Clinical features and effects of intravascular intervention of expanded aneurysm on the broken tentorium – Nguyen Duy Thanh

Journal of military pharmaco-medicine n o 9-2018 172 CLINICAL FEATURES AND EFFECTS OF INTRAVASCULAR INTERVENTION OF EXPANDED ANEURYSM ON THE BROKEN TENTORIUM Nguyen Duy Thanh1; Nguyen Hung Minh2; Vu Van Hoe2 SUMMARY Objectives: To describe the clinical features and effects of intravascular intervention of expanded aneurysm on the broken tentorium. Subjects and methods: Cross-sectional descriptive study of 65 patients, who were diagnosed with expanded aneurysm on the broken tentorium at 115 People’s Hospital from January 2011 to August 2017. Results: The most common age was from 40 to 60 years old (49.2%). Women had a higher incidence of disease than men (66.2%); for prevalence of high blood pressure, clinical symptoms included sudden headache of 98.5%, vomiting of 56.9% and nausea of 49.2%, meningitis of 69.2%, sensory impairment of 43.1%, seizures of 3.1%, focal neurology of 35.4%, drooping eyelid of 62% and language disorders of 9.2%. Clinical symptoms at the time of hospitalization: 12.3% for Hunt-Hess level I, 46.2% for level II, 35.4% for level III and 6% for level IV. Treatment of expanded aneurysm on the broken tentorium with coils and insertion ball had 29 cases (45%), obstruction with coils and stents had 34 cases (52%) and change in flow had 2 cases (3%). Total obstruction was 87%, partial obstruction was 5%, change in flow was 3% and failure was 5%. Right ventricle dilatation with VP shunt was 1 case, pneumonia was 9 cases and residual aneurysm was 1 case. These results were assessed in Glasgow, positive at 71%, negative at 25% and mortality at 5%. According to Hunt-Hess I - III, 46/65 patients were positive at 71.5%, and Hunt-Hess IV - V were negative at 4.6%. * Keywords: Intracranial aneurysm; Hemorrhagic meningine; Clinical features; Intravascular intervention. INTRODUCTION Intracranial aneurysm is a common system of cerebral arteries. Intracranial aneurysm accounted for 1 to 8% [5] of the population, most of the intracranial aneurysms were detected after they had broken. The rupture of the intracranial aneurysm was a type of stroke with a severe neurological disease, rapid and complex progression, causing many complications, sequelae as well as high mortality. The rupture of the intracranial aneurysm usually occurred suddenly, severe headache, with or without meningeal signs and local or total neurological dysfunction. After rupture, about 10% of patients died before being admitted. The number of surviving patients with primary bleeding was conservative, and the recurrent bleeding was the main cause of death, especially in the first two weeks. 1. 115 People′s Hospital 2. 103 Military Hospital Corresponding author: Nguyen Duy Thanh (thanhndngoaitk@gmail.com) Date received: 19/09/2018 Date accepted: 21/11/2018 Journal of military pharmaco-medicine n o 9-2018 173 In fact, the rupture of intracranial aneurysms was a tragedy for patients, families and society. Therefore, the rapid diagnosis, timely intervention and removal of the intracranial aneurysms from the brain circulation cycle by intravascular intervention to seal the intracranial aneurysms with coils (coil) to prevent patients from a serious surgery to open the skull bulging the intracranial aneurysms was a matter of concern in connection with our topic. The aims of this study were: To describe the clinical features and effects of intravascular intervention of expanded aneurysm on the broken tentorium. SUBJECTS AND METHODS 1. Subjects. Patients diagnosed with expanded aneurysm on the broken tentorium were treated at 115 People's Hospital from January 2011 to August 2017. * Criteria for selection: All patients with the expanded aneurysm on the broken tentorium were diagnosed clinically. Patients treated with intravascular intervention at 115 People's Hospital. Clinical classification of Hunt-Hess I, II, III. Obstruction of aneurysm with coils and stents across the neck for spherical aneurysm (aneurysm/neck ratio < 1.5) [2]. Congestion of diamond aneurysm and giant aneurysm. Patients and their families agreed to treatment. * Criteria for exclusion: Patients diagnosed with the rupture of the intracranial aneurysm on the tentorium were treated surgically. Patients were diagnosed with the rupture of the intracranial aneurysm on the narrow neck. Patients with severe medical and clinical illnesses of Hunt - Hess five, did not accept this treatment method. 