Anterior communicating artery aneurysm associated with duplicated hypoplastic right A1 segment

Variations of the anterior cerebral artery(ACA)-anterior communicating artery(ACo A) complex are commonly observed when associated with a symptomatic intracranial aneurysm. We report an asymptomatic ACo A aneurysm associated with duplicated hypoplastic A1 segment of the right ACA, observed in a 70-year-old female cadaver. Furthermore, the aneurysm, practically substituting the ACo A, caused a remarkable depression on the internal surface of the right frontal lobe, anterior to the optic chiasm. Aneurysms and other anomalies of the ACA and ACo A are common and their microvascular surgical management requires sound knowledge of the normal and variant vascular anatomy. Persistence of some embryonic vessels that normally disappear, disappearance of vessels that would normally persist or sprouting of new vessels due to hemodynamic and genetic factors are the usual causes for such anomalies. The high incidence of coexisting vascular anomalies and aneurysm suggests that such abnormalities predispose to aneurysm formation due to changes in the regional blood flow. A1 segment duplication has been reported to occur in 4% of subjects in cadaveric studies and in up to 0.5%-9.7% of cases of ACo A aneurysm surgery. Angiographic hypoplasias and aplasias of the A1 seg-ment have been also correlated with ACo A aneurysm patients.

Influence of Clip Locations on Intraaneurysmal Flow Dynamics in Patient-specific Anterior Communicating Aneurysm Models with Different Aneurysmal Angle

To improve aneurysm treatment,this study examined the influence of clip locations on hemodynamic factors in patient-specific anterior communicating artery(ACoA)aneurysms with different aneurysmal angle.We proposed a simplified classification of ACoA aneurysms using aneurysmal angle,defined by the angle of pivot of the aneurysmal dome and the virtual two-dimensional plane created by both proximal A2 segments of anterior cerebral artery(ACA).ACoA aneurysms with three different aneurysmal angles,which are 15°,80°and 120°,were analyzed in our study.In this work,we obtained hemodynamics before and after clipping surgery with three clip locations based on clinical clipping strategies in three ACoA aneurysms with different aneurysm angles.Results showed that local high pressure occurs at impingement region of the ACoA aneurysm before clipping and new impingement region close to the clipping location after clipping treatment.For clipping the aneurysm with aneurysmal angle 15°and a wide neck,wall shear stress(WSS)distribution is more uniform when the clipping angle of two clips close to 180°comparing with other two angles.In addition,for clipping the aneurysm with aneurysmal angle 80°and 120°,local high pressure appears on new impingement region and high WSS distributes around the clipping location when the clip plane is normal to the direction of inflow of aneurysm from the dominance of A1 segment of ACA.Hence,we should avoid the impingement of inflow from the A1 segment and choose a favorable clipping location for the fastness of clip.The results of our study could preoperatively give a useful information to the decision of surgical plan.

Evaluation of an ischemic model in ischemia prone and general Mongolian gerbils by neurological symptom, injury,and sex difference

Background: In the previous study, we established an ischemia-prone gerbil population(IG), which was selectively bred to increase the incidence of unilateral carotid arterial occlusion(UCO)-induced ischemia in Mongolian gerbils. However, if the characteristics of ischemia model in IG are the same as those in general gerbils(GG), and if the neurological symptoms are associated with the neurological insults in IG is still unclear.Methods: In the present study, we evaluated the UCO model in IG by analyzing neurological symptoms, neurological injury in the hippocampal CA1 region and compared with GG.Results: The data showed that the ratios of neurological symptom scores ≥ 2 in the IG and GG groups were 65.0% vs 30.0%, respectively, and were significantly different(P <.01).The neuronal damage following a UCO ischemic insult in the IG group was more severe compared to the GG group. There was a high correlation between the neurological insults' scale and the neurological symptom score in the IG and GG groups(r =.979 and.943 in the IG and GG groups, respectively). In animals with mild neurological symptom scores(2 and 3), the neuronal insults were significantly different between female and male gerbils in both IG and GG.Conclusion: Our findings suggest that IG population would likely be more advantageous to establish an ischemic model.

