1 INTRODUCTION TO THESIS Posterior communicating artery (PcomA) aneurysm is the most common type of aneurysm, accounting for 30% 37% of all type of brain aneurysm Nowaday, PcomA aneurysm still difficu[.]
1 INTRODUCTION TO THESIS Posterior communicating artery (PcomA) aneurysm is the most common type of aneurysm, accounting for 30%-37% of all type of brain aneurysm Nowaday, PcomA aneurysm still difficult for both surgery and embolization Comprehensively evaluate the disease of rupture PcomA aneurysm, we research this thesis “Results of microsurgery treatment for rupture PcomA aneurysms” with objects: Study on clinical and imaging characteristics of PcomA aneurysms Evaluation results of treatment PcomA aneurysms and factors related to outcome of microsurgical treament THESIS LAYOUT The dissertation consists of 112 pages, of which there are 27 tables, 22 figures and charts Problem Set (2 pages); Chapter 1: Documentation Overview (36 pages); Chapter 2: Objectives and Methods (16 pages); Chapter 3: Research Results (20 pages); Chapter 4: Discussion (35 pages); Conclusion (2 pages); List of research results published dissertations (1 page); References (151 documents including Vietnamese documents, English documents); Appendices CHAPTER OVERVIEW 1.1 HISTORY OF ANEURYSMS RESEARCH 1.1.1 WORDWIDE Galen and Richard Wiseman (1969) are the pioneers use the aneurysm to describe cerebral dilation In 1676, Thomas Willis discovered Willis polygons and began research on stroke 1978, Gionis described the clinical picture of subarachnoid heamorrhage and 1775 Hunter described the aneurysms and anterovenous malformations Hutchinson (1875) described the symptoms of cavenous sinus aneurysms: headache, and paralysis of cranial nerve: III IV, VI and V1 Seldinger (1953) applied an easy method of angiogram through a catheter In 1983, Maneft et al discovered a method of Digital Subtraction Angiography (DSA) Boulin A and Pierot L compared the results of angiography and MRI Angiography (TOF) followup after coiling: MRI is difficult to detect a small flow that has just emerged, either with small flows remaining in an aneurysms or with a vascular sharp turn 1.1.1.2 Rupture aneurysms treatment - Surgical treatment: Norman Dott (1897-1973): The first neurosurgeon directly approach to cerebral aneurysm in 1931 In that surgery, he performed the muscle package to reinforce the wall at junction positions Patient have good outcome and live healthy 12 years later and died from myocardial infarction This surgery marks an advantaged in rupture aneurysms surgery Normam Dott was also the first aneurysm sugery based on imagine of angiography (1933) He conclusion that all of the brain aneurysms originate from branching sites and always accompany weak vascular walls If aneurysms near Willis polygons, he suggested that neurosurgeon should occlusion the carotid artery If aneurysm far from Willis polygons, open surgery and use muscles to wrap should be taken However, these are passive strategies with certain limitations, so neurosurgeons devise a strategy to completely isolate aneurysms from circulation while maintaining the diameter of the main trunk arteries On March 23, 1937, Walter Dandy used a V-shaped silver clip to clamp the neck of aneurysms, preserving the parents arteries in posterior communicating- intracerebral carotid artery (Pcom-ICA) aneurysm 43 year old with palsy CN III Dandy published the first book describing methods for aneurysms surgery, he also noted to neurosugeron about “the small neck of aneurysm is the best place to put a device to remove the aneurysm” Endovascular treatment In the 1960s, Luessenhop and Valasquez the pioneers of catheterization of the intracranial artery, they used a tube and injected Silastic directly into the intracranial vessels In 1990, a new type of spring: GDC- Guglielmi Detachable coil invented by Guglielmi, this is an electrolyti coil Only after being inserted into aneurysms through a microguidewire catheter, the spring will be cut with direct current and will be completely inside the sac of aneurysms 1.1.2 In Viet Nam 1962, Nguyen Thuong Xuan et al studied on the diagnosis and treatment of surgical for rupture aneurysms 2006, Nguyen The Hao reported surgical treatment