Results of the surgical treatment of the aneurysms of anterior cerebral artery – anterior communicating artery complex
Objective – to establish the features of clinical presentation and to optimize surgical treatment of arterial aneurysms (AA) of the anterior cerebral artery–anterior connecting artery (ACA–AComA) complex.
Materials and methods. The results of surgical treatment of 267 (100 %) patients with AA of the ACA–AComA complex during the period from 01.01.2011 till 31.12.2017 were analyzed. There were 143 (53.6 %) women and 124 (46.4 %) men. Microsurgical clipping was performed in 165 (61.8 %)
cases, endovascular coiling in 122 (38.2 %) cases. The organization of the medical care, clinical and instrumental examinations, medical and surgical treatment was done according to the current protocols (the Decree of the Ministry of Health of Ukraine dated April 17, 2014, N 275, EBM Guidelines, 28.8.2017, Juha E. Jääskeläinen).
Results. The AA rupture was diagnosed in 238 (89.2 %) patients. 181 (67.9 %) patients were hospitalized till the 28th day since AA rapture. The severity of the patients state according to the level of conscious during hospitalization: in conscious – 92 (34.4 %), obtunded – in 127 (47.6 %), stuporous – in 28 (10.5 %), comatose – 20 (7.5 %). The severity of subarachnoid hemorrhage (SAH) according to WFNS (World Federation of Neurological Surgeons) Grading Scale: grade I – in 63 (23.6 %) patients, grade II – in 43 (16.1 %) patients, grade III – in 78 (29.2 %) patients, grade IV – in 36 (13.5 %) patients, grade V – in 18 (6.8 %) patients. Altered mental status was found in 87 (32.6 %) patients, among them in 29 (10.8 %) patients with non-hemorrhagic presentation. Motor deficiency was diagnosed in 116 (43.4 %) patients, cranial nerve palsy – in 42 (15.7 %) patients, particular visual disturbances – in 28 (10.5 %) cases, oculomotor palsy – in 5 (1, 9 %) cases, visual and oculomotor disturbances – in 9 (3.3 %) cases.
Subarachnoid hemorrhage with intracerebral hematoma was detected in 184 (77.3 %) patients. Localization of hematomas: frontal lobes – 161 (87.5 %) cases, corpus callosum – 15 (8.1 %) and/or septum pellucidum – 8 (4.4 %). The intraventricular hemorrhage was diagnosed in 81 (34 %) patients: 1–4 points according to Graeb score – in 32 (39.5 %) patients, 5–8 points – in 27 (33.3 %) patients, 9–12 points – in 22 (27.2 %) patients. Lateral or axial dislocation was found in 28 (11.8 %) cases. Cerebral vasospasm in acute period was observed in 59.7 % of patients, and in 19.3 % of patients in «cold» period.
The localization of the AA of ACA–AComA complex (according to M.G. Yasargil): anterior – in 50 (18.7 %) cases, posterior – in 42 (15.7 %), superior – in 98 (36.7 %), inferior – in 35 (13.2 %),
mixed projection – 42 (15.7 %) cases. Saccular aneurysms were found in 192 (71.9 %) patients, «complex» AA – in 75 (28.1 %). The size of AA in the most observations (252 (94.3 %)) was less than 15 mm. Hypoplasia or aplasia of one A1 segments of ACA we revealed in 45 (18.9 %) cases.
Comorbid conditions: hypertension (HTN) – in 175 (65.5 %) patients, the combination of HTN with ischemic heart disease (IHD) – in 117 (43.8 %), hypertension, HTN in combination with systemic atherosclerosis – in 87 (32.6 %), diabetes mellitus (DM) – in 61 (22.8 %), combination of HTN, IHD, DM and systemic atherosclerosis – in 47 (17.6 %) cases.
According to the timing of procedure, there were 54 (20.2 %) emergency procedure, 127 (47.6 %) urgent, and 86 (32.2 %) semi-elective. In 37 (68.5 %) cases, emergency surgical interventions were microsurgical clipping, in 32 (59.3 %) – combined. Class I of occlusion of the treated AA according to Raymond scale was achieved in 93.9 % after microsurgical clipping, and 77.5 % after endovascular coiling. Favorable outcome according to Extended Glasgow Outcome Scale (GOSE) after surgical treatment were achieved in 75.3 % with a total mortality of 7.1 %, and significant differences in outcome in groups with different timing of surgery.
Conclusions. It was found that hemorrhagic presentation with the formation of intracerebral hematoma in the frontal lobes, with dislocation syndrome, intraventricular expansion, cerebral vasospasm with clinical manifestations of the I–III grade of SAH of WFNS scale, motor deficiency
(43.4 % of cases), cranial nerve palsy (15.7 %) and altered mental status (32.6 %) was typical for AA of ACA–AComA complex. It was found the dependence of outcome after surgical treatment of AA of ACA–AComA complex from the timing and method of surgical procedure. The criteria for the selection of optimal surgical tactic are the type of clinical presentation of the disease, the timing after aneurysms rapture, the severity of the preoperative condition, the presence of cerebral vasospasm, anatomical and topographical characteristics of the aneurysm.
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