Surgical Outcome in 110 cases of ACOM, MCA & ICA communicating segment aneurysms each

156 Pages·2016·2.71 MB·English

Surgical Outcome in 110 cases of ACOM, MCA & ICA communicating
segment aneurysms each- a retrospective cohort study.

Submitted for M.Ch Neurosurgery
By

Dr. Thakur Vishal Vishnu
October 2016
Department of Neurosurgery
Sree ChitraTirunal Institute for Medical Sciences & Technology
Thiruvananthapuram – 695011

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Surgical Outcome in 110 cases of ACOM, MCA & ICA communicating
segment aneurysms each- a retrospective cohort study.

Submitted by : Dr. Thakur Vishal Vishnu

Programme : MCh Neurosurgery

Month & year of submission : October, 2016

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CERTIFICATE

This is to certify that the thesis entitled “Surgical Outome in 100 cases of ACOM, MCA &
ICA communicating segment aneurysms each- a retrospective cohort study” is a bonafide
work of Dr.Thakur Vishal Vishnuand was conducted in the Department of Neurosurgery,
SreeChitraTirunal Institute for Medical Sciences & Technology, Thiruvananthapuram
(SCTIMST), under my guidance and supervision.

Prof. Suresh Nair N.
Professor and Head
Department of Neurosurgery
SCTIMST,
Thiruvananthapuram

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DECLARATION

This thesis titled “ Surgical Outome in 100 cases of ACOM, MCA & ICA communicating segment
aneurysms each- a retrospective cohort study”,is a consolidated report based on a bonafide study
of the period from January 2007 to March 2014, done by me under the Department of
Neurosurgery, SreeChitraTirunal Institute for Medical Sciences & Technology,
Thiruvananthapuram.
This thesis is submitted to SCTIMST in partial fulfillment of rules and regulations of MCh
Neurosurgery examination.

Dr. Thakur Vishal Vishnu,
Department of Neurosurgery,
SCTIMST,
Thiruvananthapuram.

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ACKNOWLEDGEMENT
The guidance of Prof. Suresh Nair, Professor and Head of the Department of Neurosurgery,
has been invaluable and I am extremely grateful and indebted for his contributions and
suggestions, which were of invaluable help during the entire work. He will always be a
constant source of inspiration to me.
I owe a deep sense of gratitude to Dr. Mathew Abraham for his invaluable advice,
encouragement and guidance, without which this work would not have been possible. His
critical remarks, suggestions, helped me in achieving a high standard of work.
I am deeply indebted to Dr. Easwer H. V., Dr. Krishnakumar K., Dr. George Vilanilam,
DrJayanandSudhir, Dr. Prakash Nair and colleagues and I thank them for their constant
encouragement and support.
I am also deeply indebted to Dr. Immanuel Thomas (Professor in Psychology, Kerala
university) for guiding and helping me in the statistical analysis.
Last but not the least, I owe a deep sense of gratitude to all my patients without whom this
work would not have been possible.

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INDEX

INTRODUCTION 7
AIMS AND OBJECTIVES 9
MATERIALS AND METHODS 10
REVIEW OF LITERATURE 13
OBSERVATIONS & RESULTS 70
DISCUSSION 80
CONCLUSIONS 110
BIBLIOGRAPHY 111
ANNEXURES 121
i. Proforma
ii. Masterchart and abbreviations
iii. IEC approval
iv. Originality report

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INTRODUCTION

Aneurysms of the cerebral vasculature is a common neurosurgical problem. The incidence of
intracranial worldwide is difficult to estimate.
A recent systematic review collecting data from many countries studying retrospective and
prospective autopsy studies showed prevalence of 0.4% and 3.6% respectively . Similarly
retrospective and prospective angiographic studies found prevalence of 3.7% and 6.0%
respectively. 63
Intracranial aneurysms are mostly asymptomatic. They become problematic after rupture
leading to parenchymal hemorrhage, or more often subarachnoid hemorrhage(SAH).
Annually, approximately 30,000 people in the United States suffer SAH from aneurysms. 1
SAH has a mortality rate of 25% to 50%, permanent disability occurs in nearly 50% of the
survivors, and hence 1/3 rd patients have a positive outcome. 86
The four main types of intracranial aneurysms seen are :saccular, fusiform, dissecting and
mycotic type. The saccular type accounts for 90% of them.
85% saccular aneurysms arise from the arteries of the circle of Willis. In 35% cases the
aneurysms are located in anterior communicating artery , followed by 30 % in the internal
carotid artery (carotid artery itself, the posterior communicating artery, and the ophthalmic
artery), followed by the middle cerebral artery (22%), and finally, the posterior circulation
sites(basilar artery tip). Multiple aneurysms are encountered in 30% of the cases.16

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Figure 1
The focus of this study is aneurysms in the region of anterior communicating artery (Acom),
the internal carotid artery communicating segment aneurysm (ICA)and the proximal middle
cerebral artery(MCA).
Multiple preoperative, intraoperative and postoperative parameters and events influence the
surgical outcome of these aneurysms. Studying the outcome of these aneurysms and
investigating and assessing the factors which affect their respective outcomes may help to
perform better by taking care of these factors and executing better control for their prevention
with better technical performance and postoperative care.
Although many studies in literature are available on various factors affecting the outcome.
Very few are available studying the surgical outcome and factors affecting it for all the three
most common aneurysms in the anterior circulation tree.

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AIMS & OBJECTIVES:

The hypothesis to undertake this study is that the surgical outcome differs between aneurysms
in different subarachnoid cisterns. Our aim is to study outcome for surgery on ruptured
aneurysms on 3 common locations and to study the factors influencing the same. The
conclusion of this study would probably influence the decision making and choice of
treatment in the management of aneurysms in different locations on the intra cranial vascular
tree.
Following key questions would be answered:
1. Is the outcome in all three aneurysms comparable to the outcome in previous studies
in literature?
2. Are the factors affecting outcome significant and if they can be taken care of more
meticulously to improve the outcome further?

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MATERIALS & METHODS :

A retrospective analysis of consecutive 330 patients comprising 110 from each category of
the Anterior communicating artery ( Acom ), Proximal Middle cerebral artery (MCA) & the
communicating segment of the internal carotid artery ( ICA communicating segment) who
have undergone surgery at our institute from January 2007 till March 2014 was performed..
Only operated patients in good grade (WFNS grade 1 and 2) were allocated to the study. The
surgical outcome and the factors affecting the same of these were studied .The primary
outcome studied would of quality of life and independence achieved at 3 months and one
year of follow up. This would be measured using the modified Rankin score. The secondary
outcomes would be complications and the need for repeat postoperative interventions .
Multiple pre-operative, intraoperative and postoperative factors which affect the primary and
secondary outcomes would be studied to find any correlations.

Inclusion criteria:
 Patients who presented with SAH, WFNS grade 1 or 2 and diagnosed with Acom OR
MCA OR ICA communicating segment aneurysm and then underwent surgical
management.

Exclusion criteria:
 Giant aneurysm; size > 2.5 cm
 Multiple aneurysms
 Should not be in a patient suffering from any connective tissue disorder. Or any other
systemic disease eg. Polycystic kidney disease which are associated with a high
number of concomitant intracranial aneurysms.

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