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Introduction Anterior communicating artery aneurysms (ACoAAs) are intracranial aneurysms whose treatment is still considered a challenging task. Materials and Methods Altogether, 74 patients were included in this study. The variables included age, sex, comorbidities, incidence of subarachnoid hemorrhage (SAH), the Fisher, Hunt-Hess, and WFNS scores, approach side, length of hospital stay, and mortality. We also investigate A1/A2 dimensions, association with approach side choice and the influence of surgeon's experience on the outcome. Results There were 61 patients (82.2%) admitted with SAH and 13 were treated for unruptured aneurysms. The A1 and A2 branches were larger ipsilaterally to the selected approach side (p < 0,001). No deaths occurred in the unruptured aneurysm group. In the SAH group, mortality was strongly correlated with the Hunt-Hess score (p < 0.001), Fisher grade (p < 0.001), and WFNS score (p < 0.001). No significant difference was found in mortality between the right-side and the left-side approaches (p » 0.253). A significant survival difference was identified on the group operated by the senior surgeon versus the non-senior group (p » 0.048). Discussion and Conclusion A1 dominance was identified as a factor associated to the approach side for SAH cases at our center. Understanding the factors involved in brain aneurysm surgery remains a relevant and underexplored subject. Further studies involving larger case series and multicenter collaborations are necessary to elucidate these factors and to determine the external validity of our findings.
Introdução Os aneurismas da artéria comunicante anterior (ACoAA) são aneurismas intracranianos cujo tratamento ainda é considerado uma tarefa desafiadora. Materiais e Métodos Ao todo, 74 pacientes foram incluídos neste estudo. As variáveis incluíram idade, sexo, comorbidades, incidência de hemorragia subaracnóidea (HAS), escala de Fisher, Hunt-Hess e WFNS, lado de abordagem, tempo de internação e mortalidade. Também investigamos as dimensões A1/A2, a associação com a escolha do lado de abordagem e a influência da experiência do cirurgião no resultado. Resultados Foram admitidos 61 pacientes (82,2%) com HAS e 13 foram tratados por aneurismas não rotos. Os ramos A1 e A2 foram maiores ipsilateralmente ao lado de abordagem selecionada (p < 0,001). Nenhuma morte ocorreu no grupo de aneurismas não rotos. No grupo HAS, a mortalidade esteve fortemente correlacionada com a escala de Hunt-Hess (p < 0,001), pontuação de Fisher (p < 0,001) e pontuação WFNS (p < 0,001). Não foi encontrada diferença significativa na mortalidade entre as abordagens direita e esquerda (p » 0,253). Foi identificada diferença significativa de sobrevida no grupo operado pelo cirurgião sênior versus o grupo não sênior (p » 0,048). Discussão e Conclusão A dominância A1 foi identificada como fator associado ao lado de abordagem dos casos de HAS em nosso centro. A compreensão dos fatores envolvidos na cirurgia de aneurisma cerebral permanece um assunto relevante e pouco explorado. Mais estudos envolvendo séries de casos maiores e colaborações multicêntricas são necessários para elucidar esses fatores e para determinar a validade externa de nossas descobertas.
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RESUMEN: El círculo arterial cerebral (CAC) mencionado también como polígono de Willis es una red de anastomosis vascular situado en la base del cerebro, constituido por ramas de la arteria carótida interna (ACI) y del sistema vertebro-basilar. Este estudio evaluó la morfología de las arterias que conforman el CAC en una muestra de individuos colombianos. Previa canalización de la ACI y de la arteria vertebral (AV), se perfundió con resina poliéster (palatal 85 % y estireno 15 %) los lechos vasculares del CAC de 70 encéfalos extraídos de cadáveres a quienes se les practicó necropsia en el Instituto de Medicina Legal de Bucaramanga, Colombia. La arteria comunicante anterior (ACoA) se observó en 68 encéfalos (97,1 %), con ausencia en 2 de las muestras (2,9 %); en promedio su diámetro fue de 1,91?1,04 mm y su longitud 2,21?0,97 mm respectivamente. Asimismo, se encontró hipoplasia en 6 muestras (8,4 %). La arteria comunicante posterior (ACoP) estuvo ausente en 2 de las muestras (5,7 %); su longitud fue 11,63?2,12 mm, mientras que su calibre fue de 1,21?0,58 mm, siendo ligeramente mayor en el lado derecho, sin diferencias estadísticamente significativas con relación al lado de presentación (p= 0,763). Se encontró hipoplasia de la ACoP en forma bilateral en 19 de las muestras (27,1 %) y unilateral en 15 muestras (21,4 %). En 8 muestras (20 %) de 35 CAC evaluados se observó configuración fetal. La incidencia de hipoplasia de la ACoP y de configuración fetal encontrados en el presente estudio, se ubican en el segmento superior de lo reportado en la literatura. Estas expresiones morfológicas han sido consideradas como coadyuvantes en el desarrollo de accidentes cerebro-vasculares (ACV).