Morphological predictors of posterior communicating artery aneurysms rupture

Objective: The conflicting findings of previous morphological studies on intracranial aneurysm rupture may be caused by the different locations of aneurysms. We aimed to determine the independent risk factors of aneurysm rupture by focusing on only posterior communicating artery(Pcom A) aneurysms. Methods: In 89 PcomA aneurysms(58 ruptured, 31 unruptured), clinical and morphological characteristics were compared between the ruptured and unruptured groups. Multivariate logistic regression analysis was performed to determine the independent predictors for the rupture status of PcomA aneurysms. Results: In univariate analyses, the aneurysm dome size, aspect ratio, size ratio,dome‐to‐neck ratio, and inflow angle were significant parameters. With multivariate analyses, only the aneurysm dome size and inflow angle were significantly associated with the rupture status of PcomA aneurysms. Conclusions: Morphology was related with rupture of PcomA aneurysms. The aneurysm dome size and inflow angle were found to be the independent parameters characterizing the rupture status of PcomA aneurysms.

Intentional Compartmentalized Embolization of Wide-neck Aneurysms Incorporating the Posterior Communicating Artery to Preserve Flow

Background:Endovascular coiling for wide-neck aneurysms with a branch arising from the aneurysmal sac is challenging and sometimes considered impossible.This study aims to present our experience in treating wide-neck internal carotid artery(ICA)aneurysms with a posterior communicating artery(PComA)arising from the sac using a strategy of stenting the ICA and intentional compartmentalization to preserve the flow in the PComA.Methods:Eight consecutive cases of wide-neck ICA aneurysms with a fetal-type PComA arising from the aneurysmal sac were embolized from January 2015 to June 2018 at the First Affiliated Hospital,College of Medicine,Zhejiang University.Demographics,angiographic technique,procedural complications and clinical outcomes were reviewed.Results:There were 2 men and 6 women ranging from 56 to 81 years of age.Of the 8 cases,3 were ruptured and 5 were unruptured aneurysms.Stents were successfully deployed in all 8 cases.Near-complete occlusion was achieved in 3 cases(37.5%),neck remnant in 4(50%)and sac remnant in one(12.5%)of the cases.One case suffered transient ischemic attack after procedure completion.The clinical outcome was favorable in all 8 cases(modified Rankin scale 0-1).No rebleeding occurred during clinical follow-up.Conclusion:Stent-assisted compartmentalized embolization is feasible and safe in the treatment of wide-neck ICA aneurysm with a PComA arising from the sac.

Factors determining the side of approach for clipping ruptured anterior communicating artery aneurysm via supraorbital eyebrow keyhole approach

Purpose:The purpose of this study was to review the microsurgical anatomy and clipping of ruptured anterior communicating artery(AComA)aneurysms and to plan and avoid complications before operation.Methods:A total of 523 cases of cerebral aneurysms admitted to the neurosurgery department of the Third Affiliated Hospital of Sun Yat-Sen University from September 2010 to October 2018 were analyzed retrospectively.Among them,85 patients had ruptured AComA aneurysms.This study was limited to 85 of these cases,whose satisfactory preoperative angiographic diagnostic films can be retrieved from the hospital database system because of the need for detailed review.Results:We performed supraorbital eyebrow keyhole approach(SOEK)craniotomy in 85 patients to clip 85 AComA aneurysms,in the setting of subarachnoid hemorrhage(SAH).Patients’mean age was(52.69±9.94)years(range,28e78 years).The proportions of small,medium and large aneurysms were 83.5%,15.3%,and 1.2%,respectively.The average size of the aneurysms was(5.07±2.36)mm.There were 77.8% of patients with inferior aneurysms and 81.3% of patients with superior aneurysms achieved good results.There was a significant correlation between A1 dominance and operation method(p<0.001).There was no significant relationship between surgical approach and aneurysm projection or A2 plane(p=0.157&p=0.318).Conclusion:Regardless of whether the A2 plane is open or closed,the A1 dominant side is still a better choice for accessing AComA aneurysms to avoid dangerous premature bleeding.

