J Huazhong Univ Sci Technol[Med Sci] 34(5):716-721,2014 DOI 10.1007/s11596-014-1341-x J Huazhong Univ Sci Technol[Med Sci] 34(5):2014

716

Surgical Treatment of Poor Grade Middle Cerebral Artery Aneurysms Associated with Large Sylvian Hematomas Following Prophylactic Hinged Craniectomy* Hai-jun WANG (王海均)1, You-fan YE (叶佑范)2, Yin SHEN (沈 寅)1, Rui ZHU (朱 瑞)3, Dong-xiao YAO (姚东晓)1#, Hong-yang ZHAO (赵洪洋)1# 1 Department of Neurosurgery, 2Department of Ophthalmology, 3Department of Integrated Traditional Chinese Medicine and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China © Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2014

Summary: The clinical characteristics of patients who presented in poor clinical grade due to ruptured middle cerebral artery aneurysms (MCAAs) associated with large sylvian hematomas (SylH) were analyzed and an ingenious designed prophylactic hinged craniectomy was introduced. Twenty-eight patients were graded into Hunt-Hess grades Ⅳ-Ⅴ and emergency standard micro-neurosurgeries (aneurysm clipping, hematoma evacuation and prophylactic hinged craniectomy) were performed, and their clinical data were retrospectively analyzed. 46.43% of the patients reached encouraged favorable outcomes on discharge. The favorable outcome group and the poor outcome group significantly differed in terms of patients’ anisocoria, Hunt-Hess grade before surgery, extent of the midline shift and time to the surgery after bleeding (P0.05). However, ingenious designed prophylactic hinged craniectomy efficiently reduced the patients’ intracranial pressure (ICP) after surgery. It was suggested that preoperative conditions such as Hunt-Hess grading, extent of the midline shift and the occurrence of cerebral hernia affect the prognosis of patients, but time to the surgery after bleeding and prophylactic hinged craniectomy are of significant importance for optimizing the prognosis of MCAA patients presenting with large SylH. Key words: aneurysm; sylvian hematoma; middle cerebral artery; early surgery; craniectomy; angiography

It was noted that patients with middle cerebral artery aneurysms (MCAAs) may have worse outcome than patients with other anterior circulation aneurysms[1]. Ruptured MCAAs leading to large sylvian hematomas (SylH) are inclined to cause brain herniation, poor Hunt-Hess grades and a high rate of mortality[2]. The patients are usually in bad clinical condition and need urgent surgical management. We not only report the favorable outcomes of surgeries in patients who presented in poor clinical grade (Hunt-Hess grades Ⅳ-Ⅴ) due to ruptured MCAAs associated with large SylH, but also introduce the special prophylactic hinged craniectomy and surgery experience in this study. The data and the factors described in this study will be benefit for improving the prognosis of these patients. 1 CLINICAL DATA AND METHODS 1.1 General Characteristics We analyzed the data of 28 consecutive patients, all of whom accepted surgery treatment in the neurosurHai-jun WANG, E-mail: [email protected] # Corresponding authors, Hong-yang ZHAO, E-mail: [email protected]; Dong-xiao YAO, E-mail: [email protected]. * This project was supported by National Natural Science Foundation of China (No. 81201026).

gery department, suffering from large SylH caused by ruptured MCAAs. We reviewed the patients’ hospital records including medical charts, intensive care unit records, operative records, anesthesia records, operation video records and radiological findings such as cerebral computed tomography (CT) scans and angiography. There were 11 males and 17 females with age ranging from 38 to 71 years old (mean 55.4 years). All patients were stratified into Hunt-Hess Ⅳ or Ⅴgrade before operation[3]. The anisocoria was found in 13 cases before surgery, suggesting the progression of the brain herniation. The hematomas distributed equally in both hemispheres. The precise locations were re-confirmed during the course of surgery. Sixteen patients underwent three-dimensional computed tomography angiography (3D-CTA) before intervention, and the rest 12 patients received digital subtraction angiography (DSA). General data are shown in table 1. 1.2 Methods Emergency surgeries were implemented in all patients and performed by experienced neurosurgeons employing standard microneurosurgical technologies. Postoperative patients were under surveillance in Nervous Intensive Care Unit (NICU) and their vital signs and intracranial pressure (ICP) were monitored. Routine dosage of nimodipine injection was administered periopera-

717

J Huazhong Univ Sci Technol[Med Sci] 34(5):2014

tively (20 mg, 24-h continuous intravenous infusion for 2 weeks). Hypertensive, hypervolemic and hemodilution treantments were executed in cases of symptomatic vasospasm. Each patient received daily neurological examinations and a re-examination of CT scan or 3D-CTA scan. The volume of hematoma was calculated following the acknowledged Coniglobus formula[4]. Patients with a hematoma volume of 30 mL or larger were included in

Parameters n Sex Male Female Age (years) Location of aneurysms MCAA Pcoa Size of AN (mm) Location of haematoma Right Left Size of haematoma (mL) Anisocoria Midline shift (mm) Angiogram DSA CTA Hunt and Hess Ⅳ Ⅴ Time to the surgery after bleeding

GR 4

this study. Routine follow-up was performed after each patient was rehabilitated and discharged. Neurological functions were assessed on discharge according to the acknowledged Glasgow Outcome Scale (GOS)[5]. The GOS describes good recovery (GR), moderate disability (MD) as favorable outcomes, whereas severe disability (SD), vegetative state (VS) and death (D) constitute poor outcomes.

Table 1 Basic information of patients Favorable outcomes MD SD 9 6

4 9 55.78±8.99

7 8 55.07±7.88

13 1 8.92±3.15

15 0 9.60±3.78

6 7 45.23±8.70 3 8.54±1.80

8 7 48.60±11.54 10 11.47±2.83

2 11

10 5

9 4 7.08±3.10

4 11 26.03±5.43

1.3 Surgical Technique Extended pterional approach was adopted in this group of MCAA patients presenting with large SylH. A standard skin incision in the shape of a reverse question mark was made. Endocranium enlarged duraplasty was applied after aneurysm clipping and hematoma evacuation. Temporal bone was partly removed as a prophylactic routine. The frontal bone flap was re-fixed by two pieces of suture which hinged the bone flap to the parietal bone. So when ICP was elevated, the mobile bone flap could rise up and reduce the space-occupying effect, and it would drop down to the former position when ICP decreased (fig. 1 and 2). 1.4 Statistical Analysis The data were expressed as ±s, and comparisons between groups were made using the unpaired t test or chi-square test. All data were analyzed by SPSS15.0 software. P

Surgical treatment of poor grade middle cerebral artery aneurysms associated with large sylvian hematomas following prophylactic hinged craniectomy.

The clinical characteristics of patients who presented in poor clinical grade due to ruptured middle cerebral artery aneurysms (MCAAs) associated with...
2MB Sizes 0 Downloads 5 Views