ДІАГНОСТИКА І ЛІКУВАННЯ РОЗРИВІВ ЦЕРЕБРАЛЬНИХ АРТЕРІАЛЬНИХ АНЕВРИЗМ (СУЧАСНИЙ СТАН ПРОБЛЕМИ)

Abstract

Introduction: The article is dedicated to current issues of improving outcomes of ruptured intracranial arterial aneurysms treatment by developing means to manage complications, refine indicators, terms, and methods of surgical treatment based on the analysis of the dynamics of clinical and angiometric perioperative indicators.Objectives: To determine current issues and research areas for the treatment of brain aneurysms.Methods: Literature sources on the diagnosis and treatment of intracranial arterial aneurysms published in the past 15 years have been analyzed using MEDLINE, Google Scholar, Researchgate medical databases, as well as our own prospective data obtained during the treatment of 184 patients with aneurysmal intracranial haemorrhage.Results: The most common complications in patients with ruptured intracranial arterial aneurysms include angiospasm (37.2%); intracerebral and intraventricular haemorrhages (27.6%); secondary cerebral ischemia (22.2%); intraoperative complications (9.1%); repeated aneurysm rupture (6.5%). Reliable criteria for predicting the unfavourable outcome of the surgery are high Hunt-Hess (> 2.7 ± 0.2) and WFNS (> 2.1 ± 0.2) scores in patients at the time of aneurysms exclusion. During the acute period (1-14 days), postoperative mortality after clipping (16.2%) differs from the coiling group (10.2%). Intraoperative cerebral angiospasm is a leading factor contributing to complications following the surgery and leading to an increase in mortality up to 27.8% while preventing successful surgery in 38.8% of cases. Regardless of the surgery timing, significant (p<0,05) reduction in the diameter of the middle cerebral artery at the end of surgery compared to its beginning by an average of 30.1% constitutes an unfavourable criterion as opposed to a favourable course when there is an unreliable (p>0,2) narrowing of the artery by an average of 8.4%. Immediate hospitalization, transcranial interventions within 10.5-14.3 days, and endovascular interventions in the first day are strongly recommended for patients with ruptured intracranial arterial aneurysms. They provide the best clinical results. If the aneurysm is amenable by each of the methods, endovascular embolization is preferred, since in this case, the average patient day is statistically significantly shorter (p <0,01) than after transcranial clipping.Conclusion: During 2008-2018, 789 intracranial arterial aneurysms were treated surgically in the Municipal Non-Profit Enterprise "Lviv Clinical Emergency Care Hospital". Postoperative mortality decreased from 29.9% in 2008 to 8.2% in 2018. Advantages of endovascular treatment in the early stages of haemorrhage and higher radicality of aneurysm exclusion using the microsurgical method have received theoretical justification and clinical confirmation. Provided literature, clinical, and instrumental data expand the understanding of the pathogenesis of complications in cases of ruptured intracranial arterial aneurysms and show their predictive value. The choice of the optimal surgery term and method constitutes an effective means to reduce the level of postoperative mortality in case of aneurysmal intracranial haemorrhages. We have developed and implemented a new method for determining intraoperative angiospasm severity, and optimized a choice of coil parameters for safe and effective cerebral aneurysms embolization.