Nghiên cứu hình thái tổn thương và đánh giá kết quả phẫu thuật điều trị túi phình động mạch não tt tieng anh

1
INTRODUCTION
Cerebral aneurysm (cerebral artery) is a common pathology of
cerebral artery system. Research on bodies shows that cerebral
aneurysm accounts for 0.2-7.9% of the population, some studies
show an aneurysm rate of 5%. The fatal complication is usually the
rupture aneurysm and this is also one of the causes of brain stroke.
To date, the world as well as in Vietnam has used the methods of
treating cerebral aneurysms such as: micro-surgery aneurysm,
intravascular interventions. Each method has its advantages and
limitations, but microsurgical clipping aneurysm still plays an
important role.
In the process of micro-surgery an aneurysm, there is a part of the
neck that is missing, which is the cause of secondary bleeding and
rupture of the aneurysm at 2.5%. Clipping aneurysm can clip to the
cranial nerves to cause damage. Especially can be inserted into oblique
arteries, arteries carrying aneurysm causes 9.52% brain anemia in
them.
Surgical results, the rate of complications in surgery closely related
to aneurysm morphology. The study of the location, shape, size,
aneurysm direction as well as related factors through clinical, imaging,
observation during surgery helps surgeons have appropriate treatment
tactics and prognosis after surgery. In order to improve the quality of
treatment for cerebral artery disease, we conduct the project: " research
in morphology and assessing surgical results treatment of cerebral
aneurysms" with the following objectives:
1. Describe the morphological pattern of cerebral aneurysm
surgical indications.


2

2. Assess the results of cerebral aneurysm surgery
New contributions of the thesis:
The study described aneurysm morphology on CTA and DSA
images. The shape of aneurysm is mainly bag shaped, on CTA
accounting for 98.7%, on CTA is 100%. The aneurysm site is mainly
found in the anterior communicating artery, on CTA is 38.3%, on
DSA is 35.8%. The size of aneurysms ≤5mm is the most popular,
accounts for 65.6% on CTA and 57.6% on DSA. Along with the
development of intravascular intervention to treat cerebral aneurysm,
surgery is still a basic method of choice, with good treatment results
of 76.4%, the percentage of aneurysms clipped completely is 94.4%.
Thesis structure
Total 134 pages: 2 - page problem section; Chapter 1: Overview
33 pages; Chapter 2: Subjects and research methods 26
pages; Chapter 3: Research results 35 pages; Chapter 4: Discussion
37 pages; Concluding remarks 02 pages, Proposal 01 page. The thesis
has: 41 tables, 35 pictures and 5 charts, 178 references.

CHAPTER 1
OVERVIEW
1.1. Research situation of cerebral aneurysm
1.1.1. Studies over the world:
The cerebral aneurysm was first described in the early 18th century
and subarachnoid hemorrhage was primarily caused by the aneurysm. In


3
1938, Dandy W.E. announced the first successful surgical case to treat
cerebral aneurysm with an aneurysm clipping. Gallagher J.P (1963)
introduced the technique of coagulation aneurysm by inserting animal

hairs into aneurysm at high speed using an air gun ("hair
pump"). Serbinenko F.A occluded the aneurysm with balloon in 1970. In
1989, Guglielmi G., the Italian neurosurgeon, firstly invented the
method of using a metal coil (coil) attached to a wire to pass through a
wire microcatheter into aneurysm. This is then cut off by direct current,
which coagulates the aneurysm to remove aneurysm from the brain
artery system while preserving the artery called the detachable metal
spiral (GDC). In 2003, Reisch R. et al reported a 10-year experience of
using supraorbital craniotomy in surgical aneurysm and base skull. The
average skull cap size the authors made was 2.5x1.5cm.
1.1.2. Researches in our country
The first aneurysm surgery was reported by Nguyen Thuong
Xuan et al in 1962. In 2006, Nguyen The Hao conducted the first
doctoral thesis "Research diagnosis and surgical treatment of
subarachnoid hemorrhage due to rupture of the internal carotid artery
aneurysm". Nguyen The Hao et al (2015) published the study
"Results of treatment of cerebral aneurysm with minimally invasive
surgery at Bach Mai Hospital" including 48 patients with good results
87.5%, without residual aneurysm, nerve damage on eye socket
10.3%, ciliary muscle 7.7%, temporal muscle 5.1%, aesthetic patient
complete satisfaction 76.9%. Pham Dinh Dai (2011) has implemented
the topic: "Study of clinical features, subclinical, results of treatment
after intravascular intervention in patients with stroke due to cerebral
aneurysm rupture"
1.2. Diagnostic image of cerebral aneurysm
1.2.1. Computerized tomographic without injection of contrast
material


