Complications after intracranial aneurysm clipping and nursing care! !

In 2006, the mortality rate of intracranial aneurysm rupture was close to 40%, and the mortality rate after rebleeding was about 50% ~ 75%, r1j. Therefore, finding intracranial aneurysms in time, choosing appropriate surgical methods, improving surgical skills and actively preventing rebleeding of intracranial aneurysms are of great significance for reducing the mortality and disability rate of patients with intracranial aneurysms and improving clinical efficacy. From June 2006 to September 2005, 36 patients with ruptured intracranial aneurysm were treated by early microsurgery, and the effect was satisfactory. The report is as follows. 1 materials and methods 1. 1 general data: there were 36 cases in this group, including 9 cases of male/kloc-0 and 4 cases of female/kloc-0. The average age was (4J4.311.8) years. Among them, posterior communicating artery aneurysms 13, anterior communicating artery aneurysms 9, middle cerebral artery and its branches 6, intracranial internal carotid artery aneurysms 5, basilar artery terminal aneurysms 2, and ophthalmic artery branch aneurysms near the clinoid process 1 3. According to Hunt-Hess classification, there were 27 cases of grade I-III and 9 cases of grade III or above. There were 2 cases with typical symptoms of spontaneous subarachnoid hemorrhage (SAH) such as headache and vomiting, and 2 cases with conscious disturbance. 6 cases showed oculomotor nerve paralysis such as ptosis and blurred vision; Sudden coma with quadriplegia and cerebral hernia in 5 cases. After admission, head CT or MRI examination and cerebrospinal fluid examination were diagnosed as intracranial hematoma or subarachnoid hemorrhage. Among them, intracranial hematoma broke into ventricle in 5 cases, accompanied by cerebral infarction in 4 cases and obstructive hydrocephalus in 4 cases. Emergency digital silhouette angiography (SA) confirmed that 34 cases were single cerebral aneurysm and 2 cases were two or more cerebral aneurysms. 1.2 surgical methods 36 cases in this group were clamped by microsurgery within 72 hours after onset. The surgical method was Yasargil pterional approach. After craniotomy, the dura mater was cut and the lateral fissure was fully exposed under microscope. Then cerebrospinal fluid is slowly released through the cistern of lateral fissure and the cistern of skull base, and the frontal lobe and temporal lobe automatically stretch into a snake shape. The willis arterial ring at the base of skull is exposed through the lateral fissure and reaches the aneurysm (the anterior clinoid process should be ground in the dura mater to expose the aneurysm). Fully dissect and separate the aneurysm and its surrounding tissues, and clamp the aneurysm neck under the microscope. Results Three cases died after operation, including 2 cases with rebleeding and cerebral hernia, and their families gave up treatment and died 2 weeks after operation. In addition, 1 case was an exception of intraoperative aneurysm, complicated with massive cerebral infarction after operation and died on the third day after operation. Surviving patients were followed up for 3 months. According to Glasgow coma (GOS) prognosis score, 23 patients recovered well and took care of themselves. 5 cases were accompanied by mild disability and needed care; 5. Severe disability, completely bedridden. Discussion The occurrence of intracranial aneurysm is related to the local congenital defect of cerebral artery wall and the increase of intracavitary pressure, which is more common in the bifurcation of cerebral basilar artery. According to its location, 70% of intracranial aneurysms are located in the first half of the basilar artery ring, mostly internal carotid artery, posterior communicating artery and anterior communicating artery, and also found in the branches of middle cerebral artery or anterior cerebral artery. The posterior half ring of basilar artery accounts for about 30%, and it mainly occurs in vertebrobasilar artery, posterior cerebral artery and its branches. In this group, 36 cases were operated, of which 34 cases were aneurysms of internal carotid artery system. More than 80% of clinical spontaneous subarachnoid hemorrhage is caused by ruptured aneurysm. When an aneurysm ruptures, there are usually precursor symptoms, such as headache, followed by bleeding symptoms, such as severe headache, irritability, nausea and vomiting, and then increased intracranial pressure. It may be accompanied by disturbance of consciousness and neurolocalization symptoms in the corresponding parts. Patients with large hematoma caused by aneurysm bleeding often deteriorate rapidly, leading to cerebral hernia crisis. According to statistics, after the first rupture of aneurysm, the mortality rate is as high as 30% ~ 40%, most of them die within 48 hours after the onset, and about 30% of the surviving