小板方案可提高术后复发动脉瘤的闭塞率     

颈动脉闭塞性血管病的颅内脑血流改变与临床表现的关系

目的　分析颈内动脉严重狭窄 (狭窄≥ 75 % )或闭塞患者 (ICASO)颅内脑血流改变与临床表现的关系。方法　经全脑数字减影血管造影 (DSA)检查证实的ICASO患者 66例 (单侧病变 5 0例 ,双侧 16例 )。临床分为脑梗死组、TIA组和无体征组。应用经颅多谱勒超声 (TCD)检测双侧大脑中动脉 (MCA)血流速度 (Vmca)并判断颅内侧枝循环的开放。结果　①与DSA比较TCD对前交通动脉 (ACOA)判断的敏感性 97% ,特异性 93 % ;后交通动脉 (PCOA)敏感性 92 % ,特异性83 % ;眼动脉 (OA)开放的敏感性 98% ,特异性 90 %。无体征组和TIA组ACOA和PCOA同时存在的出现率高 ,而脑梗死组则仅有OA存在的出现率最高。②狭窄同侧Vmca(3 9 5 5± 13 2 8)cm/s明显低于对侧 (78 90± 2 4 15 )cm/s(P <0 0 1) ,频谱低平呈波浪状。脑梗死组低于TIA组和无症状组 (P <0 0 5 )。结论　TCD可以无创性地检测颈内动脉严重狭窄或闭塞后脑血流动力学的改变 ,并与临床表现相关。前后交通动脉代偿良好时不易出现脑梗死 ;仅有眼动脉反向存在及大脑中动脉血流速度的明显降低往往提示代偿不足 ,易发生缺血性病变。     

Treatment of ruptured internal carotid artery trunk aneurysms: feasibility of endovascular trapping or proximal obliteration of the ICA

Objective

Ruptured aneurysms arising from non-branching sites of the internal carotid artery (ICA) are often difficult to treat by neck clipping or endosaccular coiling. We discuss the feasibility of simple endovascular ICA ligation or trapping to treat aneurysms.

Methods

Data from eleven patients were retrospectively analyzed regarding Hunt and Hess grade on admission, angiographic collateral capacities during digital carotid compression, results of balloon test occlusion of the ipsilateral ICA, type of treatment, and Glasgow outcome scale at discharge.

Results

First endovascular treatments were performed by day 5 in four cases. Two patients with good clinical grade and good collateral capacity underwent endovascular ICA trapping in the acute stage and showed good outcomes. Two patients displaying poor clinical grade but good collaterals underwent endosaccular embolization. These aneurysms recurred later and the ICAs were trapped by coils in the chronic stage. Four cases underwent first endovascular treatments in the chronic stage. Three patients with good collaterals underwent endovascular ICA trapping or ligation and showed favorable outcomes.

Conclusions

Seven of eleven patients could be treated by endovascular ICA trapping or ligation, which offers a simple, safe method for ruptured ICA trunk aneurysms, if collateral capacity is good and neurological condition is not serious.     

Multiple aneurysms associated with agenesis of internal carotid artery

Agenesis of internal carotid artery (ICA) is a rare anomaly. The contralateral dominant artery has a high incidence of aneurysms. A 50-year-old male patient had aneurysmal subarachnoid hemorrhage due to rupture of a paraclinoid aneurysm. He also had an anterior communicating artery (Acom) aneurysm and the contralateral ICA was absent. To the best of the authors knowledge, the combination of agenesis of unilateral internal carotid artery with the unique association of a paraclinoid and an Acom aneurysm has not been previously reported. A meticulous assessment of the collateral blood circulation prior to surgery is mandatory in these cases for avoiding postoperative ischemic injury.     

颅内-外动脉搭桥在复杂颈内动脉瘤治疗中的运用

目的探讨颅内-外动脉搭桥术在复杂颈内动脉瘤治疗中的适用范围、手术方法和疗效。方法回顾性分析33例颅内-外搭桥术临床资料,搭桥后分别采用慢性阻断颈部颈内动脉、闭塞载瘤动脉或孤立动脉瘤等。结果术后血管造影或CTA示30例吻合血管通畅,1例吻合口狭窄伴血管痉挛,2例吻合口不通。29例通过阻断颈内动脉使动脉瘤不显影而达到治愈。29例治愈患者随访未见动脉瘤复发或破裂。结论采用颅内-外动脉搭桥术,结合急性或慢性闭塞颈内动脉,是复杂颈内动脉瘤治疗的一种有效途径。     

Multiple basilar trunk aneurysms and bilateral internal carotid artery hypoplasia

We describe a case of a 32-year-old woman with bilateral hypoplastic internal carotid arteries who presented with subarachnoid haemorrhage and was found to have two basilar trunk aneurysms. Carotid angiography showed that both internal carotid arteries were narrowed at their origin and terminated at the cervical segment. Vertebral angiography demonstrated a dilated vertebrobasilar system which supplied sufficient blood flow for both cerebral hemispheres through the posterior communicating arteries. The patient was successfully treated by multiple operations.     

颈内动脉大型和巨大型动脉瘤的手术策略

目的探讨颈内动脉巨大动脉瘤的特点和手术策略。方法回顾性分析48例颈内动脉大型和巨大型动脉瘤的手术经验。手术均采用翼点人路，床突旁动脉瘤病例预先暴露颈部颈内动脉以备临时阻断。从硬脑膜内磨除前床突、视神经管上壁以及外侧嵴，以显露动脉瘤的近侧角。术中采用逆向抽吸法使动脉瘤塌陷，如动脉瘤内含机化血栓，则在临时阻断后切开瘤体，用CUSA和取瘤镊去除瘤内血栓，再将动脉瘤夹闭并达到视神经减压的目的。术中监测脑电图和体感诱发电位，并采用术中超声多普勒检查动脉血流。结果46例动脉瘤直接夹闭，2例海绵窦段动脉瘤行动脉瘤孤立并分别做颞浅动脉-大脑中动脉和大隐静脉移植颈外动脉-大脑中动脉搭桥手术。43例术后行DSA检查，绝大多数动脉瘤夹闭满意。按GOS评分术后良好为41例（85．4％），差为5例，死亡2例。结论充分显露、合理应用临时阻断技术、有效的动脉瘤减压，以及术中应用电生理监测和超声多普勒检查等辅助措施，能够取得动脉瘤的满意夹闭。     

颈内动脉巨大动脉瘤的血管内治疗

目的探讨血管内栓塞方法治疗颈内动脉巨大动脉瘤的效果和安全性。方法回顾性分析3例应用弹簧圈进行瘤腔内栓塞和27例应用载瘤动脉闭塞方法治疗的颈内动脉巨大动脉瘤的结果和随访资料。结果2例瘤腔内栓塞动脉瘤的患者症状完全消失;1例患者出现缺血性并发症,半年后随访动脉瘤再通。球囊闭塞载瘤动脉的患者1例出现迟发缺血性症状;1例吻合支开放,3个月后患者出血死亡;其余患者症状均有不同程度改善。结论颅内巨大动脉瘤是否进行瘤囊内弹簧圈栓塞需要综合考虑各种条件,采用个体化的治疗方案。球囊闭塞载瘤动脉是比较安全有效的方法。