4

With the new generation com machines for accurate diagnosis ≥
95% of cases of subarachnoid hemorrhage in the first 48 hours. With
images of increasing the proportion of blood in the subarachnoid in the
base of the skull (pituitary apoplexy, pontine cistern), Sylvius fissure,
inter hemispherical fissures, cerebellum tent, even brain cortex.
1.2.2. Computerized tomography angiography
Computerized tomography angiography (CTA) results in
diagnosing aneurysms up to 97% with the advantage of being a safe,
effective method that can be used to diagnose both unruptured and
ruptured aneurysms. CTA for 3D images helps to identify the oblique
veins separated from the aneurysm, as well as the anatomical
connection between the aneurysm and the base of skull, which is
important in the development of the surgery plan. CTA is also
valuable in diagnosing vasospasm.
1.2.3. Magnetic
angiography

resonance

imaging

and

magnetic

resonance

Magnetic resonance imaging (MRI) in the diagnosis of
subarachnoid hemorrhage is not sensitive within the first 24-48 hours
(due to too little met-Hb) especially with thin blood layers. MRI

gives the best results within 4-7 days (positive results are in a semiacute period of 10-20 days). Imaging on the Flair pulse provides the
highest sensitivity to subarachnoid hemorrhage with increased signal
imaging in the brain sulcus. An MRI can detect a dilated aneurysm,
the image of aneurysm without a blood clot in the upper T2W is
usually regular, relatively clear, no signal, hollow flow, continuous
with a blood vessel.
Magnetic
resonance
angiography
(MRA)
diagnoses
aneurysmswith 87% sensitivity, 92% specificity, but difficult to
diagnose aneurysm smaller than 3 mm.


5
1.2.4. Digital subtraction angiography
This is the gold standard for determining the
aneurysm active brain circuits. DSA found 80-85% of cases of
ruptured cerebral aneurysms causing subarachnoid hemorrhage (the
rest are unexplained subarachnoid hemorrhage)
1.3. Micro surgical treatment of cerebral aneurysm
1.3.1. Surgical approaches of aneurysm
+ Frontotemporosphenoidal approach: also known as the pterional
approach is indicated for cases of aneurysm of the anterior cerebral
circulation: the internal carotid arteries of aneurysm, the middle cerebral
artery, the anterior cerebral artery; or basilar tip aneurysm.
+ Subfrontal approach: is indicated for anterior communicating
artery aneurysm with an aneurysm upwards, especially in cases
where intracerebral hemorrhage large.

+ Anterior interhemispheric approach: is indicated for anterior
communicating artery aneurysm, with the advantage of a small brain lift.
+ Transcallosal approach: indicative for vesicular aneurysm.
+ The superior temporal gyrus approach: is indicated for the
aneurysm of the middle cerebral artery, with little advantage of the
brain, can reduce the risk of vasospam.
+ Suboccipital approach: indicative of the aneurysm of the
basilar vertebral artery complex.
+ Subtemporal approach: designates the basilar aneurysm at the
same height as the superior cerebellar artery.


6
+ Orbitozygomatic approach: Some authors use to access the
basilar aneurysm.
+ Transcondylar approach.
1.3.2. Microsurgical treatments for cerebral aneurysm
+ Clipping aneurysm.
+ Wrapping aneurysm.
+ Constricting artery carrying aneurysm.

CHAPTER 2
SUBJECTS AND METHODS OF THE STUDY
2.1. Research subjects
Including 156 patients who were diagnosed and treated for
microsurrgical clipping at Department of Neurosurgery - Viet Duc
Hospital from January 2011 to December 2013.
2.1.1. Criteria for selecting a patient
+ Patients diagnosed with cerebral aneurysms disease identified
by: DSA and or CTA.

+ Patients underwent surgery at the Department of Neurosurgery
- Viet Duc Hospital with clear surgical records, image on noninjected brain CT scan, CTA, DSA cerebrovascular clearly, with
sufficient reliability.


