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Objectives: To evaluate results of cerebral aneurysm surgical clipping. Methods: A retrospective and prospective study. Results: 156 patients with 166 aneurysms were treated by surgical clipping.
Journal of military pharmaco-medicine no8-2018 SURGICAL RESULT OF CEREBRAL ANEURYSM CLIPPING Nguyen Thanh Bac1; Dong Van He2; Nguyen The Hao1; Vu Van Hoe1 SUMMARY Objectives: To evaluate results of cerebral aneurysm surgical clipping Methods: A retrospective and prospective study Results: 156 patients with 166 aneurysms were treated by surgical clipping The patients were divided into two groups: Unruptured and ruptured; with the mean age of 75.1 ± 4.3 Proportion of aneurysms was the highest in anterior communicating artery (39.4%); followed by posterior communicating artery (16.4%); middle cerebral artery (17.0%); internal carotid artery (2.4%); middle cerebral artery (4.2%); ophthalmic artery (3.0%); posterial cerebellar artery (2.4%); bifurcation of basilar artery (2.4%); vertebral artery (3.0%); anterior cerebral artery (1.8%); basilar artery (3.0%) and superior hypophyseal artery was 3.6% Glasgow Coma Scale at discharge of hospital was significantly higher in unruptured aneurysm group than in the ruptured one (p = 0.001) The mean Glasgow Coma Scale of unruptured group and ruptured group were 14.4 ± 0.5 and 12.7 ± 3.1, respectively The average of both groups was 12.9 ± 2.9 According to Modified Rankin Scale, at hospital discharge, the results were as followed: good 21.1%, average 45.5%, bad 26.3%, dead 7.1% There were no statistically significant differences between the two groups with p = 0.226 For far results, there was no difference in Modified Rankin Scale between the unruptured and ruptured aneurysm group, with a good outcome of 76.4%, an average of 11.4%, negative 4.9%, and dead was 7.3% With Digital dubtraction angiography postoperation, results showed that the incidence of aneurysm was 94.4%, the residual rate of the aneurysm was 5.6%, the occlusion of the aneurysm was 3.7% and the carotid artery obstruction the bulge was 0.9% Conclusion: Aneurysm clipping surgery is still a selected method that brings good results for intracranial artery aneurysm patients * Keywords: Intracranial aneurysm; Clipping surgery; Modified Rankin Scale; Glasgow Coma Scale INTRODUCTION A cerebral aneurysm is a focal abnormal dilation of the wall of an artery in the brain Autopsy studies indicate that cerebral aneurysms are fairly common in adults, with a prevalence ranging between 1% and 5% [4, 5] Prevalence of intracranial aneurysms among adults is estimated between 1.0% and 3.2% [6, 7] Therefore, to 12 million Americans harbor intracranial aneurysms The incidence of reported ruptured aneurysms is about to in every 100,000 people per year [8] In the world as well as in Vietnam, there are several used methods to treat brain aneurysm such as: microsurgical clipping, 103 Military Hospital Vietduc Hospital Corresponding author: Nguyen Thanh Bac (bacnt103@gmail.com) Date received: 20/08/2018 Date accepted: 02/10/2018 204 Journal of military pharmaco-medicine no8-2018 intravascular intervention Each method has its advantages and drawbacks, but microsurgical clipping for aneurysm still plays an important role We conducted this study: To evaluate the surgical results of cerebral aneurysm clipping surgery Hospital from January 2011 to December 2013 Methods This is a retrospective and prospective study * Factors: - Patients were divided into two groups: Unruptured and ruptured aneurysm group SUBJECTS AND METHODS Subjects - Results about age, sex 156 patients with 166 aneurysms (unruptured, ruptured aneurysms) were diagnosed with digital dubtraction angiography (DSA) and/or CT-scan and treated with clipping aneurysm surgery in Department of Neurosurgery, Vietduc - Clinical results at hospital discharge: Glasgow and Modified Rankin Scale - Clinical results: Modified Rankin Scale - DSA postoperative results: No aneurysm, residual aneurysm, narrowed aneurysm blood vessels, obstructive blood vessels Table 1: Modified Rankin Scale Level Clinical properties No symptoms No complication but slight symptom, abilities to everything a day Slight complication: Uncompleted all activities as before, self-serve without other help Middle complication: Patients need some help, but they can walk without assistance Relatively severe complication: Patients can not walk themselves, not self-service if without help Severe complication: Paralysis and spasm disorder Dead (* Source: Askiel Bruno (2013) [6]) * Footnotes: Rankin score - 2: good clinical condition; Rankin score 3: middle clinical condition; Rankin