of 73 carotid aneurysms rupture: the good result is 84,7%, the average result is 5,6%, the bad result is 9,7% 2008, Tran Anh Tuan researching the value of MSCT 64 slices compared with DSA in diagnosing cerebral aneurysm showed the sensitivity, specificity and accuracy of 94,5%, 97,6% and 95,5% And also showns the reconizable signs of rupture aneuryms: irregular margins, knobs or two bottoms 4 1.2 Diagnosis Clinical symtoms: Typical form bleeding: severe pain, different from previous headaches The patient complains of a headache like “hammering”, feeling “has never hurt like that” In studies around the world, it is found that 50%-80% of typical headache signs as described, no relief even with common drug for reduce the pain Headaches are usually localized in the forehead or occipital area spreading down the neck or eyes Nguyen The Hao 85,3% have headache, Vo Hong Khoi 97,8% Signs of meninggeal irritaion (nausea, vomiting, neck pain and meningeal syndrome) are common symptoms, accounting 57%-61%, and 35%-70% of meningeal syndrome have: muscle spasticity (tringger position), stiff neck, sign of Kernig, Brudzinski, Babinski, may be positive, increased pain sensation, photophobia light and sound, meningeal line positive General epilepsy can occur suddenly due to intracranical pressure (ICP) increase when aneurysms rupture accounts 12%-31% Combined intracranial hematoma: 10%-30% of rupture aneurysms have intracranical hematoma (ICH) The ICHs aggravate brain damage and increase ICP, so patients are often in severe condition, coma, or possibly with focal neurological signs Complications: Recurrent bleeding: 4,1% within the first 24 hours, 20% within weeks, and 30% within month, 50% within months and had worse prognosis and mortality rate was high 60%-80% Acute ventricular dilation Chronic ventricular dilation Ischemic: due to cerebral vasospasm, this can be seen usually from 4-14 days after aneurysms rupture Prognosis: Accoding to World Federation Nerosurgery (WFNS) classification 5 1.2.2 Radiography: 1.2.2.1 CT scaner: Fisher classification 1.2.2.2 Computer tomo angiography (CTA) In assessment of cerebral aneurysm, CTA has limited sensitivity to detect vesicles < 4mm Wintermark resently published 94,8%, 95,2% and 94,9% ovarall accuracy, specificity and sensitivity, if using Multi Series CT Scaner 1.2.2.3 DSA DSA are still considered the gold standard for the diagnosis of brain aneurysms Angiography can measure the accuracy size of the lesion, the traumatic vessel and evaluate the aneurysm to decide to perform endovascular or surgical treatment 1.2.2.4 MRI Non-invasive, safe, non-radioactive method, highly valuable in cerebral vascular assessment and without risk of complications like DSA and CTA TOF 3D technique (time of fly): Showns higher sensitivity than phase-contrast vascular MRI in detection aneurysms The sensitivity of TOF 3D from 55%-93% depending on the size of aneurysms 1.3 Treatment 1.3.1 Medical treatment - Prevent of cerebral vasospasm: (according to AHA – 2009) - Nimodipin: Is indicated to reduce poor recovery relate to subarrachnoid heamorrhage due to rupture of aneurysms Nimodipin is recommended to treat through 21 days and could be discontinued earlier in patients with less risk of vasospasm and in good clinical condition - Triple – H therapy for treatment of vasospasm after subarrachnoid heamorrhage: Increased circulating volume (Hypervolemia) Hypertension therapy Blood dilution therapy (Hemodilution): maintain the Hematocrit at 30% 6 1.3.2 Endovascular therapy 1.3.2.1 Coiling Indications: For all positions, with narrow or medium neck with the ratio dome /neck >1,5 or from 1,2 to 1,5 1.3.2.2 Coiling and Stenning Indication: for aneuryms with wide necks, the ratio dome/neck 3mm 2.4.6 Evaluate results of treatment 2.4.6.1 Evaluate short-term outcome 2.4.6.2 Evaluate long-term outcome 2.5 Methods of colection data and processing Research indicators were collected according to predesign form Data on each patient step by step Use SPSS software to calculate the results Research results presented in form of distribution tables and illustrative charts 10 CHAPTER RESEARCH RESULTS 3.1 Clinical and imaging characteristics 3.1.1 The clinical characteristics of the study