SUMMARY: The cerebral arterial circle (CAC), also referred to as the polygon of Willis is a network of vascular anastomoses located at the base of the brain, consisting of branches of the internal carotid artery (ICA) and the vertebrobasilar system (VBS). This study evaluated the morphology of the arteries forming the CAC in a sample of Colombian individuals. After cannulation of the ICA and the vertebral artery (VA), the vascular beds of the ACC of 70 brains extracted from cadavers at the Institute of Legal Medicine of Bucaramanga, Colombia, were perfused with polyester resin (85 % palatal and 15 % styrene). The anterior communicating artery (ACoA) was observed in 68 brains (97.1 %), with absence in 2 of the samples (2.9 %); on average its diameter was 1.91?1.04mm and its length 2.21?0.97mm respectively. Likewise, hypoplasia was found in 6 samples (8.4 %). The posterior communicating artery (ACoP) was absent in 2 of the samples (5,7 %); its length was 11.63?2.12mm, while its caliber was 1.21?0.58mm, being slightly larger on the right side, with no statistically significant differences in relation to the side of presentation (p= 0.763). Hypoplasia of the ACoP was found bilaterally in 19 of the samples (27.1 %) and unilaterally in 15 samples (21.4 %). Fetal configuration was observed in 8 samples (20 %) of 35 CACs evaluated. The incidence of ACoP hypoplasia and fetal configuration found in the present study are in the upper segment of those reported in the literature. These morphological expressions have been considered as coadjuvants in the development of cerebrovascular accidents (CVA).
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Humans , Male , Adolescent , Adult , Middle Aged , Aged , Young Adult , Brain/blood supply , Circle of Willis/anatomy & histology , Anatomic Variation , Cadaver , Cerebral Arteries/anatomy & histology , ColombiaABSTRACT
Introducción: Los aneurismas de la arteria comunicante anterior (AComA) se presentan frecuentemente como causa de hemorragia subaracnoidea espontánea (HSAE), en casos raros se asocian a síntomas visuales por compresión mecánica o ruptura y su tratamiento quirúrgico a menudo representa un desafío. Descripción del caso: Se presenta el caso clínico de una paciente adulta con disminución de la agudeza visual del ojo derecho a predominio temporal, y hallazgos en RMN cerebral y angiografía compatibles con un aneurisma grande de AcomA, asociado a trombosis parcial; se realizó clipaje y trombectomía del aneurisma, la panangiografia de control evidenció exclusión completa de la lesión con posterior resolución del déficit visual. Discusión: El déficit visual por un aneurisma de la AcoA se puede generar por varios mecanismos, uno de ellos es la ruptura del aneurisma hacia el nervio óptico, con la subsecuente formación de un hematoma, adherencias y fibrosis; el otro mecanismo es la compresión mecánica de un aneurisma gigante no roto. El manejo quirúrgico a menudo implica técnicas complejas microquirúrgicas para intentar resolver el efecto de masa y excluir el aneurisma. La terapia endovascular es otra alternativa de tratamiento, pero tiene desventajas respecto a la cirugía. Conclusión: Los aneurismas de la AComA en raros casos se pueden asociar a síntomas visuales, debido a que por lo general se romepen cuando son pequeños, y no alcanzan a tener el tamaño suficiente para generar compresión de la vía óptica. Las técnicas microquirúrgicas ofrecen un método efectivo para disminuir el efecto de masa y mejorar los síntomas visuales
Introduction: Aneurysms of the anterior communicating artery (AComA) frequently present as a cause of spontaneous subarachnoid hemorrhage (HSAE), in rare cases they are associated with visual symptoms due to mechanical compression or rupture and their surgical treatment often represents a challenge. Description of the case: We present the clinical case of an adult patient with a decrease in visual acuity due to the right eye with a temporal predominance and findings on brain MRI and angiography compatible with a large AcomA aneurysm associated with partial thrombosis; clipping and thrombectomy of the aneurysm were performed, the control panangiography showed complete exclusion of the lesion. With subsequent resolution of the visual deficit. Discussion: The visual deficit due to an AcoA aneurysm can be generated by several mechanisms, one of them is the rupture of the aneurysm towards the optic nerve, with the subsequent formation of a hematoma, adhesions and fibrosis; The other mechanism is mechanical compression of a giant, unruptured aneurysm. Surgical management often involves complex microsurgical techniques to try to resolve the mass effect and exclude the aneurysm. Endovascular therapy is another treatment alternative, but it has disadvantages compared to surgery. Conclusion: AComA aneurysms in rare cases can be associated with visual symptoms, because they generally rupture when they are small, and are not large enough to generate compression of the optic pathway. Microsurgical techniques offer an effective method to alleviate the mass effect and improve visual symptoms
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Female , Aneurysm , Optic Nerve , Visual Acuity , Thrombectomy , EyeABSTRACT