Endoscopic anatomical study on anterior communicating artery aneurysm surgery by endonasal transphenoidal approach

Background:Endonasal transphenoidal approach by neuroendoscopy has its own advantage,such as direct access invasive,better visualization of the anterior communicating artery aneurysm and so on.The study is to provide anatomical knowledge for anterior communicating artery aneurysm surgery by endonasal transphenoidal approach with neuroendoscopy.Materials:Take 10 skull base specimens,observe and measure the anatomical structures around anterior communicating artery.Take 10 cadaveric heads,simulate the anterior communicating artery aneurysm surgery with neuroendoscopy by endonasal transphenoidal approach.Find the natural opening of sphenoid sinus,then open the skull base,expand bone window in anterior skull base.After that,cut off the dura,find the optic nerve,optic chiasm,cisterna lamina terminalis,anterior cerebral artery,a portion of frontal lobe,anterior communicating artery complex and its important branches,such as heubner artery,hypothalamic artery,orbitofrontal artery and so on.Lift up anterior communicating artery complex and seperate arachnoid in cisterna lamina terminalis,the lamina terminalis is exposed.Block bilateral A1 of anterior cerebral artery with aneurysm clip,the anterior communicating artery complex and its important branches are in view,so we can clip anterior communicating artery aneurysm safely.Results:Anterior communicating artery aneurysm surgery can be finished with neuroendoscopy by endonasal transphenoidal approach.The vital structures can be clearly observed with neuroendoscopy.The rhombus anatomic region formed by bilateral olfactory nerve and optic nerve is a safe surgical area.According to the calculation,the safe surgical area is about 161.48 ± 12.78 mm2.Measure the distance between the important anatomic structures in the rhombus anatomic region.By means of SPSS 17 Statistical analysis softvvare,the measuring distance is expressed with (x ± S)mm.Conclusion:The anterior communicating aneurysm surgery by endonasal transphenoidal approach with neuroendoscopy has its own advantage,such as direct access,minimally invasive,less bleeding,light pain,quick recovery,better visualization of the anterior communicating artery aneurysm and so on.This operation approach needs further study and exploration to clinical application,in order to become a mature approach of anterior communicating artery aneurysm surgery.

Terson Syndrome:A Case of Anterior Communicating Artery Aneurysm Rupture with Spontaneous Subarachnoid Hemorrhage

Terson syndrome is manifested as retinal and vitreous hemorrhage with aneurysmal subarachnoid hemorrhage(SAH),and is associated with the severity,high mortality and poor prognosis of aneurysmal SAH.Severe Terson syndrome can lead to vision loss or even permanent blindness.The prevalence of Terson syndrome is 2.6%-50%on a global scale;however,it is often misdiagnosed due to the lack of routine ophthalmologic examination and the early comorbidities of cognitive disorder,laloplegia and coma.Herein,we report a 29-year-old male patient who suffered from aneurysmal SAH with Terson syndrome in department of neurosurgery,the First Affiliated Hospital,Zhejiang University,School of Medicine,to highlight the importance of early diagnosis and treatment of Terson syndrome.

动脉瘤性蛛网膜下腔出血后综合康复195例临床分析

目的探讨动脉瘤性蛛网膜下腔出血患者的综合康复治疗效果,了解不同部位动脉瘤对患者功能障碍的影响。方法回顾性分析2011-10—2021-10中国康复研究中心收治的195例动脉瘤性蛛网膜下腔出血患者的一般资料、手术方法、量表评分、主要功能障碍。结果经过康复治疗,患者简易精神状态检查量表评分(t=—8.239,P<0.001)、Fugl-Meyer评定量表运动评分(t=—7.360,P<0.001)和Fugl-Meyer平衡评分(t=—10.096,P<0.001)、ADL明显改善(t=—12.392,P<0.001),NIHSS评分下降(t=8.257,P<0.001)。不同位置动脉瘤手术方法选择不同,前交通动脉瘤、颈内动脉瘤行介入栓塞术较高分别达56.2%、73.3%,差异有统计学意义(χ^(2)=4.844,P=0.028;χ^(2)=5.229,P=0.022),大脑中动脉瘤行夹闭术组更高,达77.8%,差异有统计学意义(χ^(2)=16.167,P<0.001)。动脉瘤的位置对于运动功能障碍单双侧(χ^(2)=20.819,P=0.004)、锥体外系功能障碍(χ^(2)=16.190,P=0.001)、动眼神经损伤(χ^(2)=12.384,P=0.004)的影响有统计学差异。结论综合康复治疗能改善动脉瘤性蛛网膜下腔出血患者的认知功能、运动功能、平衡功能以及日常生活能力。大脑中动脉瘤选择夹闭术者更多。前交通动脉瘤导致双侧肢体运动障碍的比例明显增高,前交通动脉瘤、大脑前动脉瘤破裂更容易造成锥体外系运动功能障碍,后交通动脉瘤则更易造成动眼神经损伤。不同障碍患者需要进行个体化康复治疗。

