Early hybrid surgery for management of complex anterior circulation aneurysm with hematoma: analysis of 11 cases

Abstract

Objective To assess the efficacy of early hybrid surgery for treatment of complex anterior circulation aneurysm with hematoma but without cerebral hernia. Methods We retrospectively analyzed the clinical data of 11 patients with complex anterior circulation aneurysm with hematomas, who underwent early hybrid surgery in our hospital between November, 2014 and November, 2017. In all the cases, the aneurysms were managed and the hematomas were removed by a hybrid approach combining intraoperative digital subtraction angiography (DSA), temporary balloon occlusion and microsurgery. Five of these patients underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass combined with aneurysm isolation, in which endovascular balloon occlusion was performed for trapping the aneurysms after intraoperative DSA for verifying the patency of the bridge vessel; in 6 cases, intraoperative angiography and temporary balloon occlusion-assisted aneurysm shaping and clipping were performed, and the clipping effect was verified with intraoperative DSA. The outcomes of the patients following the surgeries were evaluated with modified Rankin scale (mRS). Results In all the 11 cases, emergency microsurgery and hematoma evacuation were completed successfully in the hybrid operation room within 72 h after onset. In the 5 patients receiving STA-MCA bypass, intraoperative angiography verified the patency of the blood vessels and the aneurysms were trapped successfully in the one-stage operation. In the 6 patients treated with aneurysm shaping and clipping, intraoperative DSA showed that the aneurysm clips needed to be adjusted in 4 patients, including 3 with mistaken clipping of the perforator vessels and 1 with incomplete clipping; the clipping effect was satisfactory after adjustment. Focal cerebral infarction occurred in 1 patient and epilepsy in another after the operation, and all the other patients showed no new neurological dysfunction after the operation. The 11 patients were followed up for 3-24 months postoperatively, during which new neurological dysfunctions, relapse or rupture of the aneurysms did not occur. The postoperative mRS score was 0 in 3 cases (27.3%), 1 in 6 cases (54.5%), 3 in 1 case (9.1%) and 4 in 1 case (9.1%). Conclusion Hybrid operation can be a safe and effective approach to treatment of complex anterior circulation aneurysms with hematomas that can not be managed by direct surgical clipping or endovascular intervention.

Keywords

• ntracranial aneurysm
• intracranial hematoma
• hybrid surgery
• superficial temporal artery-middle cerebral artery bypass
• aneurysm trapping
• aneurysm clipping