Surgical result of cerebral aneurysm clipping

Journal of military pharmaco-medicine no8-2018

SURGICAL RESULT OF CEREBRAL ANEURYSM CLIPPING
Nguyen Thanh Bac1; Dong Van He2; Nguyen The Hao1; Vu Van Hoe1
SUMMARY
Objectives: To evaluate results of cerebral aneurysm surgical clipping. Methods: A retrospective
and prospective study. Results: 156 patients with 166 aneurysms were treated by surgical
clipping. The patients were divided into two groups: Unruptured and ruptured; with the mean
age of 75.1 ± 4.3. Proportion of aneurysms was the highest in anterior communicating artery
(39.4%); followed by posterior communicating artery (16.4%); middle cerebral artery (17.0%);
internal carotid artery (2.4%); middle cerebral artery (4.2%); ophthalmic artery (3.0%); posterial
cerebellar artery (2.4%); bifurcation of basilar artery (2.4%); vertebral artery (3.0%); anterior
cerebral artery (1.8%); basilar artery (3.0%) and superior hypophyseal artery was 3.6%.
Glasgow Coma Scale at discharge of hospital was significantly higher in unruptured aneurysm
group than in the ruptured one (p = 0.001). The mean Glasgow Coma Scale of unruptured
group and ruptured group were 14.4 ± 0.5 and 12.7 ± 3.1, respectively. The average of both
groups was 12.9 ± 2.9. According to Modified Rankin Scale, at hospital discharge, the results
were as followed: good 21.1%, average 45.5%, bad 26.3%, dead 7.1%. There were no
statistically significant differences between the two groups with p = 0.226. For far results, there
was no difference in Modified Rankin Scale between the unruptured and ruptured aneurysm
group, with a good outcome of 76.4%, an average of 11.4%, negative 4.9%, and dead was
7.3%. With Digital dubtraction angiography postoperation, results showed that the incidence of
aneurysm was 94.4%, the residual rate of the aneurysm was 5.6%, the occlusion of the
aneurysm was 3.7% and the carotid artery obstruction the bulge was 0.9%. Conclusion:
Aneurysm clipping surgery is still a selected method that brings good results for intracranial
artery aneurysm patients.
* Keywords: Intracranial aneurysm; Clipping surgery; Modified Rankin Scale; Glasgow
Coma Scale.

INTRODUCTION
A cerebral aneurysm is a focal abnormal

dilation of the wall of an artery in the brain.
Autopsy studies indicate that cerebral
aneurysms are fairly common in adults,
with a prevalence ranging between 1%
and 5% [4, 5]. Prevalence of intracranial
aneurysms among adults is estimated

between 1.0% and 3.2% [6, 7]. Therefore,
3 to 12 million Americans harbor intracranial
aneurysms. The incidence of reported
ruptured aneurysms is about 6 to 7 in
every 100,000 people per year [8].
In the world as well as in Vietnam,
there are several used methods to treat
brain aneurysm such as: microsurgical clipping,

1. 103 Military Hospital
2. Vietduc Hospital
Corresponding author: Nguyen Thanh Bac ()
Date received: 20/08/2018
Date accepted: 02/10/2018

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Journal of military pharmaco-medicine no8-2018
intravascular intervention. Each method
has its advantages and drawbacks, but
microsurgical clipping for aneurysm still
plays an important role. We conducted

this study: To evaluate the surgical results
of cerebral aneurysm clipping surgery.

Hospital from January 2011 to December
2013.
2. Methods.
This is a retrospective and prospective
study.
* Factors:
- Patients were divided into two groups:
Unruptured and ruptured aneurysm group.

SUBJECTS AND METHODS
1. Subjects.

- Results about age, sex.

156 patients with 166 aneurysms
(unruptured, ruptured aneurysms) were
diagnosed with digital dubtraction
angiography (DSA) and/or CT-scan and
treated with clipping aneurysm surgery in
Department of Neurosurgery, Vietduc

- Clinical results at hospital discharge:
Glasgow and Modified Rankin Scale.
- Clinical results: Modified Rankin Scale.
- DSA postoperative results: No aneurysm,
residual aneurysm, narrowed aneurysm
blood vessels, obstructive blood vessels.

