Abstract】 Objective To treat acute ruptured intracranial aneurysms with early interventional embolization and microsurgery, in order to reduce the mortality and disability rate. To improve the diagnosis and treatment of intracranial aneurysm. Methods Over the past 5 years, 120 cases of cerebral aneurysm rupture and bleeding were treated with early comprehensive clinical rescue and treatment methods. All of them were treated with life support, emergency comprehensive treatment and cerebral angiography under green channel on admission. Early (within 72 hours) interventional embolization or microsurgical treatment was performed. Immediately after surgery, blood cerebrospinal fluid was released, anti-vascular spasm was applied, cerebral perfusion was maintained, and complications were prevented. Results Good 98 cases, 16 cases with mild disability, 3 cases with severe disability, and 3 cases with death. The good treatment rate was 80%. There were 2 cases of rebleeding during hospitalization. There were 5 cases of severe cerebral vasospasm leading to coma. Conclusion For intracranial aneurysm, strengthening early comprehensive treatment, early interventional embolization or microsurgery, paying attention to cerebrovascular spasm and hydrocephalus prevention and treatment can effectively reduce rebleeding during hospitalization, prevent or reduce the occurrence of severe cerebrovascular spasm and hydrocephalus, reduce mortality and improve patients’ prognosis.
1.Data and methods
1.1 General data
There were 47 male cases and 73 female cases, aged 28-73 years old, with an average of 48.5 years old and 6 cases aged 65 years old.
1, 2 Clinical manifestations
All patients had acute subarachnoid hemorrhage (or combined intracerebral hematoma) as the first symptom, including 96 cases with one hemorrhage, 24 cases with two or more hemorrhages, 5 cases of combined actinic nerve palsy, 8 cases of mild hemiparesis, 2 cases of hemianesthesia, 4 cases of aphasia, and 2 cases of synoptic hemianopia; according to Hunt and Hess’ SAH grading criteria, 10 cases were classified as grade 0, 21 cases as grade I, 43 cases as grade II, and 37 cases as grade III upon admission. According to Hunt and Hess’ SAH grading criteria, 10 cases were classified as Grade 0, 21 cases as Grade I, 37 cases as Grade II, 37 cases as Grade III, and 9 cases as Grade IV-V.
1.3 Imaging examination
Cerebral angiography was performed in all patients, and 126 aneurysms were found in 120 cases, including 45 anterior communicating aneurysms, 38 posterior communicating aneurysms, 20 middle cerebral aneurysms, 18 internal carotid aneurysms, and 5 posterior group circulation aneurysms (2 cases at the vertebrobasilar junction, 2 cases at the tip of the basilar artery, and 1 case in the posterior inferior cerebellar artery).
1. 4 Treatment methods
A green channel for admission of cerebrovascular patients was implemented. When patients entered the hospital and were confirmed to have subarachnoid hemorrhage by brain CT, they were referred to neurosurgery (including neurointerventional) physicians for full consultation and treatment. Early and comprehensive treatment measures: green channel for admission of cerebrovascular patients, admission of SAH patients to NICU, emergency tracheal intubation and ventilator assisted breathing for patients with respiratory failure, extraventricular drainage for acute hydrocephalus, hemostasis, sedation, pain relief and laxation, and psychological care. After admission, blood pressure control was performed until the aneurysm was controlled. When the patient’s vital signs are stabilized, control the patient’s cranial pressure and blood pressure, and control the blood pressure at a low level with oral drugs or intravenous antihypertensive drugs. This is usually around 100/70 mmHg, but the mean arterial pressure should not be lower than 70 mmHg to maintain cerebral perfusion. In hypertensive patients, blood pressure is controlled at about 85% of the basal blood pressure. Patients with difficult blood pressure control are mostly due to high cranial pressure and need to be given cranial pressure-lowering drugs at the same time. Patients with acute hydrocephalus immediately undergo extraventricular drainage, but avoid sudden reduction of cranial pressure to induce hemorrhage.
Anti-vascular spasm: Early and continuous application of anti-vascular spasm drugs such as nimodipine injection. Early postoperative application of lumbar puncture or lumbar subarachnoid placement to release bloody cerebrospinal fluid, use of 3H therapy, etc. Whole brain angiography was performed immediately after vital signs were stabilized.
Early surgery was performed, and all cases were treated with interventional embolization of the aneurysm or microsurgical aneurysm clamping within 72 hours. Among them, 92 aneurysms were treated endovascularly in 85 cases and 35 aneurysms were treated surgically in 35 cases. Postoperatively, blood cerebrospinal fluid was released as soon as possible, anti-vascular spasm and control of intracranial pressure were performed to maintain cerebral perfusion. Prevent complications.
2. Results
Survivors were followed up for at least 3 months. There were 2 cases of preoperative rebleeding. Severe cerebral vasospasm leading to coma was observed in 6 cases. Eight cases underwent shunt surgery for late hydrocephalus.
Causes of death and disability: mainly preoperative rebleeding, rebleeding after incomplete interventional embolization or failed surgical clamping, cerebral vasospasm and large cerebral infarction; and complications of embolization or microsurgical techniques, cerebral vasospasm leading to cerebral infarction, hydrocephalus, etc.