group 3.1.1.1 Age, gender: the most common age in this research is from 60 year to 79 years, accounting 56,9% The youngest is 19 years old, and the oldest is 90 years old Mean age is 61,5 ± 13,6 3.1.1.2 History and coincident dieases: Hypertension is the most popular 53,8%, diabete occurs in 32,3% 3.1.1.3 Time to diagnosis: within 24 hours is a high rate 53,5% 3.1.1.4 Onset symtoms: Sudden (86,1%), severe headache (82,6%), nausea and vomiting (44,2%), temporary loss consciousness 15,1% 3.1.1.5 Clinical admission: Severe headache was 73,8%, nause and vomitting was 30,8% 3.1.1.6 Clinical classification according to WFNS admission: Good WFNS grade is 70,8% 3.1.1.7 Clinical classification according to WFNS before surgery: WFNS grading score I-II is about 36,9%, III-IV is 63,1% 3.1.2 Imaging Characteristics: 3.1.2.1 Image of bleeding: Subarachnoid bleeding on CT scaner is 100%, intracerebral hematoma 27,7%, ventricular heamorrhage is 67,7% 3.1.2.2 Timing of NCCT: 86,2% patients was performed CT within 24h from onset 3.1.2.3 Fisher grading score: 66,1% patients in Fisher 3-4 3.1.3 Aneurysms characteristics: Mean size of Pcom aneurysms are: 6,11 ± 2,91mm, including 58,5% Pcom aneurysm under 5mm Mean aneurysm neck size are 3,29 ± 1,54mm, including 67,7% under 4mm Aneuryms horizontal orientation: Lateral (58,5%), posterior (41,5%) 11 41 patients had dome/neck ratio under (63,1%) – 24 patients had dome/neck ratio over (26,9%) 3.2 Treatment results and related factors 3.2.1 Results of microsurgical treatment At the time of hospital discharge, the rate of good and moderate results (mRS score = 0-4) accounted for 92.3%, the rate of severe sequelae and death (mRS score = 5-6) was 7.7% At months, months and 12 months after treatment, the rate of achieving good results (mRS score < 3) was 37.1% - 44.7% and 52.3%, respectively At months, months and 12 months after treatment, the rates of severe sequelae and death (mRS score = 5-6) were 7.7% - 15.3% and 15.3%, respectively At the time of discharge, we had patients with severe sequelae and death After months, there were additional deaths, in which patient died from exhaustion and patient died from pneumonia (these two patients were in the group with mRS score = 3-4 when discharged from the hospital) and 01 patient died from pneumonia Patients moved from mRS score = 3-4 to the group of patients with mRS score = 5-6 However, 07 patients with good recovery switched from the group with mRS score = 3-4 at the time of discharge to the group with mRS score = 0-2 after months of treatment No patient with mRS score = 0-2 at the time of discharge progressed to the group with mRS score ≥ at this time After months, there was more death due to during rehabilitation exercise, traumatic brain injury (patient with mRS score = 0-2 at months), and case from mRS score =3-4 converts to mRS score = 5-6 The number of patients with severe sequelae and death (mRS score = 5-6) after 12 months of treatment remained the same compared to the time after months of treatment There were more patients with good progress changed from the group with mRS score = 3-4 at the time of 12 months of discharge to the group of patients with mRS score = 0-2 after 12 months of treatment The length of hospital stay of the patients under days, from to 14 days and over 14 days was 15,4% - 41,5% and 43,1%, respectively, with the mean duration of treatment was 15,3 ± 9,7 days Electrolyte disturbances and pneumonia were the two most common complications in the study, 33.3% and 30.6%, respectively The most common types of post-operative injury were cerebral contusion (27,7%), followed by cerebral ischemia (18,4%), subdural hematoma (15,4%), intraventricular bleeding (12,3%), epidural hematoma (9,2%) and cerebral edema (7,7%) 98.5% of cases were clamped completely on CTA film after surgery, there was only case of TP left over neck (1.5%) months after surgery, we conducted CTA to check 51 patients out of the remaining 57 patients (8 patients died and severe sequelae could not be examined), accounting for 87.7% After months and 12 months, we took CTA to check 51 patients out of the remaining 55 patients 13 3.2.1 Factors related to the outcome of microsurgical rupture of posterior communicating