To investigate the efficacy of early diagnosis and early surgery for middle cerebral artery aneurysm combined with lateral fissure hematoma. Methods: 23 patients with combined lateral fissure hematoma were examined by emergency DSA, CTA and CT, and early craniotomy + aneurysm clamping + lateral fissure hematoma removal was performed through expanded pterygoid approach. The prognosis after surgery was excellent in 18 cases, with 4 cases of severe disability and 1 case of death. Conclusion The rupture of middle cerebral artery aneurysm with hematoma has a high disability and death rate, so early preoperative diagnosis, early evaluation and early surgery are the keys to improve the outcome.
Middle cerebral artery aneurysm combined with hematoma in the lateral fissure area is a common clinical disease with high misdiagnosis rate, disability rate, and mortality rate. From 2009-03 to 2012-03, our department treated 23 patients with middle cerebral artery aneurysm combined with lateral fissure hematoma by early craniotomy + aneurysm clamping + lateral fissure hematoma via expanded pterygoid approach, and achieved good clinical results. The results are reported as follows.
I. Data and methods
1. General data: Among the 23 patients in this group, 10 were male and 13 were female, aged 38-73 years old, with an average of 47.4 years old. All cases underwent CT examination before surgery, among which 16 cases were clearly diagnosed by DSA examination, 5 cases were clearly diagnosed by CTA examination, and 2 patients underwent aneurysm clamping due to hematoma in the lateral fissure area, which was found to be middle cerebral artery aneurysm during emergency hematoma removal surgery.
2. Symptoms and signs: Clinical manifestations were mainly headache, hemiparesis and impaired consciousness, including 8 cases with unequal pupil size and 2 cases with bilateral pupil dilatation, and all cranial CT examinations suggested SAH+ lateral fissure hematoma with midline shift. Hunt-Hess classification: grade II in 8 cases, grade III in 13 cases, grade IV in 2 cases.
3. Auxiliary examinations: CT examination suggested hematoma in the lateral fissure area, mostly combined with subarachnoid hemorrhage, and then DSA or CTA examination was performed to clarify the diagnosis, and two of them had emergency exploratory surgery based on CT results.
4. Surgical method: All patients in this group were operated within 48 hours of the onset of disease, using an expanded pterygoid approach, dissecting the lateral fissure pool and carotid pool under the microscope, releasing cerebrospinal fluid, first removing part of the lateral fissure hematoma to fully decompress it, exploring and revealing the middle cerebral artery and branches, avoiding aneurysm rupture during traction, fully revealing the aneurysm and choosing a suitable aneurysm clip to close it, thoroughly removing the hematoma again, dural decompression suture, and frontal bone flap retraction. The frontal bone flap was returned, while the temporal bone flap was not returned to achieve sub-temporal muscle decompression to relieve postoperative cerebral edema, and if the brain tension was high, the bone flap was directly decompressed.
II. Results
In 23 cases, while removing the lateral fissure hematoma, the aneurysm neck was completely clamped in 16 cases, the wide carotid aneurysm was clamped parallel to the longitudinal axis of the middle cerebral artery in 4 cases, and the aneurysm neck remained partially in 3 cases. The postoperative cranial CT was reviewed 1 to 3 d after surgery and showed that the hematoma was almost completely cleared by surgery and the midline structures were displaced and returned. The postoperative pupil examination showed that the preoperative dilated pupil was retracted to different degrees. 18 cases had improved muscle strength of the affected limb from 1 to 3 d, 17 cases had improved consciousness, 1 case had vegetative survival, and 1 case had postoperative death.
III. Discussion
Middle cerebral artery aneurysm combined with hematoma in the lateral fissure area is a common clinical disease with high disability and mortality rate. Early clinical judgment, surgical selection and treatment outcome are closely related, and the purpose of surgery is no longer simply to save the patient’s life, but mainly to minimize the degree of disability and improve the patient’s survival quality of life. In our group, 23 patients with middle cerebral artery aneurysm with hematoma in the lateral fissure area achieved better clinical results after early surgical treatment.
1. Differential diagnosis: middle cerebral artery aneurysm combined with lateral fissure hematoma needs to be distinguished from hypertensive cerebral hemorrhage, vascular malformation, smog disease and other hemorrhagic diseases, and a clearer diagnosis can be obtained by CTA, MRA, DSA and so on. The hematoma of a ruptured middle cerebral artery aneurysm is usually located in the proximal cortex of the lateral fissure, and is often combined with subarachnoid hemorrhage of varying degrees; those with a history of hypertension are especially well differentiated from hypertensive basal ganglia hemorrhage.