经眶颧-海绵窦入路夹闭基底动脉瘤的应用解剖研究

目的探讨在经眶颧-海绵窦入路手术中增加基底动脉上段显露的方法。方法在10例标本上模拟经眶颧-海绵窦入路,观察磨除前、后床突后对基底动脉上段的显露情况。结果磨除前床突后形成的间隙为床突间隙;前床突下颈内动脉与动眼神经间的膜为颈内动脉动眼神经膜,沿此膜可进入海绵窦;磨除后床突后,暴露鞍背、上斜坡,即可显露基底动脉上段。结论在经眶颧-海绵窦入路手术中磨除前床突和后床突,可增加对基底动脉上段的显露。

硬膜外途径磨除前床突在后交通动脉动脉瘤夹闭术中的应用效果分析

目的探讨经硬膜外途径磨除前床突在后交通动脉动脉瘤(PCoAA)夹闭术中的应用效果。方法回顾性分析2012年1月—2014年1月开颅手术的42例PCoAA患者的临床资料,其中22例磨除前床突,20例未磨除前床突,分析术中夹闭动脉瘤难易程度及术后疗效。结果在22例磨除前床突术中,动脉瘤均得到满意夹闭,术中均未使用脑牵开器,术后仅有1例出现脑梗死,无动眼神经麻痹病例,无动脉瘤夹闭不全病例。20例未磨除前床突病例中,3例瘤夹置入困难造成动脉瘤夹闭不全,2例出现脑梗死,1例出现动眼神经麻痹。结论经硬膜外途径磨除前床突给PCoAA夹闭手术带来便利,术中能有效避免瘤夹置入困难,应用安全,降低术后并发症。

前交通动脉瘤破裂因素分析

目的：研究前交通动脉瘤的破裂因素，以提高临床诊治的疗效。方法：回顾性总结近年来经CTA及动脉瘤夹闭术确诊证实的110例破裂前交通动脉瘤，分析其破裂因素。结果：110例前交通动脉瘤患者中，男49例，女61例，男女比0．8：1，年龄17～77岁，平均49．3岁。CTA提示，110例前交通动脉瘤患者中大脑前动脉A1优势征63例（57．2％），其中左侧A1优势征46例，右侧A1优势征17例；大脑前动脉A1对称47例（42．8％）。另外，110例前交通动脉瘤患者中已诊断为高血压的58例（53％），血压正常的52例（47％）。结论：大脑前动脉A1优势征及高血压等先天性及后天性因素与前交通动脉瘤的破裂有密切的关系。