artery mRS < Age mRS ≥ OR 95%CI N % N % p < 60 10 45,5 12 54,5 OR = 4,28 ≥ 60 16,3 36 83,7 (1,33-13,75) p= 0,014 Gender WFNS at admission Size Neck size Dome/neck ratio Female 15 30,0 35 70,0 OR = 2,78 Male 13,3 13 86,7 (0,55–13,89) p = 0,211 I – III 16 34,8 30 65,2 OR = 9,60 IV – V 5,3 18 94,7 (1,17-78,64) p = 0,035 < 5mm 35,3 11 64,7 OR = 1,83 ≥ 5mm 11 22,9 37 77,1 (0,55-6,09) p = 0,322 ≥ 4mm 33,3 14 66,7 OR = 1,70 < 4mm 10 22,7 34 77,3 (0,53-5,36) p = 0,365 ≤2 12 29,3 29 70,7 OR = 1,57 >2 20,8 19 79,2 (0,47-5,18) p = 0,457 14 Fisher grading score 1-2 12 54,5 10 45,5 OR = 4,51 3-4 11,6 38 88,4 (1,72 – 8,26) p = 0,041 Temporary clipping No 28,3 32 71,7 OR = 9,54 Yes 33,3 16 66,7 (0,52-172,23) p = 0,126 - Patient age is a predictor of treatment outcome at the time of hospital discharge The percentage of patients under 60 years of age with good treatment results (mRS score < 3) at the time of discharge was 45.5%, compared with the group of patients over 60 years old was 16.3%, this difference is statistically significant millet with p = 0.014 The likelihood of patients under 60 years of age having good treatment results at discharge is 4.28 times higher than that of patients over 60 years old (95% CI - 1.33-13.75) - WFNS grade at the time of admission is also a predictor of treatment outcome at the time of discharge The proportion of patients with WFNS class I-III at the time of admission with mRS score < at discharge accounted for 34.8% compared with the group of patients with WFNS grade IV-V at admission was 5.3%, the difference This difference is statistically significant with p = 0.035 The prognosis of good treatment outcome (mRS score < 3) in patients with WFNS class I-III at hospital admission was 9.6 times higher than in patients with WFNS grade IV-V on admission (95% CI) – 1.17-78.64) - Fisher grade on cranial CT film is also a predictor of outcome at the time of hospital discharge Only 11.6% of patients with Fisher grade 3-4 had mRS score < at hospital discharge, compared with 54.5% of 15 patients with Fisher grade 1-2, this difference was statistically significant with p = 0.041 The ability to have good treatment results of patients with Fisher grade 1-2 is 4.51 times higher than that of patients with Fissher grade 34 (95% CI - 1.72-8.26) - Other factors including gender, TP size, TP diameter, neck fundus index, temporary clip placement were not predictive of treatment outcome at the time of hospital discharge in our study Age Gender WFNS at admission Size mRS < mRS ≥ N % N % p < 60 15 68,2 31,8 OR = 2,70 ≥ 60 19 44,2 24 55,8 (0,91-7,97) p = 0,0708 Femalc 28 50,0 28 50,0 OR = 0,50 Male 66,7 33,3 (0,11-2,20) p = 0,3592 I – III 31 67,4 15 32,6 IV – V 15,8 16 84,2 OR = 11,02 (2,77-43,75) p = 0,05 < 5mm 30 78,9 21,1 ≥ 5mm 14,8 23 85,2 OR 95%CI OR = 10,93 (2,95-40,41) p = 0,053 16 ≥ 4mm 42,9 12 57,1 OR = 0,57 < 4mm 25 56,8 19 43,2 (0,19-1,62) p = 0,2941 ≤2 21 51,2 20 48,8 OR= 0,88 >2 13 54,2 11 45,8 (0,32-2,43) p = 0,8184 Fisher grading score 1-2 16 72,7 27,3 OR = 1,21 3-4 18 41,9 25 58,1 (0,43-3,340) p = 0,7146 Temporary clipping No 20 48,7 21 51,3 OR = 0,29 Yes 14 58,3 10 41,7 (0,07-1,22) p = 0,0929 Neck size Dome/neck ration - WFNS grade at 12 months after treatment is a predictor of treatment outcome at this time The proportion of patients with WFNS class I-III at the time of admission with mRS score < after 12 months of treatment accounted for 67.4% compared with the group of patients with WFNS class IV-V at admission was 15.8% This difference is statistically significant with p = 0.05 The prognosis of good treatment outcome (mRS score < 3) in patients with WFNS class I-III on admission was 11 times higher than in patients with WFNS grade IV-V on admission (95% CI-2) ,7743.75) - Other factors such as patient age, TP size, TP neck diameter, Fisher grade are not predictive factors for treatment outcome at 12 months after treatment of ruptured posterior communicating artery in our study we 17 18 CHAPTER DISCUSSION 4.1 Characteristics of the study group 4.1.1 Age Our research group is in the age group of 60 to 79 years (accounting for 56.9%), with the average age of 61.5 ± 13.6 years old It is estimated that about 2-5% of the world's population has cerebral artery TP