Objective:To explore the related factors for clinical prognoses of ruptured anterior communicating artery (ACoA) aneurysms.Methods:A retrospective study was performed on the clinical data of 309 patients with ruptured ACoA aneurysms admitted to our hospital from January 2014 to January 2020. The preoperative data included age, gender, smoking history, hypertension, Hunt-Hess grading, Fisher grading, sizes of aneurysms, and spasm of parent artery; and the postoperative data included pneumonia, intracranial infection, cerebral hernia, recurrence and re-hemorrhage of aneurysms, and delayed cerebral ischemia. Clinical prognoses were assessed by modified Rankin scale (mRS). Univariate analysis and multivariate Logistic regression analysis were used to determine the independent risk factors for clinical prognoses. Preoperative model (independent risk factors appeared before surgery) and postoperative model (independent risk factors appeared during the whole treatment process) were constructed; based on these Logistic models, the preoperative and postoperative independent risk factors were concluded. Independent risk factors presented in the preoperative and postoperative models were used as variables to analyze the predictive value of the models by receiver operating characteristic (ROC) curve.Results:Among 309 patients, 264 (85.4%) had good prognosis and 45 (14.6%) had poor prognosis. (1) Univariate analysis showed that significant differences were noted in proportion of smoking patients, and patients with hypertension, Hunt-Hess grading IV-V, Fisher grading IV, wide-necked aneurysm, re-hemorrhage of aneurysms, cerebral vasospasm, pneumonia, intracranial infection, cerebral hernia, delayed cerebral ischemia, and postoperative lumbar cistern drainage between good prognosis group and poor prognosis group ( P<0.05). (2) Multivariate Logistic regression analysis showed that Hunt-Hess grading Ⅳ-V ( OR=24.198, P=0.000, 95%CI: 4.288-136.559), Fisher grading Ⅳ ( OR=4.792, P=0.044, 95%CI: 1.040-22.079), spasm of parent artery ( OR=12.136, P=0.005, 95%CI: 2.121-69.426), pneumonia ( OR=8.177, P=0.018, 95%CI: 1.438-46.506), postoperative cerebral hernia ( OR=147.042, P=0.002, 95%CI: 6.386-3385.519) and delayed cerebral ischemia ( OR=606.720, P=0.000, 95%CI: 52.288-7040.088) were independent risk factors for prognoses; postoperative lumbar cister drainage ( OR=0.072, P=0.050, 95%CI: 0.005-1.000) was the independent protective factor. (3) ROC curve showed that the preoperative model (with Hunt-Hess grading IV-V, Fisher grading Ⅳ and cerebral vasospasm as variables) had excellent discrimination with an area under the curve (AUC) of 0.870 ( 95%CI: 0.82-0.93, P=0.000), and the postoperative model (with variables of preoperative model, pneumonia, delayed cerebral ischemia, and herniation as variables) had excellent discrimination (AUC=0.980, 95%CI: 0.97-0.99, P=0.000). Conclusion:Besides decreasing Hunt-Hess grading and Fisher grading, and relieving the arterial spasm, the management of lumbar subarachnoid continuous drainage and avoidance of postoperative complications, such as cerebral hernia, delayed cerebral ischemia and pneumonia, can also play important roles in improving the prognoses of ruptured ACoA aneurysms.
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Abstract Objective: To evaluate the morphology of the distal medial striated artery, taking into account biometric variables useful for clinical and surgical management. Methods: A descriptive transversal study was performed with a sample of brains, who underwent autopsy at the Institute of Legal Medicine and Forensic Sciences of Bucaramanga-Colombia, which were evaluated using the perfusion technique of vascular structures with polyester resin. Results: The distal medial striated artery was presented in 1.4% and 4.2% duplicated in the right and left hemispheres respectively. Agenesis was presented in 2.8% in the left hemisphere. Its origin was 44.6% of the anterior cerebral artery junction site with the anterior communicating artery and was observed in 6 cases (4.2%) presented with a common trunk with the orbitofrontal artery. The main qualitative finding was the sinuous trajectory that was observed in 57.7% on the right side and 45.1% in the left hemisphere. Also, an important alteration found at the biometric analysis was hypoplasia that could be related to the decreased blood supply to the basal nuclei. The diameter was 0.5 ± 0.2 mm and its total length was 20.3 ± 4.1 mm. Conclusions: The topographical knowledge of this structure determines the vulnerability of its morphology because it can complicate surgical procedures performed in the anterior segment of the arterial circle of the brain. Besides, the observed collateral circulation contributes to the blood supply and the perfect functionality of the subcortical nervous structures.
Resumen Objetivo: Evaluar la morfología de la arteria estriada medial distal, teniendo en cuenta variables biométricas útiles para el manejo clínico y quirúrgico. Métodos: Estudio descriptivo transversal con una muestra de cerebros que fueron sometidos a autopsia en el Instituto de Medicina Legal y Ciencias Forenses de Bucaramanga-Colombia, fueron evaluados mediante la técnica de perfusión de estructuras vasculares con resina de poliéster. Resultados: La arteria estriada medial distal se presentó en 1.4% y 4.2% duplicada en el hemisferio derecho e izquierdo respectivamente. Agenesia se presentó en 2.8% en el hemisferio izquierdo. Su origen fue 44.6% del sitio de unión de la arteria cerebral anterior con la arteria comunicante anterior y se observó en 6 casos (4.2%) que presentaban un tronco común con la arteria orbitofrontal. El hallazgo principal fue la trayectoria sinuosa que se observó en 57.7% en el lado derecho y 45.1% en el hemisferio izquierdo. También una alteración importante encontrada en el análisis biométrico fue la hipoplasia que podría estar relacionada con la disminución del suministro de sangre a los núcleos basales. El diámetro fue de 0.5 ±0.2 mm y su longitud total fue de 20.3 ±4.1 mm. Conclusiones: El conocimiento topográfico de esta estructura determina la vulnerabilidad de su morfología, porque puede complicar los procedimientos quirúrgicos realizados en el segmento anterior del círculo arterial del cerebro. Además, la circulación colateral observada contribuye al riego sanguíneo y al perfecto funcionamiento de las estructuras nerviosas subcorticales.