2. Methods. Uncontrolled cross-sectional clinical descriptive study. * Steps: Epidemiology, clinical features of the ruptured intracranial aneurysm, intravascular intervention, complications after intervention and treatment results. RESULTS AND DISCUSSIONS 1. Epidemiology. * Age: The majority of patients between 40 - 60 years of age (30 patients), accounted for 46.2%, more than 60 years of age (32 patients) accounted for 40.2% and less than 40 years of age (3 patients) accounted for 4.6%, comparing with some authors: Nguyen The Hao [1], Nguyen Son [2], L. Pierot [6], there was no difference, almost 40 - 60 years. * Gender: In our study, women accounted for 86.2% (56 patients), and men accounted for 13.8% (9 patients). Comparing with some authors: Nguyen The Hao [1], Greenberg [5], Kassell [7], there was no different about gender. But in our study, the rate of women was important, perhaps our study is not enough. Journal of military pharmaco-medicine n o 9-2018 174 2. Clinical features of the ruptured intracranial on the tentorium. * Medical history: Figure 1: Medical history distribution. Patients with a history of hypertension were 43 patients (66.2%), 9 patients with a history of hemorrhagic meninge (13.8%), 20 patients with no medical history (30.8%) and 8 patients with other medical history (12.3%). The majority of patients in our study had history of hypertension. In comparing with the other authors like: Nguyen Son 53.8% [2], Le Van Thinh 56% [3]. There were no difference. * Time from onset to admission: The fastest time was 24 hours and the latest time was 30 days. Average time 4.48 ± 6.34 days (median: 2 days). In our study group, 26 patients (40.0%) were hospitalized for the first 24 hours, 20 patients (30.8%) were hospitalized for 2 - 4 days, 11 patients (16.9%) were hospitalized for 5 - 9 days and 8 patients (12.3%) were hospitalized for more than 10 days. It was shown that the rupture of the intracranial aneurysm was progressive and sudden. In first 24 hours, there were 26 patients (40%), less than in the study by Nguyen Thi Kim Lien (70%) [4]. It can be explained that only a few of patients in city can go to the hospital early before complication. * Clinical symptoms at onset: The two most common symptoms of hemorrhagic meninge were sudden headache in 64 patients (98.5%), vomiting in 37 patients (56.9%); nausea: 32 patients (49.2%); disorder of autonomic nervous system: 6 patients (9.2%); convulsion: 2 patients (3.1%) and drooping eyelids: 4 patients (6.2%). Our results were consistent with studies by Nguyen Son (90.91%) [2], Nguyen The Hao (83.5%) [1], Le Van Thinh (98.0%) [3]. * Clinical symptoms at admission: In our study group, meningiomas accounted for a majority (45 patients = 69.2%), 28 patients (43.1%) with disorder of consciousness perception and 23 patients (35.4%) with focal neurological syndrome; blood pressure ≥ 150 mmHg: 23 patients (35.4%); polio III: 4 patients; signs of focal neuropathy: 23 patients (35.4%); hemiplegia: 20 patients; language disorder: 6 patients (9.2%) and stiffness: 45 patients (69.2%). * Clinical levels at admission according to Hunt-Hess: 61 patients (93.8%) hospitalized with clinical levels from 1 to 3, 4 patients (6.2%) with level 4. In our study, Hunt-Hess level 4 and 5 was majority in the comparing with studies by Yasargil (10.7%) [8], Heros (19.6%) [9], maybe the patients with hemorrhagic meninge were late hospitality. Journal of military pharmaco-medicine n o 9-2018 175 3. Intravascular intervention. In our study group, there were 36 patients (55.4%) with stent obstruction and 29 patients (44.6%) were supported by insertion balls using coils blockage of blood vessels; neck stent: 34 patients; stent (change in flow): 2 patients. 57 patients (87.7%) with intracranial aneurysm were intervened with total intravascular obstruction, 3 patients (4.6%) with partial intravascular obstruction, 2 patients (3.1%) with change in flow, 3 patients (4.6%) with failure. 4. Incidents and complications after intervention. * Complications after intervention: Incidents after intervention in our study group had 1 patient (1.5%) with ventricular dilatation, 1 patient (1.5%) with residual aneurysm and 9 patients (13.8%) with pneumonia. 5. Treatment results. We monitored and re-examined all patients (100%). Our follow-up time occurred until all of them were discharged from the hospital * Interventions relevant to patient age according to GOS: Table 1: Correlation between age groups and patients. GOS Less than 55 years of age, n (%) ≥ 55 years of age, n (%) Total n (%) Very good (level V) 15 71.4 18 40.9 33 50.8 Good (level IV) 4 19.0 9 20.5 13 20.0 Average (level III) 2 9.5 10 22.7 12 18.5 Negative (level II) 0 4 9.1 4 6.2 Mortality (level I) 0 3 6.8 3 4.6 Total 21 44 65 p value 0.008 We found that the negative results were higher in the old age group, the clinical findings after intervention and age were statistically significant with p = 0.008 (< 0.05). * Interventions and pre-intervention status: Table 2: GOS findings and clinical pre-intervention status (Hunt-Hess clinical