The frequency of rupture of this lesion varies by age, most commonly in the age group of 50 to 60 Recent research by Luong Quoc Chinh et al (2021) at major hospitals in Hanoi (Vietnam) showed that the average age of patients with CKD due to ruptured cerebral artery is 57 years old, in which the average age of the group of patients treated with CVA is 57 years old surgical method is 54 years old Do Hong Hai's study on 40 cases of coronary artery bypass grafting treatment with age from 40 to 65 years accounted for 85% and the mean age was 51.9 ± 9.57 years Author Nguyen The Hao found that 65.7% of patients with cerebral artery rupture were aged between 40 and 60 years old The results of these domestic studies are quite similar to our study 4.1.2 Gender 76.9% of patients in this study were female, with a female/male ratio = 3/1, similar to published studies on this pathology 4.1.3 Medical history Hypertension and diabetes were the two most common comorbidities in this study, 53.8% and 32.3%, respectively The process of formation, development and rupture of cerebrovascular TP is the result of a chronic disorder of cerebral blood vessels, in which, hypertension plays an important role 4.1.4 The patient's physical symptoms 95.4% of our patients presented with severe headache as the first symptom This was also the symptom most noted in previous studies About 70% of patients started the disease with headache symptoms, with the nature of "sudden onset, severe pain", the pain gradually increased within hour, found in 50% of cases of cerebral artery rupture Headache may also be the only manifestation of this form of disease In addition, symptoms may be encountered, including: vomiting, nausea, loss of consciousness or the appearance of focal neurological signs The three "classic" symptoms of MI due to rupture 19 of cerebral vessels accounted for 96.6% (sudden, severe headache), 54% (nausea, vomiting) and 49.2% (stiff neck) in 168 cases Research by Luong Quoc Chinh et al 4.1.5 Patient's WFNS classification on admission We had 46 patients on admission with WFNS class I-III, accounting for 70.8% of the total number of cases Hospitalized cases with severe clinical condition, WFNS IV-V classification was 29.2% We have only one case of grade WFNS V on admission, and no patient grade I 4.1.6 Time to take CT scan of brain without injection In our study, 56 patients had CT scan of the brain without injection within 24 hours after showing signs of disease onset, accounting for 86.2% Only patients (13.8%) had CT scan of the brain without injection after 24 hours from the onset of the disease 4.1.7 Fisher's grade on brain CT without injection Fisher grade 3-4 in our study accounted for 66.1%, compared with 33.9% case with Fisher 1-2 grade The observed position of CMD of our posterior communicating artery rupture was concentrated in the Sylvius cleft (66,1%), bleeding in the suprabasal, peripontine, basal cistern and interhemispheric fissures, respectively, 32% - 21,5% 15,4% and 10,7% 4.1.8 Dimensions of ruptured posterior communicating aneurysm We divided the patients in the study group into groups based on aneurysm size: < 5mm, from 6mm - 10mm and from 11mm - 25mm with the proportion of the groups respectively 58.5% - 33.8% - 7.7% The average size of aneurysms in this study was 6.11 ± 2.91 mm 4.1.9 Baseline index of ruptured posterior communicating artery aneurysm Our research found that there were 41 cases with a neck bottom index ≤ 2, accounting for 63.1% The cities with the bottom index > accounted for 36.9% with 24/65 cases 4.1.10 Direction of posterior communicating aneurysm We divided the posterior communicating artery TP into two groups based on the direction of the TP, including posterior and lateral orientation In this study, the proportion of cities facing the back accounted for 41.5% of the cases, the cities facing to the side accounted for 58.5% 20 4.2 Results of microsurgical treatment of ruptured posterior communicating artery aneurysms In a total of 65 cases of post-ruptured septal artery dissection receiving microsurgical intervention, 26.2% of patients on discharge from hospital did not have any neurological defects or mild sequelae that not affect working capacity mRS score