7
2.1.2. Exclusion criteria
+ Patients who are diagnosed with cerebral aneurysm and that the
patient and family them do not agree to surgery.
+ Patients diagnosed with cerebral aneurysm are treated with
endovascular.
2.2. Methods
Describe
a series
of prospective
non- controlled clinical clinical trials .

and

cross-cutting,

2.3. Formula to calculate sample size
+ Select a sample: Select a probability sample, using a
convenient sampling method. Select all patients diagnosed with
coronary aneurysm and received microsurgical surgical treatment for
neck aneurysm during the study.
+ Sampling selection: Probability sampling, using convenient
sampling methods. Select all patients diagnosed with coronary
aneurysms and treated for micro-aneurysms during the study period.
In this study we performed 156 patients.

2.4. Research content
2.4.1. Study clinical characteristics
+ Age of patients at the time of diagnosis to determine: average
age, minimum age, maximum age, divided into 3 groups: 13-20, 2155, 56-57.


8
+ Gender: determining the incidence between men and women.
+ Medical history: t antennas blood pressure, headache, CTSN,
cerebral stroke, polycystic kidney, alcoholism, smoking.
+ Clinical characteristics:
- Patients with unruptured aneurysm: headache, nausea,
epilepsy, cranial nerve damage. Clinically assessed on a Glasgow
scale, modified Hunt-Hess grading and modified WFNS grading.
- Patients with ruptured aneurysms: determine the time from
the onset to the time of admission, determine the time from the
onset to the time of surgery. Judged by a Glasgow coma scale,
modified Hunt-Hess grading and modified WFNS. Determine
whether an aneurysm has ruptured before surgery and the number
of ruptures.
2.4.2. Study morphological characteristics of aneurysm
2.4.2.1. Computerized tomography without contrast
* Unruptured aneurysm:
Gather information about aneurysm divided into 2 groups, including:
+ No injury detected.
+ Detecting lesions: stunned blocks, calcified images, increasing
density.
* Ruptured aneurysm:

9
+ Determine the image of subarachnoid hemorrhage, location
(pontine cisterns, pituitary apoplexy, hemispherical fissures, Sylvius
trench, posterior fossa, other locations), time from onset to at the time of
shooting, determine the relationship between the time of shooting and
accuracy in detecting subarachnoid hemorrhage, degree of subarachnoid
hemorrhage and predicting vasospasm according to Fisher.


10
2.4.2.2. Digital subtraction angiography (DSA)
Digital subtraction angiography was performed on GE Advantx
machine at the diagnostic imaging department of Bach Mai Hospital, the
diagnostic imaging department at Viet Duc Friendship Hospital. Selective
scan of the internal carotid artery and vertebral artery. Take upright,
sloping, and 3/4 poses and special positions depending on the direction of
the SEG. The evaluation criteria are divided into two groups (unruptured
aneurysms ruptured aneurysm), including:
* Number of aneurysm: 1 aneurysm, 2 aneurysms, 3 aneurysms, 4
aneurysms.
* Aneurysmposition: right, left
+ Anterior cerebral circulation:
- Superior hypophyseal artery
- Ophthalmic artery
- Posterior communicating artery
- Internal carotid artery bifurcation
- Internal carotid artery
- Middle cerebral artery
- Middle cerebral artery bifurcation
- Anterior cerebral artery

11
- Pericallosal artery
- Anterior communicating artery
+ Posterior circulatory system:
- Vertebral artery
- Posteroinferior cerebellar artery
- Basilar tip aneurysm.
* Shape aneurysms: shaped, rhombus.
* The size of the aneurysm: the neck of the aneurysm, the body
of the aneurysm, the depth of the aneurysm.
* Some characteristics: uneven or irregular aneurysm, calcified
neck of an aneurysm, aneurysm with one or multiple lobes, oblique
branches coming from aneurysm, abnormalities of coronary artery
(aplasia, deformities ).
* On the DSA image, determine the degree of vasospasm on
George's scale.
2.4.2.3. Computerized tomography angiography
Used computerized 64-layer tomography machine Somatoma
sensations of Siemens (Germany). Contrast type Xenetic 300
(Guerbet) used 50ml, injected at a rate of 5ml / s, then injected Bolus
40ml 0.9% physiological saline (Volume of drug used = X-ray
emission time of injection speed). Time delay depends Bolus
Test. Spiral cutting 0.3 s / rev, 1.25 mm cutting layer thickness, 0.75
mm hops, 0.8 mm image reproduction. Voltage of 120 KV, 240