scale). Clinical pre-intervention status Level 1 - 3 Levels 4 and 5 Total Very good result 39 0 39 Good result 6 2 8 Average result 1 14 15 Negative result 0 3 3 Total 46 19 65 p value < 0.001 We found that the negative results were very common in patients with Hunt-Hess 4 and 5. Clinical conditions and results after intervention were statistically significant with p < 0.001. Journal of military pharmaco-medicine n o 9-2018 176 Table 3: Results, intervals of intervention, and clinical conditions upon admission. Interval Clinical level (Hunt-Hess) ≤ 4 days 5 - 10 days y > 10 days Average Level 1 - 3 22 6 34 10.56 ± 7.87 Level 4 - 5 0 2 1 8.33 ± 2.31 Total 22 8 35 10.46 ± 7.71 p 0.012 0.649 We found that no correlation between intervals of intervention and clinical conditions upon admission. Table 4: Results, intervals of intervention, and clinical conditions before intervention. Interval Clinical level before intervention ≤ 4 days 5 - 10 days > 10 days Total Very good result 11 4 24 39 Good result 3 2 3 8 Average result 8 0 7 15 Negative result 0 2 1 3 Total 22 8 35 65 p 0.024 We found that correlation between intervals of intervention and clinical conditions before intervention was found with p = 0.024. Clinical condition as light, the ability to recover better results consistent reporting Hunt-Hess (1968), with clinical status Hunt-Hess III survival rate of 50%, Hunt-Hess IV, V, (2009), the rate of good recovery with Hunt-Hess I-III accounted for 83%, the group IV-V accounted for 56%, and mortality in group I - III accounted for 5.3%, and Hunt-Hess IV - V accounted for 22%. According to Bracard (2002) [10], evaluating the results of intravascular interventions of 80 patients with clinical heavy status of Hunt-Hess grade IV, V showed the rate of good recovery accounted for 52.5%, with 37.5% of mortality in the first 6 months. Major cause of death from bleeding initial consequences in the group V and vasospasm with the group IV. Journal of military pharmaco-medicine n o 9-2018 177 * GOS-based assessments: Table 5: GOS-based intravascular interventions, GOS Number of patients Percentage (%) 1 3 4.6 2 4 6.2 3 12 18.5 4 13 20.0 5 33 50.8 Total 65 100.0 In this study, very good results (level IV - V) had 46 cases (70.8%), bad results (level II-III) had 16 cases (24.7%), mortality had 3 cases (4.6%). * Correlation between GOS at the time of discharging from the hospital and Hunt-Hess: Effective clinical assessment at the time of discharging from the hospital by Glasgow outcome on the basis of Hunt-Hess scale. Table 6: Hunt-Hess-based clinical results. Progression by Glasgow IV - V (positive) II - III (negative) I (mortality) Total Hunt- Hess n % n % n % n % I - III 46 100 70.8 16 100 24.6 0 62 95.4 95.4 IV - V 0 0 3 100 3 4.6 46 16 3 65 100 p < 0.001 (Fisher-based verification) The clinical results at discharge by Glasgow outcome in our group was positive at 70.8%, negative at 24.6%, and mortality at 4.6%. The difference between the positive group and the negative group was statistically significant with p < 0.001. Hunts-Hess I - III had 46 out of 62 patients who were discharged and assessed positively at 70.8%, Hunt-Hess IV - V had 3 out of 3 patients who died. The lower the Hunt-Hess scale was at admission, the better the results were at discharge. In this study group, the mortality rate was found to be Hunt-Hess IV - V. This difference was statistically significant (p < 0.001). Journal of military pharmaco-medicine n o 9-2018 178 CONCLUSION Through our study of intravascular intervention for 65 cases of expanded aneurysm on the broken tentorium at the Neurology Department of the 115 People's Hospital, the following conclusions were made: * Clinical features: - The most common age group was 40 - 60 (49.2%). Women had a higher incidence of disease than men. - High blood pressure accounted for 66.2%. - Common clinical symptoms included: Sudden headache, vomiting and nausea meningitis, sensory impairment, seizures, focal neurology, drooping eyelid and language disorders. - Clinical conditions at admission: 12.3% for Hunt-Hess level I; 46.2% for level II; 35.4% for level III and 6.2% for level IV. * Treatment results: - Interventions in the study group: Treatment of expanded aneurysm on the broken tentorium with coils and insertion ball had 29 cases (44.6%), obstruction with coils and stents had 34 cases (52.3%) and change in flow had 2 cases (3.1%). - Total obstruction was 87%, partial obstruction was 4.6%, change in flow was 3.1% and failure was 4.6%. - Right ventricle dilatation with VP shunt was 1 case, pneumonia was 9 cases and residual aneurysm was 1 case. - The results were assessed on Glasgow scale in our group, positive at 70.8%, negative at 24.6% and mortality at 4.6%. 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