Subject(s)
Adolescent , Adult , Aged , Aged, 80 and over , Humans , Male , Middle Aged , Young Adult , Cerebral Arteries/anatomy & histology , Brain/blood supply , Cadaver , Cerebral Arteries/abnormalities , Cross-Sectional Studies , Biometry , Colombia/ethnology , Anterior Cerebral Artery/anatomy & histology , Anatomic VariationABSTRACT
Objective To evaluate the safety and efficiency of the treatment strategy based on three-dimensional digital subtraction angioplasty (3 D-DSA) for the side selection of pterional approach to clip anterior communicating artery aneurysm. Methods All 75 continuous patients with single anterior communicating artery aneurysm(Hunt-Hess 0-III grade) treated by microsurgical clipping via the pterional approach were analyzed retrospectively. The side selection of approach was based on 3D-DSA. All patients' gender, age, Hunt-Hess grade, aneurysm size, the side of approach, complications, the length of postoperative stay, the ratio of complete occlusion, and the Glasgow outcome scale (GOS) score at discharge were collected. The ratio of complete occlusion and clinical outcome were analyzed according to the group of left or right approach and different Al dominant approach. Results (1) Fifty-six patients (74. 7%) were left Al dominants, with 30 of those treated via the left-side approach and 26 of those treated via the right-side approach. Nineteen patients (25.3%) were right Al dominants, with 15 of those treated via the right-side approach and 4 of those treated via the left-side approach. (2) Surgical exposure of all aneurysms was satisfactory during operation, which was consistent with the 3D-DSA image simulation before the operation. The median length of postoperative stay was 9(8, 11) days. Six patients(8. 0%) suffered symptomatic cerebral infarction, and 1 patient (1.3%) had an intracranial infection. Sixty-five cases performed DSA or CT antigraphy after the operation. Sixty-two aneurysms (95.4%) were completely clipped and 3 aneurysms (4.6%) existed residual segments in the neck of the aneurysm. Sixty-nine patients (92.0%) reached 5 grade of GOS, 3 patients (4.0%) reached 4 grade of GOS, 3 patients (4.0%) reached 3 grade of GOS, and no patient was below 3 grade of GOS at discharge. (3) The surgical-related complications, clipping results, hospital-stay time after operation, and GOS at discharge were insignificantly different between left and right side approach, also insignificantly different between the dominant Al side and contralateral side approach. Conclusion The treatment strategy, based on preoperative 3D-DSA imaging simulation for the side selection of pterional approach to clip anterior communicating artery aneurysms, was safe and effective.
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Introduction: Decision making regarding the surgicalapproach for ACOM artery is based on A1 dominancy,projection and how is the plane of the both A2 vessels. Thepresent study was conducted with the aim to analyze theprognosis of superiorly projecting anterior communicatingartery aneurysm with respect to position of A2 anteriorcerebral artery.Material and methods: The present retrospective analysisconsisted of 543 cases of all cerebral aneurysms operatedfrom Jan 2012 to December 2015 at Sree Chitra TirunalInstitute for Medical Sciences and Technology (SCTIMST),Trivandrum. The open A2 plane was defined as when the A2of the pterional approach side was present more posteriorlythan the contralateral A2. All patients were evaluated throughGlasgow outcome scale at the time of discharge. All the dataobtained was arranged in a tabulated form and analyzed usingSPSS software.Results: The mean age of the subjects was 54.2 years.There were 63 males and 32 females. Among 95 patients,A1dominant was present in 83 patients and co-dominance waspresent in 12 cases. Out of 54 superiorly projecting aneurysms.Intraoperative rupture was present in the 18 patients (33.3%),Gyrus rectus aspiration was done in the 35 patients (64.9%), 1patient had the perforator injury.Conclusion: Surgical approach from the A2 posteriordisplacement side (the open A2 plane) in patients with superiorprojecting aneurysms allows neurosurgeon to secure aneurysmnecks safely and prevent postoperative complications.
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BACKGROUND: A-com artery aneurysms are the most common intracranial aneurysms. Clipping and coiling are the two options available for treatment of these aneurysms. Microsurgical clipping, although invasive, is more suitable for the economically challenged sector of our society. AIM:To evaluate the mortality and morbidity of clipping A-com artery aneurysms by different surgical approaches.Settings and Design: This is a non-randomized prospective multiple centre study. MATERIALS AND METHODS:Patients with A-com artery aneurysm fullling the inclusion criteria and managed with microsurgical clipping were included in the study. Patients were evaluated preoperatively and postoperatively with CT Scan Brain (Plain), 3D- CT Angiogram of Brain or Digital substraction Angiography of Brain.STATISTICAL ANALYSIS:Data collection and analysis, was performed using the statistical package for the social sciences version 16 (SPSS, INC, Chicago, IL). RESULTS:A total of 34 patients of A-com aneurysms (non-giant) were included in the study. Male: Female ratio of 1.62:1 with male preponderance. All the aneurysms were microsurgically clipped by either Pterional transsylvian or modied gyrus rectus or interhemispheric approach. The mortality and morbidity in different surgical approaches were analyzed. CONCLUSION:Mortality depends on the preoperative grade of subarachnoid hemorrhage. Type of surgical approach has no relation to mortality or morbidity.