前交通与后交通动脉动脉瘤破裂的危险因素分析

目的探讨前交通动脉(ACoA)与后交通动脉(PCoA)动脉瘤破裂的危险因素。方法回顾性分析南京医科大学附属无锡人民医院收治的110例ACoA动脉瘤和104例PCoA动脉瘤患者的临床资料。患者分为动脉瘤破裂和未破裂组。通过单因素和多因素logistic回归分析等方法对相关临床资料进行比较分析。结果ACoA动脉瘤破裂与未破裂组在高血压、瘤高/瘤颈(aspect ratio,AR)均值、不同组别AR值及血流夹角方面,PCoA动脉瘤破裂与未破裂组在年龄均值、高血压、瘤体大小和AR均值、不同瘤体大小和AR值分组、血流夹角方面,差异均有统计学意义(P<0.05~0.001)。ACoA与PCoA动脉瘤破裂组患者的性别、年龄均值、年龄分布、瘤体大小均值和血流夹角比较,差异均有统计学意义(P<0.05~0.001)。多因素logistic回归显示,年龄<50岁(OR=9.396,P=0.028)、高血压(OR=0.166,P=0.003)、AR≥1.5(OR=0.100,P=0.001)和血流夹角(OR=1.035,P=0.007)为ACoA动脉瘤破裂的独立危险因素;年龄50~60岁(OR=5.203,P=0.035)、高血压(OR=2.981,P=0.039)、瘤体大小5~10 mm(OR=3.912,P=0.035)、AR≥1.5(OR=4.186,P=0.018)和血流夹角(OR=1.038,P=0.014)为PCoA动脉瘤破裂的独立危险因素。结论ACoA和PCoA动脉瘤破裂危险因素各有异同。ACoA和PCoA动脉瘤破裂患者在性别、年龄、瘤体大小和血流夹角方面均具有显著差异。

Nomogram model for predicting oculomotor nerve palsy in patients with intracranial aneurysm

AIM:To explore the risk factors of oculomotor nerve palsy(ONP)in patients with intracranial aneurysm(IA)and develop a nomogram model for predicting ONP of IA patients.METHODS:A total of 329 IA patients were included.Logistic regression analysis was applied to identify independent factors,which were then integrated into the nomogram model.The performance of the nomogram model was evaluated by calibration cur ve,receiver operating curve(ROC),and decision curve analysis.RESULTS:Univariate and multivariate logistic regression analysis indicated posterior communicating artery(PCo A)aneur ysm[hazard ratio(HR)=17.13,P<0.001]and aneurysm diameter(HR=1.31,P<0.001)were independent risk factors of ONP in IA patients.Based on the results of logistic regression analysis,a nomogram model for predicting the ONP in IA patients was constructed.The calibration curve indicated the nomogram had a good agreement between the predictions and observations.The nomogram showed a high predictive accuracy and discriminative ability with an area under the curve(AUC)of 0.863.The decision curve analysis showed that the nomogram was powerful in the clinical decision.PCo A aneurysm(HR=3.38,P=0.015)was identified to be the only independent risk factor for ONP severity.CONCLUSION:PCo A aneurysm and aneurysm diameter are independent risk factors of ONP in IA patients.The nomogram established is performed reliably and accurately for predicting ONP.PCo A aneurysm is the only independent risk factor for ONP severity.

Onyx栓塞治疗后循环远端动脉瘤及中期随访

目的评价瘤内Onyx栓塞后循环远端动脉瘤的可行性和安全性。方法回顾性分析应用Onyx瘤内栓塞治疗的12例后循环远端动脉瘤患者的临床资料及随访结果。结果即刻造影显示所有12个动脉瘤均完全闭塞，11例载瘤动脉保留。发生操作相关并发症1例，导致暂时性神经功能缺失。未发生永久性神经功能缺失。随访期间患者预后满意，无动脉瘤再通和再出血发生。结论Onyx瘤内栓塞后循环远端动脉瘤疗效显著，载瘤动脉保存率高，对于无法手术夹闭和弹簧圈瘤内栓塞的病例是一种可行的治疗方法。

