Nghiên cứu hình thái tổn thương và đánh giá kết quả phẫu thuật điều trị túi phình động mạch não tt tieng anh

1 INTRODUCTION Cerebral aneurysm (cerebral artery) is a common pathology of cerebral artery system Research on bodies shows that cerebral aneurysm accounts for 0.2-7.9% of the population, some studies show an aneurysm rate of 5% The fatal complication is usually the rupture aneurysm and this is also one of the causes of brain stroke To date, the world as well as in Vietnam has used the methods of treating cerebral aneurysms such as: micro-surgery aneurysm, intravascular interventions Each method has its advantages and limitations, but microsurgical clipping aneurysm still plays an important role In the process of micro-surgery an aneurysm, there is a part of the neck that is missing, which is the cause of secondary bleeding and rupture of the aneurysm at 2.5% Clipping aneurysm can clip to the cranial nerves to cause damage Especially can be inserted into oblique arteries, arteries carrying aneurysm causes 9.52% brain anemia in them Surgical results, the rate of complications in surgery closely related to aneurysm morphology The study of the location, shape, size, aneurysm direction as well as related factors through clinical, imaging, observation during surgery helps surgeons have appropriate treatment tactics and prognosis after surgery In order to improve the quality of treatment for cerebral artery disease, we conduct the project: " research in morphology and assessing surgical results treatment of cerebral aneurysms" with the following objectives: Describe the morphological pattern of cerebral aneurysm surgical indications 2 Assess the results of cerebral aneurysm surgery New contributions of the thesis: The study described aneurysm morphology on CTA and DSA images The shape of aneurysm is mainly bag shaped, on CTA accounting for 98.7%, on CTA is 100% The aneurysm site is mainly found in the anterior communicating artery, on CTA is 38.3%, on DSA is 35.8% The size of aneurysms ≤5mm is the most popular, accounts for 65.6% on CTA and 57.6% on DSA Along with the development of intravascular intervention to treat cerebral aneurysm, surgery is still a basic method of choice, with good treatment results of 76.4%, the percentage of aneurysms clipped completely is 94.4% Thesis structure Total 134 pages: - page problem section; Chapter 1: Overview 33 pages; Chapter 2: Subjects and research methods 26 pages; Chapter 3: Research results 35 pages; Chapter 4: Discussion 37 pages; Concluding remarks 02 pages, Proposal 01 page The thesis has: 41 tables, 35 pictures and charts, 178 references CHAPTER OVERVIEW 1.1 Research situation of cerebral aneurysm 1.1.1 Studies over the world: The cerebral aneurysm was first described in the early 18th century and subarachnoid hemorrhage was primarily caused by the aneurysm In 1938, Dandy W.E announced the first successful surgical case to treat cerebral aneurysm with an aneurysm clipping Gallagher J.P (1963) introduced the technique of coagulation aneurysm by inserting animal hairs into aneurysm at high speed using an air gun ("hair pump") Serbinenko F.A occluded the aneurysm with balloon in 1970 In 1989, Guglielmi G., the Italian neurosurgeon, firstly invented the method of using a metal coil (coil) attached to a wire to pass through a wire microcatheter into aneurysm This is then cut off by direct current, which coagulates the aneurysm to remove aneurysm from the brain artery system while preserving the artery called the detachable metal spiral (GDC) In 2003, Reisch R et al reported a 10-year experience of using supraorbital craniotomy in surgical aneurysm and base skull The average skull cap size the authors made was 2.5x1.5cm 1.1.2 Researches in our country The first aneurysm surgery was reported by Nguyen Thuong Xuan et al in 1962 In 2006, Nguyen The Hao conducted the first doctoral thesis "Research diagnosis and surgical treatment of subarachnoid hemorrhage due to rupture of the internal carotid artery aneurysm" Nguyen The Hao et al (2015) published the study "Results of treatment of cerebral aneurysm with minimally invasive surgery at Bach Mai Hospital" including 48 patients with good results 87.5%, without residual aneurysm, nerve damage on eye socket 10.3%, ciliary muscle 7.7%, temporal muscle 5.1%, aesthetic patient complete satisfaction 76.9% Pham Dinh Dai (2011) has implemented the topic: "Study of clinical features, subclinical, results of treatment after intravascular intervention in patients with stroke due to cerebral aneurysm