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A fenestration tube is a clipping reconstruction technique that allows the preservation of critical vessels in aneurysm surgery. A patient with a ruptured anterior communicating artery (ACoA) aneurysm with a posterior projection was admitted to our neurosurgery unit. A right dominant A1 with rotation of the A2 fork was observed on preoperative computed tomography angiography (CTA). During surgery, we observed that the recurrent artery of Heubner branched off the A2 just distal to the neck of the aneurysm. Successful clipping was achieved by building an "A1A2 fenestration tube," with preservation of the recurrent artery and of the ACoA perforators. Surgical nuances and the advantages of fenestration tubes are discussed.
Subject(s)
Humans , Aged , Intracranial Aneurysm/surgery , Intracranial Aneurysm/complications , Intracranial Aneurysm/diagnostic imaging , Anterior Cerebral Artery/abnormalities , Computed Tomography AngiographyABSTRACT
Background: The Circle of Willis plays an important role as cerebral collateral channel. Aneurysms are commonlyarising in the anterior half of the circle of Willis, those originating on the anterior communicating artery areregarded as the most complex. This complexity is caused by the frequent variants of normal anatomy. The twoanterior cerebral arteries, Anterior communicating artery, Artery of Heubner and perforating vessels arisingfrom these vessels are called the anterior cerebral- anterior communicating complex. The anatomy of thiscomplex is characterized by numerous anomalies &variations, so it gains a great surgical importance.AIM: To study the microanatomy of anterior portion of Circle of Wills in south Indian cadavers.Materials and Methods: This study done in 100 formalin fixed human brains obtained from routine dissectionfrom cadavers with 10x magnification. The length, various anomalies noted in the following arteries: A1, A2segments of anterior cerebral artery, anterior communicating artery and photographed for documentation.Results: The mean length of right and left A1 segments of anterior cerebral artery (ACA), anterior communicatingartery (ACoA) was 14.44 mm, 13.61 mm, 2.73 mm. Standard deviation was 2.53, 1.69, 1.16 respectively. HypoplasticA1 segment noted in 6% of right side. In A2 segment of ACA, the Median anterior cerebral artery found in 2% andazygous artery found in 2%. Anterior communicating artery duplicated in 10%, hypoplastic in 6%, fenestrated in16% . ACoA was absent in 2% of specimens.Conclusion: The variations found in our study was more in the ACoA and A2 segment of ACA rather than A1segments of ACA. The knowledge of anatomical variations in this region is essential for neurosurgeons toplanning the neurosurgical procedures to avoid unexpected neurological complications.
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Background: Anterior communicating artery, a short trunk connecting the anterior cerebral arteries is importantin stabilizing blood flow by acting as collateral channel. The present study was conducted to note the variationsin anterior communicating artery which may be one of the reason for formation of aneurysm.Materials and Methods: Anterior communicating artery was observed for its number, course, length and variationsin 50 adult embalmed cadaveric brains after injecting with latex solution.Results: Duplication of anterior communicating artery was found in 4 specimens (8%) and it was absent in 2%.The course of ACoA was oblique in 54.2% and transverse in 45.8%. The length of ACoA was on an average of2.82mm. The mean diameter of ACoA was 1.12mm. Fenestration of ACoA was seen in 4%.Median artery of corpuscallosum was found in 1 specimen.Conclusion: Congenital anomalies of the intracranial arteries predispose to the formation of aneurysms due toan increased haemodynamic stress. Knowing the length, course and diameter of ACoA is important as it mayguide radiologists in interpretation and neurosurgeons in microsurgical procedures.
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Objective To determine clinical features and rupture risk of anterior communicating artery (AComA) aneurysms in different age groups. Methods The clinical data of 519 consecutive patients with AComA aneurysms in the First Affiliated Hospital of Wenzhou Medical University between December 2007 and February 2015 were reviewed and divided into younger group (<65 years) and older group (≥65 years). The clinical characteristics and aneurysm morphologies were compared between the two groups. Results There were 390 aneurysms in younger group, and 129 in older groups. For the younger group, hypertension,the size of the aneurysms, maximum height, perpendicular height, size ratio (SR), aspect ratio (AR), aneurysm angle, A1 segment configuration, morphology showed significantly differences in ruptured aneurysms group compared with those in unruptured aneurysms (P<0.05). The multivariate analysis showed that significant difference between the two groups was aneurysm size ( OR＝1.461,95% CI 1.027-2.079, P＝0.035). For the older group, there were statistically significant differences in hypertension,size of the aneurysms, maximum height, perpendicular height, SR, aneurysm angle, vessel size and the distribution of aneurysm projection between the ruptured aneurysms group and unruptured aneurysms group (P<0.05). The multivariate analysis showed that SR ( OR＝11.516,95% CI 1.782-74.445,P＝0.01) was the only significant predictor of aneurysm rupture. Between the younger and older groups,the distributions of sex, hypertension, smoke, vessel size and SR were statistically significant (P < 0.05). Conclusions For younger people, the males who smoked are more likely to have AcomA aneurysms and the size of the aneurysms is independent risk of aneurysm rupture. For older people, the females with hypertension also more often have AcomA aneurysms and the SR is independently associated with aneurysm rupture.