12
mA. The height of the box cuts from the horizontal C4 level to the

end of the skull. The image is 3-5-10mm thick, the maximum density
projection ( MIP ), the multi-plane volume reconstruction (MPR ),
the volume processing technique (VRT). Research targets :
+ Number of aneurysms.
+ Aneurysm location.
+ Shape of an aneurysm: a bag, a rhomb.
+ Aneurysm are regular or uneven.
+ Calcium neck aneurysm.
+ An aneurysm has one or more lobes
+ Oblique branches come out of the aneurysm.
+ The abnormalities of cerebral artery (aplasia, deformities).
+ Aneurysms size: neck, body, aneurysm depth.
2.4.3. The approach
* Frontotemporosphenoidal approach (pterional approach) : the
aneurysm in the anterior cerebral circulation, basilar tip aneurysm.
* Suboccipital approach: the vascular aneurysm follow.
* Supraorbital keyhole: aneurysm informed in advance .
* Anterior interhemispheic approach : anterior communicating
artery, pericallosal artery.


13
2.4.4. Evaluation of morphology of aneurysm during surgery
+ Studying morphological characteristics of an aneurysm: number,
position, shape, calcification of an aneurysm, clot in an aneurysm, an
anomalous or irregular aneurysm, an aneurysm with a single or
multiple lobes, oblique vessels, abnormalities of coronary system
(malformation, hypoplastic).
+ Evaluation of difficult factors in surgery: cerebral edema,
intracerebral hemorrhage, thin vault arch, vasospasm, calcification of the

neck of the vesicle, the lateral vascular, the difficult aneurysm position.
+ Statistics of surgical complications: rupture of the aneurysm
during surgery (before surgery, when the neck is anatomy, when
clipping the neck of the aneurysm), vascular lesions, cranial nerve
damage, aneurysm failure or incomplete clips.
2.4.5. Techniques for managing aneurysm
+ Clip merely.
+ Clip combination to taking hematoma.
+ Clip and bypass.
+ Clip and aneurysm wrap.
+ Wrap the balloon bag.
+ Clip the proximal and distal end clips with aneurysm.
2.4.6. Additional tachniques during surgery


14
Taking hematoma, craniectomy, ventricular drainage, revealing the
internal carotid artery and outside the skull, cutting the anterior clinoid
process, cutting a straight back, supporting endoscopy.
2.4.7. Evaluation of clinical results of microsurgical treatment
+ Assess the clinical results of patients on discharge according to
Glasgow outcome scale, mRankin.
+ Evaluate far results: based on clinical condition of patients based
on mRankin scale.
2.4.8. Evaluate the image diagnosis result after surgery.
2.4.8.1. Computerized tomographic without injection of contrast
material
+ Identify images of cerebral hemorrhage.
+ Identify images of ischemic brain.
+ Identify images of hydrocephalus (new appearance, old, improved).

+ Identify images of contusion brain.
2.4.8.2. Digital subtraction angiography after surgery
+ Completely out of aneurysm: there is no more aneurysm and neck.
+ Remaining balloon bag.
+ Whether the artery carrying aneurysm is narrow or not.
+ Brain embolism .


15
2.4.9. Determine the relationship between the outcome of treatment
and the factors
+ Age.
+ Preoperative clinical classification of GCS, Hunt-Hess, WFNS.
+ The extent of damage to the ruptured aneurysm: hematoma,
cerebral edema, rebleeding, subarachnoid hemorrhage to Fisher.
+ Rebleeding, ruptured aneurysm during surgery.
+ The degree of vasospasm according to George.
+ Aneurysms location.
+ Size of aneurysms.
2.5. Data processing methods
The study was processed according to STATA 13.0 software.
+ Calculate the rate, mean value and standard deviation of the
index in the research group.
+ Testing of average ratios and indicators by the method of
medical statistics through the processing of T-test tables, χ ².
+ Sensitivity (Se): the percentage (%) correctly diagnosed as having
disease in the total number of people diagnosed with the disease.
+ Specificity (Sp): the rate (%) correctly diagnosed that there is no
disease in the total number of people diagnosed with no diseases.

16
+ Positive predictive value (PPV): the ratio (%) is correct when
the disease is forecasted.
+ Negative predictive value (NPV): the ratio (%) is correct when
the prediction is disease or no disease.
+ Accuracy: the percentage (%) of correct diagnosis is a disease
among the total number of people diagnosed with the disease.
+ Comparing the difference: p <0.05 is statistically significant, p
<0.01 is statistically significant, p> 0.05 is not statistically significant.
2.6. Research ethics: compliance regulations on medical ethics in the
research process.