Table 1: Modified Rankin Scale.
Level

Clinical properties

0

No symptoms

1

No complication but slight symptom, abilities to do everything a day

2

Slight complication: Uncompleted all activities as before, self-serve without other help

3

Middle complication: Patients need some help, but they can walk without assistance

4

Relatively severe complication: Patients can not walk themselves, not self-service if without help

5

Severe complication: Paralysis and spasm disorder

6

Dead

(* Source: Askiel Bruno (2013) [6])
* Footnotes:
Rankin score 0 - 2: good clinical condition; Rankin score 3: middle clinical condition;
Rankin score 4 - 5: bad clinical condition; Rankin score 6: dead.
Data were statistic processed by using SPSS software, version 15.0 (statistical
package for social science).
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Journal of military pharmaco-medicine no8-2018
RESULTS AND DISCUSSION
Table 2: Location of aneurysm.
Unruptured
aneurysm
(n = 22)

Ruptured
aneurysm
(n = 144)

Superior hypophyseal artery

2

Ophthalmic artery

Location of aneurysm

Anterior
circulation

Posterior
circulation

Total (n = 166)
n

%

4

6

3.6

3

2

5

3.0

Posterior communicating artery

3

24

27

16.4

Internal carotid bifurcation

0

5

5

3.0

Internal carotid artery

2

2

4

2.4

Middle cerebral artery

1

6

7

4.2

Middle cerebral bifurcation

4

24

28

17.0

Anterior cerebral artery

0

3

3

1.8

Pericallosal artery

1

2

3

1.8

Anterior communicating artery

4

61

65

39.4

Vertebral artery

2

3

5

3.0

Posterior cerebellar artery

0

4

4

2.4

Bifurcation of basilar artery

0

4

4

2.4

22

144

166

100.0

Total

Table 2 showed that the anterior communicating artery aneurysm was the highest;
followed by posterior communicating artery aneurysm and middle cerebral artery.
According to Ito et al (2017), middle cerebral artery aneurysm was the most common

(34%), followed by anterior communicating artery aneurysm (27.5%) [10].
Table 3: Glasgow Coma Scale at hospital discharge.
Indexes
Glasgow Coma Scale at
hospital discharge

Unruptured aneurysm
(n = 21)

Ruptured aneurysm
(n = 135)

Total
(n = 156)

p

14.4 ± 0.5

12.7 ± 3.1

12.9 ± 2.9

0.001

Glasgow Coma Scale of unruptured aneurysm group at hospital discharge was
significantly higher than ruptured aneurysm group (p = 0.001).
According to Nguyen Trung Thanh et al (2015), among 16 patients with large and
giant aneurysm in middle cerebral artery (3 cases of unruptured aneurysm, and 13
cases of ruptured aneurysm), Glasgow Score at hospital discharge were 13 - 15 points

in 15 patients (93.75%), and 5 points in 1 patient (6.25%); the results of the reexamination were good 75%, average 18.75%, bad 6.25% (aneurysm ruptured in the
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Journal of military pharmaco-medicine no8-2018
operation) [3]. A retrospective study by S Claiborne (2001) showed that mortality rate of
postoperation in unruptured aneurysm patients was 3.5% [11].
Table 4: Modified Rankin Scale at discharge.
Results

Good
Average
Bad
Dead

Modified
Rankin
Scale

Unruptured aneurysm
(n = 21)

Ruptured aneurysm
(n = 135)

n

%

n

%

1

1

4.8

4

3.0

2

4

19.0

24

17.8

3

14

66.7

57

42.2

4

2

9.5

37

27.4

5

0

0.0

2

1.5

6

0

0.0

11

8.1

According to Modified Rankin Scale,
good results reached 21.1%, average
45.5%, bad 26.3%, dead 7.1%. There
was no statistically significant difference
between the two groups.
According to Wiebers (2003), in a
multicentre study on unruptured aneurysm
(ISUIA), patients underwent surgery with
a mortality rate for the first 30 days was
13.7%, for the first year 12.6%; the results
of age-related surgery (≥ 50 years, RR
2.4 [1.7 - 3.3], p < 0.0001), aneurysm size
(> 12 mm) were associated with poor

Total
(n = 156)
n

%

33

21,1

71

45.5

41

26.3

11

7.1

p

0.226

outcomes (2.6 [1.8 - 3.8], p < 0.0001);
rate of ruptured aneurysm in the
surgery, intracranial clot postoperation,
cerebral infarction were 6%, 4%, 11%,
respectively [4]. Ten years later, also in
the ISUIA study by Lawson et al (2013),
mortality after intra-vascular and surgical
interventions were 2.17% and 2.66%;
severe were 2.16% and 4.15%; the best
treatment outcomes for surgery were in
patient ≤ 70 years old, and intravascular
interventions were in patient ≤ 81 years
old [12].