Early surgery can prevent the increase of hematoma caused by rebleeding of the aneurysm, and clear the hematoma in the lateral fissure when clamping the aneurysm, blocking the occupational injury and brain herniation of the original hematoma, while early surgery can clear the The early surgical removal of blood clots in the subarachnoid space and around the large arteries at the skull base may reduce or mitigate the occurrence of cerebral vasospasm and the degree of reaction, and reduce the occurrence of complications such as postoperative hydrocephalus. In this group of cases, 21 cases were examined by emergency DSA or CTA, and 2 patients with critical condition were considered to have middle cerebral aneurysm rupture and bleeding and underwent emergency craniotomy in combination with CT results and medical history. 17 cases showed significant improvement compared with preoperative condition, and 1 case died due to postoperative rebleeding.
3. Key points of surgical treatment
(1) Pay attention to preoperative assessment: patients with hematoma in the lateral fissure should pay high attention, especially in cases of exploratory surgery. On the premise of mastering the distribution of normal lateral fissure vascular alignment, we should consider the effect of hematoma occupancy on vascular displacement and focus on exploring the M1M2 segment of middle cerebral artery, paying attention to avoid damaging the M1 segment of the doublestem artery; High brain tension is also an unfavorable factor affecting surgical exposure and separation.
(2) Surgical approach: Our group mostly adopts the enlarged pterygoid approach to open the skull and design a good bone window, which is mostly 8cmX10cm in size. The requirement of full exposure was achieved. The middle cerebral aneurysm toward the anterior and superior part of the lateral fissure may be attached to the dura mater of the pterygoid wing, so it is important to avoid damaging the dura mater when dealing with the inner and lower part of the pterygoid crest.
(3) Lateral fissure exploration: After opening the dura mater, due to the high brain tension and brain expansion caused by the hematoma occupancy effect, the lateral fissure pool is firstly dissected initially, using sharp dissection as the main method to release part of the cerebrospinal fluid, while removing the superficial blood clot in the lateral fissure, and revealing the M1M2 segment of middle cerebral artery from superficial to deep, at this time, the brain tension is reduced, and the aneurysm can continue to be revealed, separated and clamped directly through the lateral fissure, or the frontal lobe can be lifted first and revealed downward The carotid pool and optic cross pool can also be opened and the Liliequist membrane can be opened to release the subcurtain cerebrospinal fluid, and the internal carotid artery, the A1 segment of the anterior cerebral artery, and the middle cerebral artery can be revealed before the aneurysm is treated. Protect the draining veins, especially the bridging veins that return to the pterygo-parietal sinus, should not be electrocoagulated too much to reduce the brain swelling that affects the exposure.
(4) Aneurysm management techniques: Some middle cerebral artery aneurysms are characterized by large aneurysms, wide aneurysm necks, lobulated aneurysms, and multiple aneurysms, and some of the middle cerebral arteries are adjacent to the base of the bifurcation aneurysm across the aneurysm or the doublestem artery. The aneurysm can be closed by shaping the aneurysm and keeping the aneurysm-carrying vessels open.
In three cases with incomplete aneurysm neck clamping, the aneurysm body could be minimized by electrocautery and the temporalis fascia sheet could be used. The aneurysm can be wrapped around the aneurysm in a “figure of eight” cross-wrap, and the muscle at both ends can be filled and fixed with biologic adhesive.
(5) Treatment of lateral fissure hematoma: Usually part of the hematoma has been cleared and decompressed during the dissection of the lateral fissure, after the treatment of the aneurysm, the hematoma in the lateral fissure area must be further cleared, especially the blood clot around the lateral fissure artery. After complete removal of the hematoma, adequate decompression can be achieved to reduce postoperative vasospasm and promote recovery of patient’s consciousness and limb dysfunction.
In patients with hematoma in the lateral fissure area, it is important to consider the possibility of ruptured middle cerebral artery aneurysm and bleeding, so it is especially important to make early diagnosis and early surgery with medical history. Treatment of aneurysm and removal of hematoma through microscopic techniques can minimize the degree of disability and improve the patient’s survival and quality of life.