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Objective To analyze the safety and effectiveness of ultra-early microsurgical treatment of ruptured anterior communicating artery aneurysm (ACoAA) with intracranial hematoma. Methods The clinical and imaging data of 47 ACoAA with intracranial hematoma patients treated with ultra-early (within 24 h after onset) microsurgery were retrospectively analyzed from September 2008 to September 2018 in the Department of Neurosurgery, General Hospital of the Eastern War Zone. All patients received head CT and CT angiography (CTA) or DSA before operation, and underwent microsurgery via pterional lateral cerebral fissure approach. The glasgow coma scale (GCS) was used to evaluate the consciousness state of patients before and after operation. The Glasgow outcome scale (GOS) was used to evaluate the prognosis of patients. The clinical and imaging(CTA or DSA) follow-ups were regularly performed every 3 months after procedure. Results All cases of aneurysms were completely clipped. Of the 47 patients, the hematoma of 33 cases were completely cleared and the hematoma of 14 cases were partially cleared;25 cases underwent decompressive craniectomy and 26 cases underwent extraventricular drainage. Postoperative complications occurred in 10 patients (21.3%), including 3 cases with intracranial rehemorrhage (1 case died),2 cases with hypothalamic dysfunction,2 cases with hydrocephalus, 1 case with frontotemporal lobe infarction, 1 case with intracranial infection, and 1 case with malignant brain swelling; the remaining patients had no obvious postoperative complications and were observed varying degrees of clinical symptoms improvement compared with preoperative status. Of the 47 patients, except 1 patient died, no aneurysm was found in CTA or DSA in the remaining 46 patients after operation. At discharge, COS score showed 5 points in 2 cases,4 points in 9 cases,3 points in 21 cases and 2 points in 14 cases. 11 cases had good prognosis and 35 cases had poor prognosis. The postoperative (17 ± 4) d GCS score of these 46 patients showed that the consciousness state was improved (the preoperative and postoperative scores were; 5 ± 1 and 7 ±2 Respectively,t = 7. 607,P <0. 01). Of these 46 patients,29 patients were followed up (3 month to 6years,median time 9 [6, 18] months) without recurrence. Conclusion Ultra-early microsurgery is a safe and effective method for the treatment of ruptured ACoAA with intracranial hematoma, and it is very important for the improvement of the consciousness state of patients.
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OBJECTIVE: The goal of this study was to compare several parameters, including wall shear stress (WSS) and flow pattern, between unruptured and ruptured anterior communicating artery (ACoA) aneurysms using patient-specific aneurysm geometry. METHODS: In total, 18 unruptured and 24 ruptured aneurysms were analyzed using computational fluid dynamics (CFD) models. Minimal, average, and maximal wall shear stress were calculated based on CFD simulations. Aneurysm height, ostium diameter, aspect ratio, and area of aneurysm were measured. Aneurysms were classified according to flow complexity (simple or complex) and inflow jet (concentrated or diffused). Statistical analyses were performed to ascertain differences between the aneurysm groups. RESULTS: Average wall shear stress of the ruptured group was greater than that of the unruptured group (9.42% for aneurysm and 10.38% for ostium). The average area of ruptured aneurysms was 31.22% larger than unruptured aneurysms. Simple flow was observed in 14 of 18 (78%) unruptured aneurysms, while all ruptured aneurysms had complex flow (p < 0.001). Ruptured aneurysms were more likely to have a concentrated inflow jet (63%), while unruptured aneurysms predominantly had a diffused inflow jet (83%, p=0.004). CONCLUSION: Ruptured aneurysms tended to have a larger geometric size and greater WSS compared to unruptured aneurysms, but the difference was not statistically significant. Flow complexity and inflow jet were significantly different between unruptured and ruptured ACoA aneurysms.
Subject(s)
Aneurysm , Aneurysm, Ruptured , Arteries , Hydrodynamics , Intracranial AneurysmABSTRACT
Objective To evaluate the predictors of anterior communicating artery (AcoA) intracranial aneurysm formation by regression analysis using three-dimensional digital subtraction angiography (3D-DSA) and transcranial color-coded duplex (TCCD) with emphasis on Willis circle variation and hemodynamic forces alteration,and provide references for high-risk population screening for intracranial aneurysm and prevention in the future.Methods Eighty-one patients with AcoA aneurysm,admitted to our hospital from November 2010 to November 2011 and confirmed by DSA,were selected as aneurysm group;3D-DSA images were carefully evaluated to confirm the vascular structural abnormality,including the presence of A1 dominance and Willis circle variation;additionally,TCCD was performed to record the hemodynamic parameters which were used to calculate shearing stress and mechanical stretch.One hundred and eighteen patients who have a negative result checked by DSA were chosen as controls at the same period.Differences ofhemodynamic parameters and vascular architecture between the two groups were compared.The risk factors ofAcoA aneurysm formation were analyzed by using receiver operating characteristic (ROC) curve and multivariate Logistic regression with emphasis on Willis circle variation and hemodynamic forces alteration.Results There were significant differences in the aspects of A1 dominance,angle between A2 segments of bilateral anterior cerebral artery (ACA) and shearing stress between AcoA aneurysm group and control group (P＜0.05).Additionally,the ROC curve showed that the angle between A2 segments of bilateral ACA and shearing stress and significantly characterize the formation of AcoA aneurysms (P＜0.05).Gender,hypertension (grade Ⅱ),Willis circle variation (OR=14.152,95％CI:1.006-199.012,P=0.049),A1 dominance (OR=25.048,95％CI:1.438-436.337,P=0.027) are risk factors ofAcoA aneurysm formation.Diabetes (FBG at the normal level),shearing stress (OR=0.053,95％CI:0.011-0.249,P=0.000),angle between A2 segments of bilateral ACA (OR=0.037,95％CI:0.007-0.211,P=0.000) are identified as protective factors.Conclusions Willis circle variation,A1 dominance,shearing stress,angle between A2 segments of bilateral ACA are influencing factors ofAcoA aneurysm formation.There is great clinical significance to accurately assess the influencing factors of AcoA aneurysm in guiding clinical prevention and treatment decision making.