3.Discussion
The implementation of green channel for admission of cerebrovascular patients is a key measure to ensure that the life risk of patients is controlled at the first time. Hemorrhage and rehemorrhage, acute hydrocephalus, intracerebral hematoma or subdural hematoma, and increased intracranial pressure are the causes of early critical manifestations. Irregular respiration and cessation occur in a small number of critically ill patients, and some patients may be successfully resuscitated with timely tracheal intubation and respiratory assistance. Nine patients in this group had acute respiratory abnormalities, and they were resuscitated after active resuscitation, and emergency cerebral angiography confirmed the aneurysm, and then emergency interventional embolization was performed to treat the aneurysm successfully. Six of the patients returned to self-care or semi-self-care within 1-2 months. The rate of preoperative bleeding during hospitalization has been reported to be up to 16% and about 1/6. The mortality rate of ruptured aneurysm bleeding is 46%. Even 70%-90%. And most rebleeding occurs within 2 weeks, with a peak at 4-10 days. [1-3]. Cerebral angiography confirmed as an aneurysm with multiple sacs, with sub sacs and other irregular shapes suggests a high possibility of recent rebleeding. Preoperative comprehensive salvage measures become very important. Sedation and analgesia: Patients mostly have headache and other manifestations, and may experience agitation and anxiety, leading to mood swings, which can cause blood pressure changes with the possibility of rebleeding. Their rebleeding triggers include sudden changes in blood pressure due to various causes. Good care and diet, keep the ambassador fluent and maintain strict bed rest. Psychotherapy: good psychological adjustment, patient psychotherapy, stabilize patients’ emotions, reduce adverse psychological stimulation, facilitate patients to pass the preoperative rebleeding danger period, and improve patients’ cooperation with treatment. Early surgery, if the patient’s condition and treatment conditions allow, early intervention or craniotomy to drain the aneurysm outside the circulation is the most effective measure to solve rebleeding. Only 2 patients in our group had rebleeding before surgery.
Surgical method and timing: Interventional or craniotomy methods should be used to treat aneurysms within 48-72 hours after onset. 3 days later patients present with cerebral vasospasm, which causes difficulties for surgery and affects the postoperative outcome. Early intervention can be used for most acute ruptured aneurysms especially anterior communicating aneurysms and posterior circulation aneurysms and in elderly patients; early craniotomy is our choice for posterior communicating aneurysms, middle cerebral aneurysms and some anterior communicating aneurysms where embolization is difficult or has failed. Interventional treatment of aneurysms through intravascular microcatheters to deliver microspring coils into the aneurysm; some wide carotid aneurysms supplemented with balloon remodeling and neural stenting can achieve early treatment of most patients with critical emergencies and the presence of vasospasm without aggravating the patient’s condition. Because of its ease of operation and high safety, the microspring coil embolization system is particularly suitable for the early embolization treatment of ruptured aneurysms in emergency and critically ill patients. [5] It can be the treatment of choice for patients with aneurysms. For patients with aneurysms that are not easily accessible by catheter, too wide neck, huge and other aneurysms that are difficult to treat by embolization, as well as patients who have failed embolization, microsurgical clamping should be performed within 72 hours, before the vasospasm is severe, in order to remove intracerebral hematoma and subarachnoid blood intraoperatively, to reduce cerebral vasospasm with intraoperative poppies, and to release blood after early postoperative extraventricular drainage or lumbar subarachnoid placement. The cerebrospinal fluid was released by early postoperative extraventricular drainage or lumbar subarachnoid placement, and 3H treatment was given to reduce cerebral vasospasm and cerebral ischemia. Special attention should be paid to the guidance of minimally invasive concept during the whole procedure, no matter interventional surgery or craniotomy, to avoid poor planning, rough operation and aggravated injury. With skilled modern interventional and microsurgical techniques, aneurysm surgery has become safer. Endovascular treatment and microsurgery are both in the category of minimally invasive treatment, each with its own advantages and disadvantages. For most intracranial aneurysms, both methods can be used and good results can be achieved.
Postoperative complication control: cerebral vasospasm: early postoperative extraventricular drainage or lumbar subarachnoid placement to release blood cerebrospinal fluid, maintain the drainage height and keep the cranial pressure relatively stable. Also pay attention to control intracranial pressure and maintain cerebral perfusion. Re-bleeding: After interventional embolization or aneurysm clamping, cerebral angiography should be reviewed to check whether the aneurysm embolization and clamping are reliable, and further treatment should be arranged as early as possible. One patient in our group was admitted for rebleeding after interventional embolization or aneurysm clamping, and DSA confirmed that the embolization rate was <80% and incomplete clamping was the cause. Hydrocephalus: It is a common late complication with an incidence of 20-30%. It occurs due to ventricular obstruction after subarachnoid hemorrhage and impaired subarachnoid resorption. Early and repeated subarachnoid drainage and adequate cerebrospinal fluid replacement after hemorrhage can reduce the occurrence and extent of hydrocephalus by reducing the impact of blood cells and metabolites on cerebrospinal fluid circulation. If hydrocephalus persists, ventricular shunt surgery should be performed. Eight cases in this group had late hydrocephalus and improved after shunt surgery.
The implementation of early comprehensive treatment measures, including the implementation of in-hospital cerebrovascular disease treatment green channel, life support and resuscitation of critically ill patients, strong preoperative rebleeding control, early cerebral angiography, early aneurysm interventional embolization or microsurgical treatment, early control of blood pressure intracranial pressure and prevention of cerebral vasospasm throughout the whole process, timely management of subarachnoid hematoma and intracranial hematoma, is essential to save patients’ lives, promote life It is an effective method to save patients’ lives, promote life and function recovery, and reduce complications.