rupture" 1.2 Diagnostic image of cerebral aneurysm 1.2.1 Computerized tomographic without injection of contrast material With the new generation com machines for accurate diagnosis ≥ 95% of cases of subarachnoid hemorrhage in the first 48 hours With images of increasing the proportion of blood in the subarachnoid in the base of the skull (pituitary apoplexy, pontine cistern), Sylvius fissure, inter hemispherical fissures, cerebellum tent, even brain cortex 1.2.2 Computerized tomography angiography Computerized tomography angiography (CTA) results in diagnosing aneurysms up to 97% with the advantage of being a safe, effective method that can be used to diagnose both unruptured and ruptured aneurysms CTA for 3D images helps to identify the oblique veins separated from the aneurysm, as well as the anatomical connection between the aneurysm and the base of skull, which is important in the development of the surgery plan CTA is also valuable in diagnosing vasospasm 1.2.3 Magnetic angiography resonance imaging and magnetic resonance Magnetic resonance imaging (MRI) in the diagnosis of subarachnoid hemorrhage is not sensitive within the first 24-48 hours (due to too little met-Hb) especially with thin blood layers MRI gives the best results within 4-7 days (positive results are in a semiacute period of 10-20 days) Imaging on the Flair pulse provides the highest sensitivity to subarachnoid hemorrhage with increased signal imaging in the brain sulcus An MRI can detect a dilated aneurysm, the image of aneurysm without a blood clot in the upper T2W is usually regular, relatively clear, no signal, hollow flow, continuous with a blood vessel Magnetic resonance angiography (MRA) diagnoses aneurysmswith 87% sensitivity, 92% specificity, but difficult to diagnose aneurysm smaller than mm 1.2.4 Digital subtraction angiography This is the gold standard for determining the aneurysm active brain circuits DSA found 80-85% of cases of ruptured cerebral aneurysms causing subarachnoid hemorrhage (the rest are unexplained subarachnoid hemorrhage) 1.3 Micro surgical treatment of cerebral aneurysm 1.3.1 Surgical approaches of aneurysm + Frontotemporosphenoidal approach: also known as the pterional approach is indicated for cases of aneurysm of the anterior cerebral circulation: the internal carotid arteries of aneurysm, the middle cerebral artery, the anterior cerebral artery; or basilar tip aneurysm + Subfrontal approach: is indicated for anterior communicating artery aneurysm with an aneurysm upwards, especially in cases where intracerebral hemorrhage large + Anterior interhemispheric approach: is indicated for anterior communicating artery aneurysm, with the advantage of a small brain lift + Transcallosal approach: indicative for vesicular aneurysm + The superior temporal gyrus approach: is indicated for the aneurysm of the middle cerebral artery, with little advantage of the brain, can reduce the risk of vasospam + Suboccipital approach: indicative of the aneurysm of the basilar vertebral artery complex + Subtemporal approach: designates the basilar aneurysm at the same height as the superior cerebellar artery + Orbitozygomatic approach: Some authors use to access the basilar aneurysm + Transcondylar approach 1.3.2 Microsurgical treatments for cerebral aneurysm + Clipping aneurysm + Wrapping aneurysm + Constricting artery carrying aneurysm CHAPTER SUBJECTS AND METHODS OF THE STUDY 2.1 Research subjects Including 156 patients who were diagnosed and treated for microsurrgical clipping at Department of Neurosurgery - Viet Duc Hospital from January 2011 to December 2013 2.1.1 Criteria for selecting a patient + Patients diagnosed with cerebral aneurysms disease identified by: DSA and or CTA + Patients underwent surgery at the Department of Neurosurgery - Viet Duc Hospital with clear surgical records, image on noninjected brain CT scan, CTA, DSA cerebrovascular clearly, with sufficient reliability 2.1.2 Exclusion criteria + Patients who are diagnosed with cerebral aneurysm and that the patient and family them not agree to surgery + Patients diagnosed with cerebral aneurysm are treated with endovascular 2.2 Methods Describe a series of prospective non- controlled clinical clinical trials and cross-cutting, 2.3 Formula to calculate sample size + Select a sample: Select a probability sample, using a convenient sampling method Select all patients diagnosed with coronary aneurysm and received microsurgical surgical treatment for neck aneurysm during the study + Sampling selection: Probability sampling, using convenient