额外侧锁孔入路低分级颈内动脉交通段动脉瘤夹闭术中分支动脉的保护

目的探讨经额外侧锁孔入路行低分级颈内动脉交通段(C7段)动脉瘤夹闭手术时对分支动脉保护的临床经验及效果。方法选择徐州医科大学附属连云港医院神经外科自2017年1月至2020年12月行经额外侧锁孔入路动脉瘤夹闭手术治疗的52例Hunt-Hess分级Ⅰ~Ⅲ级颈内动脉C7段动脉瘤患者进行研究,其中后交通动脉瘤45例、脉络膜前动脉瘤6例、后交通动脉瘤合并脉络膜前动脉瘤1例。术中仔细明确分支动脉起始部与瘤颈的关系,并在颈内动脉第Ⅱ、Ⅲ及Ⅴ间隙探查分支动脉走形及其与瘤体的关系,必要时辅助以吲哚菁绿荧光造影;选择适合动脉瘤夹或行动脉瘤夹组合夹闭动脉瘤;夹闭完成后行镜下或内镜探查、吲哚菁绿荧光造影,对分支动脉误夹或狭窄者予以重新夹闭。结果术中有6例患者的分支动脉误夹(后交通动脉4例、脉络膜前动脉1例、颈内动脉分叉部穿支动脉1例),予以调整或更换动脉瘤夹后重新夹闭。52例患者的动脉瘤均成功夹闭。术后24 h内头颅CT复查示分支动脉供血区局灶性脑梗死5例,其中3例伴对侧肢体肌力下降(分别为4级、3级和1级),予药物及神经康复治疗;余47例一般情况好、无特殊。术后随访9~12个月,3例对侧肢体肌力下降患者的肌力分别恢复至5级、4级和2级;所有患者的动脉瘤均无残留或复发,末次随访时格拉斯哥预后评分5分47例、4分3例、3分1例、2分1例。结论在经额外侧锁孔入路动脉瘤夹闭手术治疗低分级颈内动脉C7段动脉瘤术中,采用多种保护方式积极防止分支动脉的损伤,可有效降低术后脑梗死的发生,改善患者预后。

经Dolenc入路手术夹闭27例部分复杂性后交通动脉瘤的疗效分析

目的探讨经Dolenc入路手术夹闭部分复杂性后交通动脉瘤的疗效及其临床经验。方法回顾性收集徐州医科大学附属连云港医院神经外科及首都医科大学附属北京天坛医院神经外科自2014年7月至2019年6月经Dolenc入路手术夹闭的27例部分复杂性后交通动脉瘤患者的临床资料,分析其临床疗效并总结手术经验。结果术中26例动脉瘤夹闭顺利,1例改行包裹术。术前3例动眼神经麻痹患者中术后2例好转、1例无变化;术后新发4例动眼神经麻痹,经保守治疗后2例恢复正常、1例好转、1例无变化;术后2例发生基底节局灶性脑梗死,1例因脑积水行脑室腹腔分流。26例患者术后2周内DSA或CT血管成像复查均提示动脉瘤完全夹毕、无残留。术后9~12个月内随访示格拉斯哥预后评分5分20例、4分3例、3分2例、2分1例、死亡1例,影像学复查均未见动脉瘤复发。结论经Dolenc入路可通过硬膜外磨除前床突而获得良好的操作空间,充分暴露近端载瘤动脉,从而安全有效地手术夹闭部分复杂性后交通动脉瘤。

翼点入路开颅手术夹闭后内侧下型后交通动脉瘤的临床观察

目的探讨翼点入路开颅手术中后内侧下型(颈内动脉内侧后下方、被颈内动脉遮挡)破裂后交通动脉瘤的夹闭方法。方法﹐选择联勤保障部队第九〇〇医院神经外科自2004年1月至2020年1月行翼点入路开颅手术夹闭后内侧下型破裂后交通动脉瘤患者7例进入研究,回顾性分析患者的临床资料和疗效。结果夹闭手术中误夹脉络膜前动脉2例,其中1例释放动脉瘤夹后发现并松开调整,另外1例患者经过多次调整后避开;2例患者切除前颞叶脑组织约20 mm,5例患者采用脑压板向后方牵开前颞叶。术后复查CTA显示,7例患者的动脉瘤消失,未见瘤颈残留,载瘤动脉保持通畅。1例患者的脉络膜前动脉供血区脑梗死。7例患者随访1~6年,平均27.6个月。6例患者完全康复,无神经功能障碍。1例患者对侧肢体偏瘫,肌力Ⅲ级.拄拐行走,生活基本自理。结论翼点入路开颅手术夹闭后内侧下型破裂后交通动脉瘤时操作困难,可采取扩大周围脑池间隙等方法,利用直弯、弯形动脉瘤夹夹闭动脉瘤。