score - 5: bad clinical condition; Rankin score 6: dead Data were statistic processed by using SPSS software, version 15.0 (statistical package for social science) 205 Journal of military pharmaco-medicine no8-2018 RESULTS AND DISCUSSION Table 2: Location of aneurysm Unruptured aneurysm (n = 22) Ruptured aneurysm (n = 144) Superior hypophyseal artery Ophthalmic artery Location of aneurysm Anterior circulation Posterior circulation Total (n = 166) n % 3.6 3.0 Posterior communicating artery 24 27 16.4 Internal carotid bifurcation 5 3.0 Internal carotid artery 2 2.4 Middle cerebral artery 4.2 Middle cerebral bifurcation 24 28 17.0 Anterior cerebral artery 3 1.8 Pericallosal artery 1.8 Anterior communicating artery 61 65 39.4 Vertebral artery 3.0 Posterior cerebellar artery 4 2.4 Bifurcation of basilar artery 4 2.4 22 144 166 100.0 Total Table showed that the anterior communicating artery aneurysm was the highest; followed by posterior communicating artery aneurysm and middle cerebral artery According to Ito et al (2017), middle cerebral artery aneurysm was the most common (34%), followed by anterior communicating artery aneurysm (27.5%) [10] Table 3: Glasgow Coma Scale at hospital discharge Indexes Glasgow Coma Scale at hospital discharge Unruptured aneurysm (n = 21) Ruptured aneurysm (n = 135) Total (n = 156) p 14.4 ± 0.5 12.7 ± 3.1 12.9 ± 2.9 0.001 Glasgow Coma Scale of unruptured aneurysm group at hospital discharge was significantly higher than ruptured aneurysm group (p = 0.001) According to Nguyen Trung Thanh et al (2015), among 16 patients with large and giant aneurysm in middle cerebral artery (3 cases of unruptured aneurysm, and 13 cases of ruptured aneurysm), Glasgow Score at hospital discharge were 13 - 15 points in 15 patients (93.75%), and points in patient (6.25%); the results of the reexamination were good 75%, average 18.75%, bad 6.25% (aneurysm ruptured in the 206 Journal of military pharmaco-medicine no8-2018 operation) [3] A retrospective study by S Claiborne (2001) showed that mortality rate of postoperation in unruptured aneurysm patients was 3.5% [11] Table 4: Modified Rankin Scale at discharge Results Good Average Bad Dead Modified Rankin Scale Unruptured aneurysm (n = 21) Ruptured aneurysm (n = 135) n % n % 1 4.8 3.0 19.0 24 17.8 14 66.7 57 42.2 9.5 37 27.4 0.0 1.5 0.0 11 8.1 According to Modified Rankin Scale, good results reached 21.1%, average 45.5%, bad 26.3%, dead 7.1% There was no statistically significant difference between the two groups According to Wiebers (2003), in a multicentre study on unruptured aneurysm (ISUIA), patients underwent surgery with a mortality rate for the first 30 days was 13.7%, for the first year 12.6%; the results of age-related surgery (≥ 50 years, RR 2.4 [1.7 - 3.3], p < 0.0001), aneurysm size (> 12 mm) were associated with poor Total (n = 156) n % 33 21,1 71 45.5 41 26.3 11 7.1 p 0.226 outcomes (2.6 [1.8 - 3.8], p < 0.0001); rate of ruptured aneurysm in the surgery, intracranial clot postoperation, cerebral infarction were 6%, 4%, 11%, respectively [4] Ten years later, also in the ISUIA study by Lawson et al (2013), mortality after intra-vascular and surgical interventions were 2.17% and 2.66%; severe were 2.16% and 4.15%; the best treatment outcomes for surgery were in patient ≤ 70 years old, and intravascular interventions were in patient ≤ 81 years old [12] Table 5: Modified Rankin Scale at re-examined time Results Good Average Bad Dead Modified Rankin Scale Unruptured aneurysm (n = 18) Ruptured aneurysm (n = 105) n % n % 13 72.2 66 62.9 16.7 12 11.4 5.6 13 12.4 5.6 3.8 0.0 1.0 0.0 8.6 Total (n = 123) n % 94 76.4 14 11.4 4.9 7.3 p 0.698 In re-examined patients, there was no significant difference in Modified Rankin Scale in two groups 207 Journal of military pharmaco-medicine no8-2018 Table 6: Comparison of long-term and postoperative outcomes on Modified Rankin Scale in patients undergoing follow-up Long-term outcome mRANKIN Postoperative outcome (mRANKIN) Total Good Average Bad Dead Good 22 52 20 94 Average 14 Bad 1 Dead 26 61 36 123 Total 2 χ ;p χ = 16.31; p = 0.012 There were significant differences between long-term and short outcome (after discharge time) with the trend of getting better (p = 0.012; χ2 = 16.31) The results were also related to preoperative clinical parameters and volume of intracranial blood clot, in a study by Bing Zhao et al (2015) on 24 craniectomy patients with middle cerebral artery aneurysm with WFNS level IV, V through postoperative followup of 12.3 months, good outcome of 58%, mortality of 29% Compared with standard craniectomy, there was no difference in the complication and outcome of treatment [13] The