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Objective To investigate the morphological factors related to the rupture of very small (≤3mm) anterior communicating artery (AComA) aneurysms, which provides basis for decision-making of whether or not taking intervention in very small un-ruptured AComA aneurysms. Methods (1) One hundred patients with primary AComA aneurysms, admitted to our hospital from January 2008 to June 2013, were enrolled; 84 AComA aneurysms were ruptured while 16 were un-ruptured; the morphological parameters of aneurysms were obtained by three-dimensional reconstruction with CT angiography (CTA) of the patients, and the clinical data and aneurysm morphological parameters were compared between the ruptured aneurysm group and the un-ruptured aneurysm group; multivariate Logistic regression was used to analyze the risk factors of small aneurysm rupture in the AComA, and receiver operating characteristic (ROC) curve was used to analyze the predictive efficacy of size ratio (SR) of maximum tumor depth to proximal carrier artery diameter in rupture of small aneurysms in the AComA. (2) Ninety-nine patients with primary AComA aneurysms, admitted to our hospital from June 2013 to January 2016, were enrolled; the parameters from the above analyses were applied to these patients to verify their predictive effectiveness. Results (1) Perpendicular height, AR value (Height/Neck), SR value and vessel angle were significantly different between ruptured aneurysm group and un-ruptured aneurysm group (P<0.05); multivariate Logistic analysis indicated that SR value was the independent risk factor of rupture of very small AComA aneurysms (OR=4.201, 95％CI: 1.175-15.019, P=0.012), and the lager the SR value, the higher the risk of rupture; ROC curve analysis revealed that the area under the curve was 0.699 with the optimal cut-off value being 0.9, and its diagnostic sensitivity, specificity and accuracy was 0.786, 0.625 and 0.760, respectively. (2) The SR value was then applied to the 99 patients, showing a stable predictive potential with sensitivity, specificity and accuracy of 0.676, 0.714 and 0.687, respectively. Conclusion SR value (≥0.9) is identified as independent morphological risk factor for rupture of very small AComA aneurysms; SR value is closely related to the state of aneurysms, which help make a better individualized and effective decision on the treatment of very small AComA aneurysms in clinic.
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Objective Intravascular interventional embolization has become the preferred method for the treatment of anterior communicating artery aneurysms.The purpose of this paper was to study the guiding significance of dual vessel fusion technique for in -terventional surgery of complex anterior communicating artery aneurysms. Methods A retrospective analysis was conducted on the clinical data of 31 patients with complicated anterior communicating artery aneurysms in our department from March 2015 to June 2016. All patients underwent two-vessel fusion, DSA angiography, and three-dimensional reconstruction of unilateral internal carotid artery and the images were compared to identify whether the aneurysm met the true size,the exact convergence point of bilateral A 1 and ante-rior communicating artery, anterior communicating artery aneurysm and anterior communicating artery and so on. Results There were 31 cases identified by dual vessel fusion technique on the consistency of aneurysms to true volume and 28 cases by three-dimensional reconstruction of unilateral internal carotid artery.There were 31 cases identified by dual vessel fusion technique on the exact convergence point of bilateral A 1 and anterior communicating artery and 9 cases by DSA angiography.There were 31 cases identified by dual vessel fusion technique on variations of anterior communicating artery complex and 24 cases by DSA angiography.There were 27 pa-tients who attained the optimal DSA machine projection angle by the dual vessel fusion technique which was the same as that of the unilateral internal carotid artery,in addition,the other 4 cases got better optimal DSA machine projection angle than those by three-dimensional reconstruction of unilateral internal carotid artery. Conclusion The dual vessel fusion technique helps surgeons to fully understand the anatomical relationship between anterior communicating artery complex and aneurysm,which has important guiding significance in making surgical strategies for complicated anterior communicating artery aneurysms,selecting embolization work angles and real-time observation during embolization.
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OBJECTIVE: The goal of this study was to compare several parameters, including wall shear stress (WSS) and flow pattern, between unruptured and ruptured anterior communicating artery (ACoA) aneurysms using patient-specific aneurysm geometry.METHODS: In total, 18 unruptured and 24 ruptured aneurysms were analyzed using computational fluid dynamics (CFD) models. Minimal, average, and maximal wall shear stress were calculated based on CFD simulations. Aneurysm height, ostium diameter, aspect ratio, and area of aneurysm were measured. Aneurysms were classified according to flow complexity (simple or complex) and inflow jet (concentrated or diffused). Statistical analyses were performed to ascertain differences between the aneurysm groups.RESULTS: Average wall shear stress of the ruptured group was greater than that of the unruptured group (9.42% for aneurysm and 10.38% for ostium). The average area of ruptured aneurysms was 31.22% larger than unruptured aneurysms. Simple flow was observed in 14 of 18 (78%) unruptured aneurysms, while all ruptured aneurysms had complex flow (p < 0.001). Ruptured aneurysms were more likely to have a concentrated inflow jet (63%), while unruptured aneurysms predominantly had a diffused inflow jet (83%, p=0.004).CONCLUSION: Ruptured aneurysms tended to have a larger geometric size and greater WSS compared to unruptured aneurysms, but the difference was not statistically significant. Flow complexity and inflow jet were significantly different between unruptured and ruptured ACoA aneurysms.
