Factors Influencing Outcome of Treatment of Posterior Communicating Arteries Aneurysm

INTRODUCTION

The posterior communicating artery (P Com A) is one of the most intracerebral important arteries.   Aneurysmal lesions of the posterior communicating artery (PComA) account for nearly half of all ICA aneurysms and a quarter of all intracranial aneurysms. Aneurysms of the posterior communicating arteries aneurysm (PComA) are one of the most notably and commonly seen by neurosurgeons.¹  

Recently, with the development of investigation devices and techniques, the term (true PComA aneurysms) appeared to refer to aneurysms that exit from the artery (PComA) itself, the author's estimate that these aneurysms account for 0.1% to 2.8 % of all intracranial aneurysms and 4.6 to 10.9 % of all (PComA) aneurysms. ²

A three-dimensional CTA and whole brain digital subtraction angiogram are the most confirmatory radiographic images in diagnosis of (PComA) aneurysms. ³

Endovascular Coiling (EVC) is a minimally invasive procedure with apparently higher procedural cost. EVC is now being widely used as an alternative treatment modality for the treatment of (PComA) aneurysms where coils are passed through the femoral artery route, with less morbidity and hospital stay. There are concerns regarding the coiling that could contribute to the mass effect and compromise nerve recovery. ⁴

We aimed to study the factors that are associated with better or worse outcome in cases with posterior communicating artery aneurysms. We also aimed to evaluate the outcome of the different treatment modalities of posterior communicating arteries aneurysm including the success and adverse effects of the all the modalities.

PATIENTS AND METHODS

Subjects: The study was conducted over two years on all cases that have been diagnosed with posterior communicating artery aneurysms at Neurosurgery department, Al-Azhar hospitals, and Damanhur Medical National Institute.

Inclusion criteria: Posterior communicating artery aneurysms treated by surgical or endovascular technique at Al-Azhar University Hospitals and Damanhur Medical National Institute.

Exclusion criteria: Vitally unstable patient, Cases with GCS < 6, and Patient refusing intervention.

Methods: The study was conducted over 2 years on all cases of posterior communicating arteries aneurysms that have been treated by surgical or endovascular techniques.

The cases were subjected to the following:

Demographic and basic data collection:age, sex, and medical history.

Clinical assessment: Full detailed history of present illness of patient, full neurological examination of patient

Radiological assessment:  Cross sectional (CT and MRI), and Angiography (CTA, MRA and CCA)

Decision making of the operative intervention including Counseling with the patients and relatives, surgeon preference Aneurysm characteristics as for unruptured aneurysm, endovascular is better, while for giant aneurysms with mass effect surgical clipping is considered, and Hospital policies:

Endovascular approach is the treatment of choice in our centers.

Cases where surgery is preferred are; A patient who may need long time to be prepared for EVC, aneurysms requiring stent (long term antiplatelet) with concomitant ventriculomegaly that may progress after endovascular intervention, and cases which need concomitant surgeries like massive hematoma.

Informed consent signed: Explanation of management strategy, Explanation of Operative procedure, Explanation of outcome expected and Explanation of outcome if refusing intervention.

Post operative evaluation:

Clinical: Including mRS scores. Good (≤2) and bad (>2)

Radiological: Raymond's classification which designed as early (immediate post operative) and late (3-18 months post operative), cross sectional (CT and MRI) and angiography (CTA, MRA and CCA), complication reported and cranial nerve outcome.

Statistical Analysis: On an IBM-compatible PC, all data were revised and validated before being described and analyzed using the SPSS (Statistical Package for the Social Science) application version 22.0.0, Microsoft Office Excel 2007, and Graph Pad Prism 6. For all researched parameters in the studied data, descriptive statistics were calculated and provided in the form of mean, median, standard deviation (SD), minimum, maximum, range, and percentages. When comparing parametric data that was normally distributed, the student t test was used to provide an analytical comparison across groups. Fisher's exact test was employed instead of chi-square test for comparing nonparametric data because Fisher's test creates an exact P value, whereas chi-square merely calculates an estimate.

RESULTS

This prospective study was conducted on 39 (20males and 19 female) patients who were diagnosed with posterior communicating artery aneurysm at Neurosurgery department, Al-Azhar University Hospitals and Damanhur Medical National Institute.

Table 1: Distribution of the studied cases according to technique (n=39)

This table shows that, 31 patients underwent endovascular intervention of their (PComA) aneurysms (79.5% of all cases) including coiling in 22 patients (56.4%), stent assessed coiling in 5 patients (12.8%) and stenting in 4 patients (10.3%), while 8 patients had surgical clipping (20.5% of all cases).

Table 2: Distribution of the studied cases according to clinical outcome mRS (n=39)

In our study we used modified Rankin scale as a clinical outcome assessment, patients were divided to 2 groups (good ≤2 and bad <2). 29 patients were with good outcome (74.4%) and 10 patients were in pad clinical outcome (25.6%).

Table 3: Distribution of the studied cases according to radiological outcome (Raymond's classification) (n=39)

Regarding to Raymond's classification all 39 patients among the recent study were evaluated radiologically early and late. Early evaluation (immediately post operative), 21 patients (35.8%) had complete occlusion, 10 patients (25.6%) had aneurysm remnant and 8 patients (20.5%) had neck remnant. While in late evaluation (3-18 months post operative) there were 28 patients (71.8%) with complete occlusion, 3 patients (7.7%) with aneurysm remnant and 8 patients (20.5%) still with neck remnant.

Table (4): Descriptive analysis of the studied cases between intervention technique and clinical outcome (n=39)

This table shows the relation between techniques and clinical outcome (Modified Rankin scale), out of 39 case 31 cases underwent endovascular intervention (coiling, stent assessed coiling ang stenting) 26 patients 83.9% come with good outcome (≤2) with a significant difference (P = 0.016).

Table 5: Descriptive analysis of the studied cases between technique and operative complications (n=39)

Table 6: Descriptive analysis of the studied cases between technique and post operative complications (n=39)

The relation between operative complication and post-operative complication on one side and the techniques (surgical and endovascular) from another side we find no significant difference.