good results improved from 21.1% to 76.4%, the average group decreased from 45.5% to 11.4%, the bad group from 26.3% to 4.9%, the difference was statistical significance with p = 0.012 Several previous studies had shown that longterm complications such as anxiety, depression, memory loss and bleeding risk Table 7: Results of postoperative DSA Postoperative DSA Unruptured aneurysm (n = 16) Ruptured aneurysm (n = 92) Total (n = 108) p n % n % n % No aneurysm 14 87.5 88 95.7 102 94.4 Residual aneurysm 12.5 4.3 5.6 Narrowed vessel with aneurysm 0.0 1.1 0.9 Obstructed vessel 6.3 3.3 3.7 0.48 There were no significant differences between the two groups According to Nguyen The Hao (2009), the proportion of patients undergoing DSA postoperative examination was 36.5%, of which 6.7% 208 0.216 detected cerebral embolism [2] In the study by Nguyen Minh Anh (2009), the proportion of patients who received postoperative DSA was 70.9%, with 95.3% of the aneurysms that were completely clipped [1] Journal of military pharmaco-medicine no8-2018 In study by Ito et al (2017), rate of postoperative CTA screening was 90.2%, DSA was 9.8% within 30 days, detected 2.5% of residual aneurysm, mostly in anterior communcating artery, the differences were statistically significant (p < 0.01) Good results in mRankin were 48.4%, average 39.3%, bad 12.3% [9] CONCLUSSION The results of microsurgical clipping of cerebral arterial aneurysm at the hospital discharge were good 21.1%, average 45.5%, bad 26.3%, dead 7.1% The longterm results were good 76.4%, average 11.4%, bad 4.9% and dead 7.3% Results of postoperative DSA were 94.4% completely clamped, 5.6% residual aneurysm, 3.7% vascular occlusion and 0,9% narrowed arteries that carry the aneurysm Aneurysm clipping surgery is still a selected method that bring good results for patients with cerebral arterial aneurysm REFERENCES Nguyễn Minh Anh Nghiên cứu chẩn đoán điều trị túi phình động mạch cảnh đoạn cạnh mấu giường trước vi phẫu thuật 2012 Nguyễn Thế Hào Vi phẫu thuật 318 ca túi phình động mạch não vỡ Bệnh viện Việt Đức Tạp chí Y học Thực hành 2009, 693 + 693, tr.106-111 Nguyễn Trung Thành, Nguyễn Thế Hào, Phạm Quỳnh Trang Đặc điểm lâm sàng, hình ảnh kết điều trị vi phẫu thuật túi phình động mạch não lớn khổng lồ Tạp chí Y học Thành phố Hồ Chí Minh 2015, 19 (6), tr.341-345 Wiebers D.O, Whisnant J.P, Huston J et al Unruptured intracranial aneurysms: Natural history, clinical outcome, and risks of surgical rd andendovascular treatment Lancet 2003, 362 (9378), pp.103-110 Korja M, Kaprio J Controversies in epidemiology of intracranial aneurysms and SAH Nat Rev Neurol 2016, 12 (1), pp.50-55 Atkinson J.L, Sundt T.M, Jr, Houser O.W et al Angiographic frequency of anterior circulation intracranial aneurysms J Neurosurg 1989, 70 (4), pp.551-555 Vlak M.H, Algra A, Brandenburg R et al Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: A systematic review and meta-analysis Lancet Neurol 2011, 10 (7), pp.626-636 Asaithambi G, Adil M.M, Chaudhry S.A et al Incidence of unruptured intracranial aneurysms and subarachnoid hemorrhage: Results of a statewide study J Vasc Interv Neurol 2014, (3), pp.14-17 Bruno A, Close B, Switzer J.A et al Simplified modified Rankin Scale questionnaire correlates with stroke severity Clin Rehabil 2013, 27 (8), pp.724-727 10 Ito Y, Yamamoto T, Ikeda G et al Early retreatment after surgical clipping of ruptured intracranial aneurysms Acta Neurochir (Wien) 2017 11 Johnston S.C, Zhao S, Dudley R.A et al Treatment of unruptured cerebral aneurysms in California Stroke 2001, 32 (3), pp.597-605 12 Lawson M.F, Neal D.W, Mocco J et al Rationale for treating unruptured intracranial aneurysms: Actual analysis of natural history risk versus treatment risk for coiling or clipping based on 14,050 patients in the Nationwide Inpatient Sample database World Neurosurg 2013, 79 (3 - 4), pp.472-478 13 Zhao B, Zhao Y, Tan X et al Primary decompressive craniectomy for poor-grade middle cerebral artery aneurysms with associated intracerebral hemorrhage Clin Neurol Neurosurg 2015, 133, pp.1-5 209 ... statistically significant (p < 0.01) Good results in mRankin were 48.4%, average 39.3%, bad 12.3% [9] CONCLUSSION The results of microsurgical clipping of cerebral arterial aneurysm at the hospital discharge... retreatment after surgical clipping of ruptured intracranial aneurysms Acta Neurochir (Wien) 2017 11 Johnston S.C, Zhao S, Dudley R.A et al Treatment of unruptured cerebral aneurysms in California... Table 7: Results of postoperative DSA Postoperative DSA Unruptured aneurysm (n = 16) Ruptured aneurysm (n = 92) Total (n = 108) p n % n % n % No aneurysm 14 87.5 88 95.7 102 94.4 Residual aneurysm