Table 5: Modified Rankin Scale at re-examined time.
Results

Good
Average
Bad
Dead

Modified
Rankin Scale

Unruptured
aneurysm (n = 18)

Ruptured
aneurysm (n = 105)

n

%

n

%

1

13

72.2

66

62.9

2

3

16.7

12

11.4

3

1

5.6

13

12.4

4

1

5.6

4

3.8

5

0

0.0

1

1.0

6

0

0.0

9

8.6

Total
(n = 123)
n

%

94

76.4

14

11.4

6

4.9

9

7.3

p

0.698

In re-examined patients, there was no significant difference in Modified Rankin
Scale in two groups.
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Journal of military pharmaco-medicine no8-2018
Table 6: Comparison of long-term and postoperative outcomes on Modified Rankin
Scale in patients undergoing follow-up.
Long-term outcome
mRANKIN

Postoperative outcome (mRANKIN)

Total

Good

Average

Bad

Dead

Good

22

52

20

0

94

Average

1

7

6

0

14

Bad

1

1

4

0

6

Dead

2

1

6

0

9

26

61

36

0

123

Total
2

2

χ ;p

χ = 16.31; p = 0.012

There were significant differences
between long-term and short outcome
(after discharge time) with the trend of
getting better (p = 0.012; χ2 = 16.31).

The results were also related to
preoperative clinical parameters and
volume of intracranial blood clot, in a
study by Bing Zhao et al (2015) on
24 craniectomy patients with middle
cerebral artery aneurysm with WFNS
level IV, V through postoperative followup of 12.3 months, good outcome of 58%,

mortality of 29%. Compared with standard
craniectomy, there was no difference
in the complication and outcome of
treatment [13].

The good results improved from 21.1%
to 76.4%, the average group decreased
from 45.5% to 11.4%, the bad group from
26.3% to 4.9%, the difference was statistical
significance with p = 0.012. Several
previous studies had shown that longterm complications such as anxiety,
depression, memory loss and bleeding risk.
Table 7: Results of postoperative DSA.
Postoperative DSA

Unruptured
aneurysm (n = 16)

Ruptured
aneurysm (n = 92)

Total
(n = 108)

p

n

%

n

%

n

%

No aneurysm

14

87.5

88

95.7

102

94.4

Residual aneurysm

2

12.5

4

4.3

6

5.6

Narrowed vessel with aneurysm

0

0.0

1

1.1

1

0.9

1

Obstructed vessel

1

6.3

3

3.3

4

3.7

0.48

There were no significant differences
between the two groups. According to
Nguyen The Hao (2009), the proportion of
patients undergoing DSA postoperative
examination was 36.5%, of which 6.7%
208

0.216

detected cerebral embolism [2]. In the study
by Nguyen Minh Anh (2009), the proportion
of patients who received postoperative DSA
was 70.9%, with 95.3% of the aneurysms
that were completely clipped [1].


Journal of military pharmaco-medicine no8-2018
In study by Ito et al (2017), rate of
postoperative CTA screening was 90.2%,
DSA was 9.8% within 30 days, detected
2.5% of residual aneurysm, mostly in
anterior communcating artery, the

differences were statistically significant
(p < 0.01).
Good results in mRankin were 48.4%,
average 39.3%, bad 12.3% [9].
CONCLUSSION
The results of microsurgical clipping of
cerebral arterial aneurysm at the hospital
discharge were good 21.1%, average
45.5%, bad 26.3%, dead 7.1%. The longterm results were good 76.4%, average
11.4%, bad 4.9% and dead 7.3%. Results
of postoperative DSA were 94.4% completely
clamped, 5.6% residual aneurysm, 3.7%
vascular occlusion and 0,9% narrowed
arteries that carry the aneurysm. Aneurysm
clipping surgery is still a selected method
that bring good results for patients with
cerebral arterial aneurysm.
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