CHAPTER 3
RESEARCH RESULTS
3.1. General characteristics of the study object
Table 3.1. Patient distribution by age and gender
Male
Female
Total
Age
Amou Rati Amou Rati Amou Rati
group
nt
o%
nt
o%
nt
o%
13 2

2.7
1
1,2
3
1.9
20
21 51
68.0
35
43.2
86
55.1
55
56 22
29.3
45
55.6
67
43.0
77
100.
total
75
48.1
81
51.9
156
0
± SD
Comment:

49.6 ± 11.8

55.0 ± 12.0

52.4 ± 12.1

p
0.51
3
0.00
2
0.00
1
0.00
4
0.00
1


17
The average age of study subjects was 52.4 ± 12.1 (from 13 to 77
years old). In particular, the age group 21-55 accounts for the highest
rate of 55.1%. The incidence of men is higher than women in the age
group 21-55 (p = 0.002). In contrast, the incidence of women was
significantly higher than men in the 56 -77 age group (p = 0.001).
3.2. Morphological aneurysm
3.2.1. Morphological aneurysm on computerized tomography of
cerebral vascular
Table 3.10. Number of aneurysms on computerized tomography

angiography
Unruptured
aneurysm
Amount
aneurysm

Number
of
aneurys
m
Total

0
1
2
3

Ruptured
aneurysm

Total

Patient Aneurysm Patients Aneurys Patient Aneurys
(n=18) (n=20) (n=125)
m
s
m
(n=135) (n=143 (n = 154)
)
0

0
1
0
1
0
17
17
115
115
132
142
0
0
8
16
8
10
1
3
1
3
2
2
18
20
125
134
143
154

18
Comment:
There were 18 patients CTA scan in the group without rupture of
the aneurysm, of which 17 patients had 1 aneurysm and 1 patient had
3 aneurysms.
In the ruptured group, there were 125 patients, of which 115
patients found 1 aneurysm, 8 patients found 2 aneurysms, 1 patient
had 3 aneurysms, a total of 134 patients had an aneurysm but there
was no aneurysm on CTA.
Thus, the total number of aneurysms detected on CTA of 143
patients was 154 aneurysms of which 132 patients had 1 aneurysm
and 8 patients had 2 aneurysms and 2 patients had 3 aneurysms.
Table 3.11. Characteristics of aneurysms on computerized
tomography angiography
Unruptured
Ruptured
Total
Aneurysms
Aneurysms
p
(n = 154)
Characteristics
(n = 20)
(n = 134)
aneurysm
Ratio
Ratio
Ratio
Amount

Amount
Amount
%
%
%
Figure
20
100.0
132
98.5
152
98.7
bag
Shape
0.7756
Rhombus
0
0.0
2
1.5
2
1.3
One lobe
14
70.0
115
86.5
129
84.3
Number

0.06
Multiple
of lobes
6
30,0
18
13.5
24
15.7
lobes
Erratic
12
60,0
124
92.5
136
88.3
Aneurysms
0,000
Are all
8
40.0
10
7.5
18
11.7
Calcium neck pocket
3
15.0
1

0.8
4
2.6 0.0007
There are oblique
1
5.0
8
6.0
9
5.8
0.67
branches
Comment:
The difference between 2 has statistically significant about the
properties of regular or irregular bulge, in which, the ruptured group
has a higher proportion of aneurysm (p = 0,000).


19
The situation of calcification was also different between the 2
groups. In which the ruptured group had lower calcification rate (p =
0.0007).
The characteristics of aneurysm shape, number of lobes, oblique
branch, and thrombosis were not significantly different between the
unruptured and ruptured aneurysm group.
Table 3.12. Characteristics of aneurysm position on computerized
tomography angiography
Unruptured Ruptured
Total
Aneurysms Aneurysms

(n = 154)
Location of aneurysms
(n = 20)
(n = 134)
Right Left Right Left n
%
Superior hypophyseal
0
0
0
1
1
0.6
Ophthalmic artery
1
0
0
1
2
1.3
Posterior
2
2
8
9
21
13.6
communicating artery
Internal carotid artery
0

