Вплив інтраопераційного розриву аневризм головного мозку на результати хірургічного лікування в ранній післяопераційний період

Abstract

Objective – to study features of clinical neurological manifestations of intraoperative rupture of arterial aneurysms (AA) in the early postoperative period. Materials and methods. A retrospective study of the results of surgical treatment of 69 patients (31 (44.9 %) men and 38 (55.1 %) women) with acute cerebrovascular disorder in the hemorrhagic type was performed, due to the breakdown of brain aneurysm, in which there was an intraoperative rupture of arterial aneurysm. Age of patients from 21 to 65 years, the average age is (42.2 ± 14.2) year. In all cases the disease manifested itself as a clinic of non-traumatic intracranial hemorrhage as a result of the rupture of AA. The primary gap was observed in 57 (82.6 %) patients, repeated – in 12 (17.4 %) patients. The formation of intrahepatic hematoma was observed in 36 (52.2 %) patients. During hospitalization all patients underwent computer tomography of the brain to verify hemorrhage, cerebral edema, ischemic lesions and hydrocephalus expansion of the ventricular system. Diagnosis and determination of the degree of angiospasm were performed using transcranial dopplerography. The diagnosis of cerebral aneurysms was established using cerebral angiography and multispiral computer angiography. Intraoperative doppler screening was used to assess the radicalization of the aneurysm exclusion from the bloodstream. The Hunt-Hess scale, the World Federation of Neurological Surgeon Grading System for Subarachnoid Hemorrhage (WFNS SAH grading scales), Glasgow scale, was used to assess the clinical state of patients. Results. In the acute period 47 (68.12 %) patients were operated, in the subacute and cold period – 22 (31.9 %). In 63 patients, the intraoperative aneurysm rupture occurred during the allocation of aneurysms from arachnoidal adhesions, 2 at the time of aspiration of the intracerebral hematoma, 3 in the approach to aneurysm during to retraction of spatulas, 1 – noncontact aneurysm rupture during the trepanation stage. Temporary occlusion with a clip of an arterial carrier aneurysms as a measure of prevention of intraoperative rupture of brain aneurysms was aplicated in 66 (95.65 %) cases. Persistent neurological disorders arose in 15 (21.74 %) patients. 48 patients were discharge from the hospital in satisfactory condition. Six (8.7 %) patients (3 women and 3 men from 22 to 53 years old) died: 3 – due to the rupture of the aneurysm of anterior cerebral artery-anterior communicating artery on the left, 2 – aneurysms of anterior cerebral artery-anterior communicating artery on the right, 1 – the aneurysms of anterior inferior cerebellar artery on the right. In acute period operated 4 patients, in the distant period – 2. Conclusions. Intraoperative rupture of cerebral aneurysm – the most often intraoperative complications of clipping brain aneurysms, the appearance of which worsens the general condition of the patient, leads to the formation of persistent focal deficiency and increases the likelihood of postoperative lethality. The application of adequate surgical access to the optimal position of the patient on the operating table, induced arterial hypotension, temporary occlusion of the artery carrier aneurysms are reliable methods of preventing the onset of intraoperative ruptures of arterial aneurysms. Surgical tactics with an intraoperative rupture of aneurysm depends on the stage at which the bleeding from aneurysm occurred, its intensity and on anatomic-topographic features of aneurysms and arterial links of blood supply to the brain.