cases can bleed again. Cerebral aneurysm rupture and hemorrhage is the main cause of spontaneous subarachnoid hemorrhage (SAH), with high mortality and disability rate, which seriously affects the health of patients. Therefore, it is of great significance to improve the level of diagnosis and treatment of cerebral aneurysms and effectively prevent and treat aneurysm rupture and bleeding. Aneurysm clipping is an effective method to treat intracranial aneurysms. With the gradual popularization of microsurgery, its good lighting and visual effects, perfect micro-anatomy knowledge and minimally invasive surgery technology greatly improve the safety of surgery. The timing of cerebral aneurysm surgery, correct operation during operation, postoperative treatment and prevention of complications are very important to improve the effect of intracranial aneurysm microsurgery. Different scholars have different views on the timing of cerebral aneurysm surgery. In the past, it was thought that the early stage of aneurysm rupture (within 3 days) was due to brain edema, cerebral vasospasm and other factors, which reduced the patient's tolerance to surgery and increased the difficulty of surgery. Most of them advocated postponing surgery (after 2 weeks). In recent years, some scholars have suggested that the incidence of rebleeding after intracranial aneurysm rupture 1 week is the highest, and delaying operation will lose the chance of rescue; Moreover, early operation can also clear the coagulation and bloody cerebrospinal fluid in intracranial hematoma or subarachnoid space, which has a positive effect on reducing intracranial pressure and cerebral vasospasm, so many scholars now advocate early (3d) or ultra-early (within 7h) operation H0. Three cases in this group were operated within 72 hours after onset, and the treatment effect was good. Of course, the timing of surgery should also consider the age, consciousness and general situation of the patient. If the patient is old and weak, deeply unconscious and in poor general condition, surgery can be performed after the condition improves. Patients with rebleeding and cerebral hernia during the observation period can be operated at any time to save their lives. The choice of surgical approach is the key to successful operation. Yasagil pterional approach is a classic approach for cerebral aneurysm surgery, which can expose the whole process of internal carotid artery and its main branches, and can be exposed anatomically through the initial lateral fissure of the intracranial segment of internal carotid artery, temporarily blocking the proximal end of the parent artery during the operation to control bleeding. This method can be used for anterior circulation aneurysms and partial posterior circulation aneurysms. When intracranial hematoma is formed after aneurysm rupture, the surgical approach can be improved according to the specific bleeding site. Generally, the bleeding sites are mostly in the frontal lobe and temporal lobe. Frontotemporal bone flap craniotomy or pterional approach can be used, and some hematoma can be aspirated nearby during the operation. After the brain pressure is reduced, the parent artery and the aneurysm neck can be dissected and separated, and the aneurysm can be clamped. In this group, 36 cases were separated from basilar artery ring by pterional approach and lateral fissure cistern, and the visual field was satisfactory during operation. During the operation, 1 case was ruptured and bleeding, and the parent artery was temporarily blocked and then clamped. The patient died on the third day after operation due to severe cerebral vasospasm and massive cerebral infarction. In order to improve the success rate of cerebral aneurysm surgery, we should pay attention to the following aspects: ① When pterional approach is adopted, the proximal end of internal carotid artery should be separated for temporary occlusion. For giant aneurysms or aneurysms with high possibility of bleeding during operation, the internal carotid artery can be dissected in the neck before craniotomy and temporarily blocked. ② The whole process of lateral fissure was fully exposed during the operation, and the lateral fissure cistern and skull base were opened, which was convenient for surgical exposure and reduced brain tissue traction; ③ Carefully dissect and fully expose the tumor neck. Controlled hypotension can be used during operation. If necessary, we can temporarily block the proximal end of the parent artery, pay attention to identify the tumor neck and its accompanying arteries, prevent misdiagnosis of the vagal artery, and pay attention to the important perforating arteries. ④ Prevention and treatment of postoperative complications are also very important. If calcium channel antagonists are used after operation, hypertension can be appropriately raised and cerebral perfusion caused by vasospasm can be improved.