Darkwah Oppong Marvin, Pierscianek Daniela, Ahmadipour Yahya, Dinger Thiemo Florin, Dammann Philipp, Wrede Karsten Henning, Özkan Neriman, Müller Oliver, Sure Ulrich, Jabbarli Ramazan
Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany.
Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany.
World Neurosurg. 2018 Nov;119:e349-e356. doi: 10.1016/j.wneu.2018.07.158. Epub 2018 Jul 27.
Intraoperative aneurysm rupture (IOAR) is a common complication during intracranial aneurysm (IA) surgery. In light of the paradigm shift regarding IA selected for clipping in the post-International Subarachnoid Aneurysm Trial (ISAT) era, we aimed to evaluate the risk factors and effects of IOAR in an institutional series of clipped ruptured IA (RIA) and unruptured IA (UIA).
All IAs treated with microsurgical clipping at our institution between 2003 and 2016 were eligible for this study. Demographic, clinical, and radiographic factors were correlated with occurrence of IOAR in univariate and multivariate analyses. The effect on outcome was analyzed for RIA and UIA separately.
Nine hundred and three clipped IAs were included in the final analysis (538 UIA and 365 RIA). IOAR occurred in 163 cases (18.1%), mostly during clipping of RIA (37.5% vs. 4.8%) In multivariate analysis, ruptured status (adjusted odds ratio [aOR], 10.46; P < 0.001), sack size (aOR, 1.05 per mm increase; P = 0.038) and IA location in the anterior communicating artery (aOR, 2.31; P < 0.001) independently predicted IOAR. For RIA cases, IOAR was also independently predicted by rebleeding before therapy (aOR, 3.11; P = 0.033) and clinical severity of subarachnoid hemorrhage (aOR, 1.18 per WFNS grade increase; P = 0.049). IOAR independently predicted poor outcome (aOR, 1.83; P = 0.042) after RIA surgery. In turn, IOAR affected only the risk for cerebral infarct (OR, 3.75; P = 0.003) and incomplete IA occlusion (OR, 3.45; P = 0.003) for UIA cases, but not the outcome (P = 0.263).
IOAR was independently predicted by the ruptured status, location, and size of IA and by initial severity of aneurysmal bleeding and pretreatment rebleeding. The influence of IOAR differed between RIA and UIA cases.
术中动脉瘤破裂（IOAR）是颅内动脉瘤（IA）手术中常见的并发症。鉴于国际蛛网膜下腔动脉瘤试验（ISAT）后时代IA夹闭选择的模式转变，我们旨在评估机构系列夹闭破裂IA（RIA）和未破裂IA（UIA）中IOAR的危险因素及影响。
2003年至2016年在本机构接受显微手术夹闭治疗的所有IA均符合本研究条件。在单因素和多因素分析中，将人口统计学、临床和影像学因素与IOAR的发生进行关联。分别分析RIA和UIA对结局的影响。
最终分析纳入903例夹闭IA（538例UIA和365例RIA）。IOAR发生在163例（18.1%），大多发生在RIA夹闭期间（37.5%对4.8%）。在多因素分析中，破裂状态（校正比值比[aOR]，10.46；P<0.001）、瘤袋大小（aOR，每增加1mm为1.05；P=0.038）和前交通动脉IA位置（aOR，2.31；P<0.001）独立预测IOAR。对于RIA病例，治疗前再出血（aOR，3.11；P=0.033）和蛛网膜下腔出血的临床严重程度（aOR，每增加1个WFNS分级为1.18；P=0.049）也独立预测IOAR。IOAR独立预测RIA手术后不良结局（aOR，1.83；P=0.042）。反过来，IOAR仅影响UIA病例的脑梗死风险（比值比，3.75；P=0.003）和IA不完全闭塞风险（比值比，3.45；P=0.003），但不影响结局（P=0.263）。
IOAR可通过IA的破裂状态、位置和大小以及动脉瘤出血的初始严重程度和治疗前再出血独立预测。IOAR在RIA和UIA病例中的影响有所不同。