0
0
1
1
0.6
bifurcation
Anterior
Internal carotid artery
2
1
6
6
15
9.7
cerebral
Middle cerebral artery
1
0
2
3
6
3.9
circulation
Middle cerebral artery
1
3
13
12
29
18.8

bifurcation
Anterior cerebral artery
0
0
1
2
3
1.9
Pericallosal artery
1
0
1
2
4
2.6
Anterior
4
0
55
0
59
38.3
communicating artery
Vertebral artery
1
1
3
0
5
3.2

Posterior
Posteroinferior
circulator
0
0
0
4
4
2.6
cerebellar artery
y system
Basilar tip aneurysms
0
0
4
0
4
2.6
15
Total
13
7
93
41
100.0
4
Comment:
Aneurysms are common in the anterior communicating artery
location (38.3%); followed by the position middle cerebral artery

20
bifurcation (18.8%); posterior communicating artery (13.6%).
Internal carotid artery, middle cerebral artery, posteroinferior
cerebellar artery, basilar tip aneurysms, ophthalmic artery, superior
hypophyseal,
and
internal
carotid
artery
bifurcation
9.7%; 3.9%; 3.2%; 2.6%; 2.6%; 1.3%; 0.6%; 0.6%.
Table 3.13. Size characteristics of aneurysms on computerized
tomography angiography
Unruptured
Ruptured
Total
Aneurysms
Aneurysms
p
Size
(n = 154)
(n = 20)
(n = 134)
aneurysm
Amoun Ratio Amoun Ratio Amoun Rati
t
%
t
%

t
o%
≤ 5mm
10
50,0
91
67.9
101
65.6
Size
> 5-10mm
9
45.0
40
29.9
49
31.8 0.27
> 10-25mm
1
5.0
3
2.2
4
2.6
Neck
<4mm
9
45.0
82
62.1

91
59.9
0.114
11
55.0
50
37.9
61
40.1
handbag ≥4mm
Medium aneurysms
5.95 ± 2.5
4.79 ± 2.24
4.94 ± 2.3
0.022
body
Medium aneurysms
4.38 ± 1.42
3.52 ± 1.58
3.63 ± 1.58
0.008
pocket
Medium aneurysms
7.34 ± 3.74
5.95 ± 2.96
6.13 ± 3.09
0.098
depth
Comment:
The difference was statistically significant in terms of the average

body size index and average neck aneurysms (p respectively: 0.022;
0.008). In which, the unruptured aneurysm group has a larger size.
Indicators of the size of aneurysms, neck size, average depth of
aneurysms do not differ significantly between the two groups of
ruptured or unruptured.


21
3.2.2. Morphological
aneurysm
on
digital
subtraction
angiography
Table 3.14. The number of aneurysms on digital subtraction
angiography
Unruptured
Ruptured
Total
Amount
aneurysms
aneurysms
Patients Aneurysms Patients Aneurysms Patients Aneurysms
aneurysm
(n = 14) (n = 13) (n = 87) (n = 93) (n = 101) (n = 106)
Number
1
14
13
76

76
89
89
2
0
0
7
14
7
14
of
aneurysm
3
0
0
1
3
1
3
s
Total
14
13
87
93
101
106
Comment:
There were 14 patients with DSA scan in the group without
aneurysms including 1 patient did not detect aneurysm and 13

patients had only 1 aneurysm.
In the ruptured aneurysms group, there were 87 patients taking
DSA, including 93 total with aneurysms with 76 patients with 1
aneurysm, 7 patients had 2 aneurysms, 1 patient had 3
aneurysms. Thus, the total number of aneurysms detected on DSA is
106 aneurysms, of which 89 patients have 1 aneurysm and 7 patients
have 2 aneurysms and 1 patient has 3 aneurysms.
Table 3.15. Aneurysm characteristics on digital subtraction angiography
Unruptured
Ruptured
Total
aneurysms
aneurysms
p
Characteristics
(n = 106)
(n = 13)
(n = 93)
aneurysm
Amount Ratio % Amount Ratio % Amount Ratio %
Figure
13
100.0
93
100.0
106
100.0
bag
Shape
Rhombu

0
0.0
0
0.0
0
0.0
s
Number
One lobe
10
76.9
73
78.5
83
78.3
0.57
lobe
Multiple
3
23.1
20
21.5
23
21.7


22
lobes
5
38.5

84
90.3
89
83.9
Aneurysm Erratic
0,000
s
Are all
8
61.5
9
9.7
17
16.1
Calcium neck pocket
2
15.4
0
0.0
2
1.9
0.014
Thrombosis in the bag
1
7.7
1
1.1
2
1.9
0.23