sampling methods Select all patients diagnosed with coronary aneurysms and treated for micro-aneurysms during the study period In this study we performed 156 patients 2.4 Research content 2.4.1 Study clinical characteristics + Age of patients at the time of diagnosis to determine: average age, minimum age, maximum age, divided into groups: 13-20, 2155, 56-57 + Gender: determining the incidence between men and women + Medical history: t antennas blood pressure, headache, CTSN, cerebral stroke, polycystic kidney, alcoholism, smoking + Clinical characteristics: - Patients with unruptured aneurysm: headache, nausea, epilepsy, cranial nerve damage Clinically assessed on a Glasgow scale, modified Hunt-Hess grading and modified WFNS grading - Patients with ruptured aneurysms: determine the time from the onset to the time of admission, determine the time from the onset to the time of surgery Judged by a Glasgow coma scale, modified Hunt-Hess grading and modified WFNS Determine whether an aneurysm has ruptured before surgery and the number of ruptures 2.4.2 Study morphological characteristics of aneurysm 2.4.2.1 Computerized tomography without contrast * Unruptured aneurysm: Gather information about aneurysm divided into groups, including: + No injury detected + Detecting lesions: stunned blocks, calcified images, increasing density * Ruptured aneurysm: + Determine the image of subarachnoid hemorrhage, location (pontine cisterns, pituitary apoplexy, hemispherical fissures, Sylvius trench, posterior fossa, other locations), time from onset to at the time of shooting, determine the relationship between the time of shooting and accuracy in detecting subarachnoid hemorrhage, degree of subarachnoid hemorrhage and predicting vasospasm according to Fisher 10 2.4.2.2 Digital subtraction angiography (DSA) Digital subtraction angiography was performed on GE Advantx machine at the diagnostic imaging department of Bach Mai Hospital, the diagnostic imaging department at Viet Duc Friendship Hospital Selective scan of the internal carotid artery and vertebral artery Take upright, sloping, and 3/4 poses and special positions depending on the direction of the SEG The evaluation criteria are divided into two groups (unruptured aneurysms ruptured aneurysm), including: * Number of aneurysm: aneurysm, aneurysms, aneurysms, aneurysms * Aneurysmposition: right, left + Anterior cerebral circulation: - Superior hypophyseal artery - Ophthalmic artery - Posterior communicating artery - Internal carotid artery bifurcation - Internal carotid artery - Middle cerebral artery - Middle cerebral artery bifurcation - Anterior cerebral artery 18 Comment: There were 18 patients CTA scan in the group without rupture of the aneurysm, of which 17 patients had aneurysm and patient had aneurysms In the ruptured group, there were 125 patients, of which 115 patients found aneurysm, patients found aneurysms, patient had aneurysms, a total of 134 patients had an aneurysm but there was no aneurysm on CTA Thus, the total number of aneurysms detected on CTA of 143 patients was 154 aneurysms of which 132 patients had aneurysm and patients had aneurysms and patients had aneurysms Table 3.11 Characteristics of aneurysms on computerized tomography angiography Unruptured Ruptured Total Aneurysms Aneurysms p (n = 154) Characteristics (n = 20) (n = 134) aneurysm Ratio Ratio Ratio Amount Amount Amount % % % Figure 20 100.0 132 98.5 152 98.7 bag Shape 0.7756 Rhombus 0.0 1.5 1.3 One lobe 14 70.0 115 86.5 129 84.3 Number 0.06 Multiple of lobes 30,0 18 13.5 24 15.7 lobes Erratic 12 60,0 124 92.5 136 88.3 Aneurysms 0,000 Are all 40.0 10 7.5 18 11.7 Calcium neck pocket 15.0 0.8 2.6 0.0007 There are oblique 5.0 6.0 5.8 0.67 branches Comment: The difference between has statistically significant about the properties of regular or irregular bulge, in which, the ruptured group has a higher proportion of aneurysm (p = 0,000) 19 The situation of calcification was also different between the groups In which the ruptured group had lower calcification rate (p = 0.0007) The characteristics of aneurysm shape, number of lobes, oblique branch, and thrombosis were not significantly different between the unruptured and ruptured aneurysm group Table 3.12 Characteristics of aneurysm position on computerized tomography angiography Unruptured Ruptured Total Aneurysms Aneurysms (n = 154) Location of aneurysms (n = 20) (n = 134) Right Left Right Left n % Superior hypophyseal 0 1 0.6 Ophthalmic artery 0 1.3 Posterior 2 21 13.6 communicating artery Internal carotid artery 0 