HUNT-HESS grading (according to signs and symptoms and severity of the disease, with the addition of grade 0 in the revised grading).
Grade 0: unruptured aneurysm.
Grade I: ruptured, mild headache, mild neck strength, or asymptomatic
Grade II: moderate to severe headache, moderate to severe neck strength, or cranial nerve injury
Grade III: drowsiness/confusion/confusion, mild disorientation, mild focal neurological palsy.
Grade IV: coma, moderate to severe lateralized incomplete paralysis, extensive neurological impairment
Grade V: deep coma, decerebrate, dying state.
If there is severe systemic disease such as hypertension, DM, pulmonary disease, and severe vasospasm on arterial DSA, the grading is increased by one level.
Fisher grading (according to SAH CT scan findings).
Grade I: no signs of hemorrhage.
Grade II: diffuse SAH without clots and without bleeding greater than 1 mm in thickness.
Grade III: presence of focal clots and or diffuse hemorrhage with hemorrhage greater than 1 mm in thickness.
Grade IV: small or diffuse hemorrhage but with intracerebral or intraventricular hemorrhage.
Timing of angiography: It is advocated that DSA should be performed as early as possible, except for grade V, to facilitate early surgery and prevent rebleeding. However, DSA within 5 hours is likely to cause rebleeding.
Timing of surgery (according to HUNT-HESS classification).
Grade I-II: Aim for surgical clamping within 3-4 days of onset and early surgery.
Grade III-IV: can be operated early if combined with intracranial hematoma causing life-threatening brain herniation according to the patient’s specific situation, or late (bleeding around 2W) if the condition is stable.
3. Grade V: must wait for conservative treatment to get better before surgery, but those with brain herniation should be operated urgently.
Principles of management of intracranial aneurysm.
1, condition estimation: HUNT-HESS grading.
2. impactological examination: Fisher classification.
3.Surgical methods: aneurysm neck clamping or ligation; aneurysm-carrying artery clamping or aneurysm isolation; aneurysm wrapping; transvascular embolization of aneurysm i.e. interventional surgery.
4. Develop surgical plan: avoid immature rupture of the aneurysm and “brain collapse” (fully dissect the brain base pool to put CSF, also use dehydrating agent, etc.); reveal temporary blocking of the proximal end of the aneurysm-carrying artery, sharply reveal the aneurysm, especially the aneurysm neck, in order to reduce the strain on the aneurysm by blunt separation; clip the aneurysm (according to the principle of installing the aneurysm clip The principle is parallel to the aneurysm-carrying artery), and pay attention to whether the distal end of the aneurysm-carrying artery is pulsating well after clamping.
5, post-operative treatment: early postoperative should actively prevent and treat cerebral vasospasm (generally the spasm subsides around 2W or 10-15 days after surgery); which should contain colloidal components such as plasma substitution Wan grain and low right, compound salvia, etc., that is, 3H therapy: Hypertension, Hypervolumia, Hemodilution. preventive treatment of cerebral vasospasm: Nimble Diphenhydramine, 3H therapy, low right + compound salvia (this method should be used after hemorrhage stabilization or postoperatively to prevent rebleeding from activated vessels).
Surgical access and radiation range.
1, classical frontotemporal craniotomy – pterygoid point approach / lateral fissure approach / pterygoid crest approach / Yasargil: anterior to anterior communicating aneurysm and posterior to basilar artery bifurcation aneurysm.
2. longitudinal fissure approach: mainly divided into anterior corpus callosum approach and transcallosal approach.
3, inferior temporal approach and rock-bone approach.
4, posterior suboccipital sigmoid sinus approach.
5. suboccipital extreme lateral approach.
6, suboccipital median approach.
7, Spetzler (1992)/frontal orbitozygomatic craniotomy: for tumors, aneurysms and cavernous hemangiomas of the anterior and middle skull base and the upper third of the slope.
8, internal carotid artery ligation: preoperative Matas test patients can tolerate 30 minutes without cerebral ischemic symptoms; or whole brain DSA in compression of the diseased side of the internal carotid test, if the healthy side of the contrast can reach the affected side through the anterior-posterior traffic collateral circulation, confirming good anterior-posterior traffic A collateral circulation, intraoperative ligation of the affected side of the internal carotid artery.
9.Aneurysm wrapping: suitable for aneurysm with too wide neck, shuttle-shaped aneurysm, calcification in the neck of the aneurysm that should not be clamped or ligated, or the aneurysm-carrying artery cannot be blocked.