Surgical treatment and perioperative management of intracranial aneurysms in Chinese patients with ischemic cerebrovascular diseases: a case series

Abstract

BackgroundPatients with ischemic cerebrovascular diseases are more likely to suffer from intracranial aneurysms, and their surgical treatment has a growing controversy in this condition. The current case series was aimed at exploring surgical treatment and perioperative management of intracranial aneurysms in Chinese patients with ischemic cerebrovascular diseases.MethodsMinimally invasive surgical approach through small pterion or inferolateral forehead was applied in 31 patients. Anti-platelet drugs were withdrawn 1 week before surgical operation. Systolic blood pressure was controlled to be more than 110 mmHg and increased by 20% after the clipping of intracranial aneurysms. Branches of external carotid artery were spared to ensure collateral circulation. Temporary blocking was minimized and ischemic time was shortened during surgical operation.ResultsPatients had an average age of 66 (46–78) years, and proportion of males was 39% (12 males). There were 35 unruptured intracranial aneurysms with a diameter more than 5 mm. There were 20 posterior communicating and anterior choroidal aneurysms (57%), seveb middle cerebral aneurysms (20%), and eight anterior communicating aneurysms (23%), with 21 lobular aneurysms (60%). Twenty-nine patients had normal neurological function (Glasgow Outcome Scale [GOS] 5), one patient with mild neurological defect (GOS 4), and one patient with severe neurological defect (GOS 3) at discharge. Meanwhile, there were 26 patients with modified Rankin Scale (MRS) 0–1, 4 patient with MRS 2, and one patient with MRS 3 at discharge. There were four patients lost during the follow-up. During the follow-up, 26 patients had normal neurological function (GOS 5), and one patient with severe neurological defect (GOS 3). Meanwhile, there were 25 patients with MRS 0–1, one patient with MRS 2, and one patient with MRS 3. All patients had no recurrence of intracranial aneurysms after operation.ConclusionsThe current case series found that minimally invasive surgical approach and intraoperative monitoring, supplemented by effective management of cerebrovascular perfusion, circulation and coagulation, can promote the treatment of intracranial aneurysms and prevent the development of cerebral ischemia and aneurysm rupture in Chinese patients with ischemic cerebrovascular diseases. Future studies with large sample size will be needed to confirm the results from the current case series.

Acute ischemic stroke due to unruptured small aneurysm of internal carotid artery

“…Zhang et al's study showed that invasive surgical approach, intraoperative monitoring, effective management of cerebrovascular perfusion, and coagulation can prevent the development of cerebral ischemia and aneurysm rupture. [ 11 ] However, manipulation of the intrasaccular thrombus during coiling can lead to further embolization, [ 12 ] given the risk of intraoperative thromboembolic events, it is possible that the risk of surgery in these patients is higher than in patients with asymptomatic UIA. Further studies are needed before this option can be widely implemented in these patients.…”

Prevalence and Procedural Risk of Intracranial Atherosclerotic Stenosis Coexisting With Unruptured Intracranial Aneurysm

“…As for patients with ICAS, the target was keeping systolic blood pressure no <90% of baseline blood pressure to avoid the occurrence of relative hypotension and accepted moderately elevated blood pressure, especially when the clipping was performed. 14…”

Expert consensus on blood pressure management in critically ill patients

“… [101] Usually, the blood pressure can be increased by 20% as appropriate for the specific condition and cerebral perfusion needs, and the target value can be modified by referring to the patient's pre-onset basal blood pressure to avoid hypotension and excessive blood pressure variability. [102] The use of multimodal testing such as transcranial Doppler ultrasound, electroencephalography, and cerebral oxygen to individualize the guidance of blood pressure management, reduce cerebral vasospasm, and improve cerebral perfusion has good clinical application.…”