1 0.6 bifurcation Anterior Internal carotid artery 6 15 9.7 cerebral Middle cerebral artery 3.9 circulation Middle cerebral artery 13 12 29 18.8 bifurcation Anterior cerebral artery 0 1.9 Pericallosal artery 1 2.6 Anterior 55 59 38.3 communicating artery Vertebral artery 1 3.2 Posterior Posteroinferior circulator 0 4 2.6 cerebellar artery y system Basilar tip aneurysms 0 4 2.6 15 Total 13 93 41 100.0 Comment: Aneurysms are common in the anterior communicating artery location (38.3%); followed by the position middle cerebral artery 20 bifurcation (18.8%); posterior communicating artery (13.6%) Internal carotid artery, middle cerebral artery, posteroinferior cerebellar artery, basilar tip aneurysms, ophthalmic artery, superior hypophyseal, and internal carotid artery bifurcation 9.7%; 3.9%; 3.2%; 2.6%; 2.6%; 1.3%; 0.6%; 0.6% Table 3.13 Size characteristics of aneurysms on computerized tomography angiography Unruptured Ruptured Total Aneurysms Aneurysms p Size (n = 154) (n = 20) (n = 134) aneurysm Amoun Ratio Amoun Ratio Amoun Rati t % t % t o% ≤ 5mm 10 50,0 91 67.9 101 65.6 Size > 5-10mm 45.0 40 29.9 49 31.8 0.27 > 10-25mm 5.0 2.2 2.6 Neck 5-10mm 46.2 32 34.4 38 35.9 > 10-25mm 23.1 3.2 5.7 24 > 25mm 5mm is 77.8%, straight cut is 22.2%; difficult surgery in surgery 47%; ruptured aneurysm in surgery 42%, temporary clip in surgery 11%, aneurysm residue 13.9%; good results reached 83.3% 4.4.2 Far results There was no difference in the modified Rankin points between unruptured and ruptured aneurysms, the good results were 76.4%, the average was 11.4%, the bad was 4.9%, the death was 7.3% (table 3.39) According to Wiebers D.O et al (2003), in a multicenter study with an unruptured aneurysm (ISUIA), the group of patients undergoing surgery, the mortality rate and the number of patients who died and severe in the first 30 days and in the first year was 13.7% and 12,6%; surgical outcomes related to age (≥50 years, RR 2.4 [1.7-3.3], p 12mm) related to poor results (2.6 [1.8-3.8], p 5-10mm is 31.8%, >10-25mm is 2.6% 101 patients had DSA before surgery, found 106 aneurysms, of which 89 patients had aneurysm, patients had aneurysms, patient had aneurysms The shape of a bulging bag is 100% shaped The position of anterior communicating artery is 35.8%; middle cerebral artery bifurcatin 14.2%; posterior communicating artery 16%, internal carotid artery 9.4%, middle cerebral artery 4.7%, vertebral artery 0.9%, posteroinferior cerebellar artery 3.8%, basilar tip artery 2.8%, ophthalmic artery 3.8%, superior hypophyseal 0.9%, internal carotid artery bifucartion 2.8% The size of aneurysms ≤5mm is 57.6%,> 5-10mm is 35.9%,> 10-25mm is 5.7%,> 25mm is 0.9% The ability to detect the number of aneurysms when CTA and DSA combination is sensitive 83.3%, specificity is 97.6%, positive 32 predictive value is 71.4%, negative predictive value is 98.8% with 96.6% accuracy Evaluation of surgical aneurysm brain The average score of Glasgow hospital discharge for unruptured aneurysms was significantly higher than for an aneurysms (p = 0.001) The average point of the unruptured group is 14.4 ± 0.5, the average of the ruptured group is 12.7 ± 3.1, the average of both groups is 12.9 ± 2.9 Assessing the results far away on an modified Rankin scale at 78.9% with an average of 44.2 ± 15.4 months, a good rate of 76.4%, an average of 11.4%, a bad 4, 9%, death 7.3% There is no difference between the unruptured and ruptured aneurysms group with p = 0.698 108/156 patients with DSA after surgery achieved the rate of 69.23%, the rate of complete clipping was 94.4%, the percentage of aneurysm residue was 5.6%, vascular occlusion accounted for 3.7%, vascular stenosis, blood with aneurysm is 0.9% There is no difference between groups of unruptured and ruptured aneurysms Clinical classification before surgery, degree of subarachnoid hemorrhage, age of patients, rupture of the aneurysm before surgery are related to the bad outcome after surgery ... = X-ray emission time of injection speed) Time delay depends Bolus Test Spiral cutting 0.3 s / rev, 1.25 mm cutting layer thickness, 0.75 mm hops, 0.8 mm image reproduction Voltage of 120 KV,... ventricular drainage, revealing the internal carotid artery and outside the skull, cutting the anterior clinoid process, cutting a straight back, supporting endoscopy 2.4.7 Evaluation of clinical results... superior temporal gyrus approach: is indicated for the aneurysm of the middle cerebral artery, with little advantage of the brain, can reduce the risk of vasospam + Suboccipital approach: indicative