There are oblique
1
7.7
3
3.2
4
3.8
0.412
branches
Comment:
100% aneurysms shaped-bag. The difference between the 2 groups
is statistically significant in terms of the uneven or irregular bulge, in
which, the ruptured group has the higher uneven ratio (p = 0.000).
The situation of neck calcification was also different between the
two groups, in which the ruptured group had a lower rate of
calcification (p = 0.014).
There was no statistically significant difference between the two
groups in the number of aneurysms; image of thrombosis in an
aneurysm; with oblique branch.
Table 3.16. Characteristics of aneurysm position on digital subtraction
angiography
Total
Unruptured Ruptured
(n = 106)
Location of aneurysms
aneurysms aneurysms
Ratio
(n = 13)
(n = 93)
Amount

%
Anterior
Superior
0
1
1
0.9
cerebral
hypophyseal
circulation Ophthalmic
1
3
4
3.8
artery
Posterior
communicating
3
14
17
16.0
artery
Internal carotid
arrtery
0
3
3
2.8
bifurcation
Internal carotid

4
6
10
9.4
artery


23
Middle
1
4
5
4.7
cerebral artery
Middle
cerebral arrtery
2
13
15
14.2
bifurcation
Anterior
0
2
2
1.9
cerebral artery
Pericallosal
0
3

3
2.8
artery
Anterior
communicating
1
37
38
35.8
artery
Vertebral artery
1
0
1
0.9
Posterior
Posteroinferior
circulator cerebellar
0
4
4
3.8
y system
artery
Basilar tip artery
0
3
3
2.8
Total

13
93
106
100.0
Comment:
The common site of aneurysms on a DSA is located in the
anterior communicating artery (35.8%); posterior communicating
artery(16%); middle cerebral arrtery bifurcation (14.2%); internal
carotid artery (9.4%); middle cerebral artery(4.7%); ophthalmic
artery and posteroinferior cerebellar artery (3.8%); basilar tip arrtery
and internal carotid artery bifurcation (2.8%); anterior cerebral
artery(1.9%); vertebral artery and superior hypophyseal (0.9%).
Table 3.17. Size characteristics of aneurysms on digital subtraction
angiography
Unruptured
Ruptured
Total
aneurysms
aneurysms
p
(n = 106)
(n = 13)
(n = 93)
Bag size
Ratio
Ratio
Ratio
Amount
Amount
Amount

%
%
%
Size
≤ 5mm
3
23.1
58
62.4
61
57.6 0,000
> 5-10mm
6
46.2
32
34.4
38
35.9
> 10-25mm
3
23.1
3
3.2
6
5.7


24
> 25mm
<4mm

1
6

7.7
46.2

0
50

0.0
53.8

1
56

0.9
52.8

Neck
handba
0.607
≥4mm
7
53.9
43
46.2
50
47.2
g

Medium body
10.17 ± 7.46
5.2 ± 2.27
5.81 ± 3.68
0.002
Medium neck
5.88 ± 3.53
3.88 ± 1.53
4.13 ± 1.98
0.167
Medium depth
10.21 ± 6.46
6.22 ± 2.95
6.71 ± 3.76
0.023
Comment:
The average size of aneurysms and body bags in the unruptured group
was significantly larger than that of the ruptured (p = 0,000 and p = 0.002).
The average neck size and depth of the bags were not
significantly different between the 2 groups.
3.3. Computerized tomography and digital subtraction
angiography after surgery
Table 3.33. Evaluation on postoperative DSA scan
Unruptured Ruptured
aneurysms aneurysms
Total
(n = 16)
(n = 92)
DSA after PT
p

Rat
Rat
Rat
Amou
Amou
Amou
io
io
io
nt
nt
nt
%
%
%
Empty
bags
87.
95.
94.
14
88
102
bulge
5
7
4
0.21
There is an
6

12.
excess
of
2
4
4.3
6
5,6
5
bulge
Stenosis of the
blood vessels
0
0.0
1
1.1
1
0.9
1
with
aneurysms
Vascular
1
6.3
3
3.3
4
3.7 0.48
occlusion
Comment:

Among the cases of DSA taken after surgery, the results showed
that the percentage of aneurysms was clipped completely was 94.4%.
The percentage of aneurysms was 5.6%, vascular occlusion


25
accounted for 3.7% and stenosis with vascular aneurysm is
0.9%. There were no significant differences between the two groups.