Surgical result of cerebral aneurysm clipping – Nguyen Thanh Bac

Journal of military pharmaco-medicine n o 8-2018 204 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, 3 to 12 million Americans harbor intracranial aneurysms. The incidence of reported ruptured aneurysms is about 6 to 7 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, 1. 103 Military Hospital 2. Vietduc Hospital Corresponding author: Nguyen Thanh Bac (bacnt103@gmail.com) Date received: 20/08/2018 Date accepted: 02/10/2018 Journal of military pharmaco-medicine n o 8-2018 205 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. SUBJECTS AND METHODS 1. Subjects. 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 Hospital from January 2011 to December 2013. 2. Methods. This is a retrospective and prospective study. * Factors: - Patients were divided into two groups: Unruptured and ruptured aneurysm group. - Results about age, sex. - 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 0 No symptoms 1 No complication but slight symptom, abilities to do everything a day 2 Slight complication: Uncompleted all activities as before, self-serve without other help 3 Middle complication: Patients need some help, but they can walk without assistance 4 Relatively severe complication: Patients can not walk themselves, not self-service if without help 5 Severe complication: Paralysis and spasm disorder 6 Dead (* Source: Askiel Bruno (2013) [6]) * Footnotes: Rankin score 0 - 2: good clinical condition; Rankin score 3: middle clinical condition; Rankin score 4 - 5: bad clinical condition; Rankin score 6: dead. Data were statistic processed by using SPSS software, version 15.0 (statistical package for social science). Journal of military pharmaco-medicine n o 8-2018 206 RESULTS AND DISCUSSION Table 2: Location of aneurysm. Total (n = 166) Location of aneurysm Unruptured aneurysm (n = 22) Ruptured aneurysm (n = 144) n % Superior hypophyseal artery 2 4 6 3.6 Ophthalmic artery 3 2 5 3.0 Posterior communicating artery 3 24 27 16.4 Internal carotid bifurcation 0 5 5 3.0 Internal carotid artery 2 2 4 2.4 Middle cerebral artery 1 6 7 4.2 Middle cerebral bifurcation 4 24 28 17.0 Anterior cerebral artery 0 3 3 1.8 Pericallosal artery 1 2 3 1.8 Anterior circulation Anterior communicating artery 4 61 65 39.4 Vertebral artery 2 3 5 3.0 Posterior cerebellar artery 0 4 4 2.4 Posterior circulation Bifurcation of basilar artery 0 4 4 2.4 Total 22 144 166 100.0 Table 2 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 Unruptured aneurysm (n = 21) Ruptured aneurysm (n = 135) Total (n = 156) p Glasgow Coma Scale at hospital discharge 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 5 points in 1 patient (6.25%); the results of the re- examination were good 75%, average 18.75%, bad 6.25% (aneurysm ruptured in the Journal of military pharmaco-medicine n o 8-2018 207 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. Unruptured aneurysm (n = 21) Ruptured aneurysm (n = 135) Total (n = 156) Results Modified Rankin Scale n % n % n % p 1 1 4.8 4 3.0 Good 2 4 19.0 24 17.8 33 21,1 Average 3 14 66.7 57 42.2 71 45.5 4 2 9.5 37 27.4 Bad 5 0 0.0 2 1.5 41 26.3 Dead 6 0 0.0 11 8.1 11 7.1 0.226 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 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. Unruptured aneurysm (n = 18) Ruptured aneurysm (n = 105) Total (n = 123) Results Modified Rankin Scale n % n % n % p 1 13 72.2 66 62.9 Good 2 3 16.7 12 11.4 94 76.4 Average 3 1 5.6 13 12.4 14 11.4 4 1 5.6 4 3.8 Bad 5 0 0.0 1 1.0 6 4.9 Dead 6 0 0.0 9 8.6 9 7.3 0.698 In re-examined patients, there was no significant difference in Modified Rankin Scale in two groups. Journal of military pharmaco-medicine n o 8-2018 208 Table 6: Comparison of long-term and postoperative outcomes on Modified Rankin Scale in patients undergoing follow-up. Postoperative outcome (mRANKIN) Long-term outcome mRANKIN Good Average Bad Dead Total Good 22 52 20 0 94 Average 1 7 6 0 14 Bad 1 1 4 0 6 Dead 2 1 6 0 9 Total 26 61 36 0 123 χ2; p χ2 = 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 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 long- term complications such as anxiety, depression, memory loss and bleeding risk. 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 follow- up 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]. Table 7: Results of postoperative DSA. Unruptured aneurysm (n = 16) Ruptured aneurysm (n = 92) Total (n = 108) Postoperative DSA n % n % n % p No aneurysm 14 87.5 88 95.7 102 94.4 Residual aneurysm 2 12.5 4 4.3 6 5.6 0.216 Narrowed vessel with aneurysm 0 0.0 1 1.1 1 0.9 1 Obstructed vessel 1 6.3 3 3.3 4 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% 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 n o 8-2018 209 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 long- term 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 1. Nguyễn Minh Anh. 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