Subject(s)
Aneurysm , Aneurysm, Ruptured , Arteries , Hydrodynamics , Intracranial AneurysmABSTRACT
One of the most common causes of stroke is rupture of aneurysms whose approach requires knowledge of anatomical variants. The aim of this study was to determine the prevalence of anatomical variants of the anterior cerebral artery (ACA) and the anterior communicating artery (AComA) by 3D computed tomography angiography (3D CTA) in Mexican individuals. A retrospective, observational, cross-sectional descriptive study of 283 patients, independent of sex or age, in which morphometric measurements of cerebral vessels were evaluated using contrasted 3D CTA from a period of two years was performed. We found at least one "atypical" variant in a third of the study population (33.93 %). The most common "atypical" variant was the absence of the AComA (14.1 %). A significant association between the hypoplastic variant of the right A1 segment and hypoplasia of the left A1 and the right A2 was found, while hypoplasia of the left A1 was associated with hypoplasia of the right A2. There is a difference in the prevalence of anatomical variants of the ACA-AComA complex in Mexican population in relation to other populations. The typical variant is the most prevalent form in the study population. However, the presence of atypical variants represents an important number that should be taken into account in clinical and surgical procedures.
Una de las causas más frecuentes de accidente cerebrovascular es la ruptura de aneurismas cuyo abordaje requiere el conocimiento de las variantes anatómicas. El presente estudio tuvo como objetivo determinar la prevalencia de variantes anatómicas de la Arteria Cerebral Anterior (ACA) y la Arteria Comunicante Anterior (AComA) mediante angiotomografías computarizadas 3D (angioTAC 3D) de individuos mexicanos. Se realizó un estudio retrospectivo, observacional, transversal y descriptivo en el que se evaluaron angioTAC contrastados con reconstrucción 3D de 283 pacientes, sin considerar género ni edad, obtenidas durante un periodo de dos años a los que se les realizaron mediciones morfométricas en los vasos de interés. Se encontró al menos una variante "atípica" en un tercio de la población estudiada (33,93 %). La variante "atípica" más común fue la ausencia de AComA (14,1 %). Se encontró asociación significativa entre la variante hipoplásica del segmento A1 derecha y la hipoplasia de A1 izquierda y A2 derecha; mientras que la hipoplasia de A1 izquierda se asoció a la variante hipoplasia de A2 derecha, encontrándose mayor tendencia de aparición de aneurismas en función del menor diámetro del segmento A2 derecho de la ACA. Existe diferencia en la prevalencia de variantes anatómicas del complejo ACA-AComA en población mexicana con respecto a otras poblaciones. La variante típica constituye la forma más prevalente en la población estudiada. Sin embargo, la presencia de variantes atípicas representa una cifra importante que deberá tomarse en cuenta en procedimientos clínicos y quirúrgicos.
Subject(s)
Humans , Male , Female , Infant , Child, Preschool , Child , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Anatomic Variation , Circle of Willis/anatomy & histology , Circle of Willis/diagnostic imaging , Multidetector Computed Tomography/methods , Cross-Sectional Studies , Image Interpretation, Computer-Assisted , Imaging, Three-Dimensional , Retrospective StudiesABSTRACT
Objective To investigate the surgical efficacy for the treatment of ruptured anterior communicating artery aneurysms with different dome projections in acute phase via supraorbital lateral approach.Methods From January 2014 to March 2017,the clinical data of 79 patients with acute ruptured anterior communicating artery aneurysm with different dome projections in acute phase treated via supraorbital lateral approach in the First Affiliated Hospital of Soochow University were retrospectively analyzed.The operative efficacy was analyzed.The Glasgow outcome scale (GOS) score was used to evaluate the prognosis at 3-36 months after procedure.Results In the 79 patients,34 were superior dome projections,37 was inferior dome projections,and 8 were complicated dome projections.All the anterior communicating artery aneurysms were successfully clipped.The patients were followed up for 3-36 months after procedure.GOS showed good prognosis in 70 cases (88.6％),of which 26 were superior dome projections,36 were inferior dome projections,and 8 were complicated dome projections;9 suffered mild disability (11.4％),of which 8 were superior dome projections and 1 was inferior dome projection.There were no severe disability,persistent vegetative state,and death.The prognosis in patients with inferior dome projection was better than that of superior dome projection (97.3％ [36/37] vs.76.5％ [26/34]).The difference was statistically significant (χ2=5.19,P<0.05).Conclusions The lateral supraorbital approach is an effective option for treating ruptured ACoAA with different dome projections in acute phase.The prognosis in patients with inferior dome projection is better than that of superior dome projection.