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Clinicoradiological Profile and Outcome of Microsurgical Clipping of Ruptured Anterior Circulation Aneurysms: A Single-Institute Experience

Introduction: Prevalence of intracranial aneurysms is estimated to be from 1% to 5% of population, most of them are small and located in the anterior circulation. The real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage (SAH). SAH is a catastrophic event with a mortality rate of 25% to 50%. Permanent disability occurs in nearly 50% of the survivors. Fifteen percent of patients expire before reaching the hospital and 25% die within 24 h. The purpose of our study is to report the clinicoradiological data and outcome of microsurgical clipping of ruptured anterior circulation aneurysms in our center. Materials and Methods: This study included ruptured anterior circulation aneurysms admitted to tertiary care hospital in northern India from January 2018 to June 2020. The final outcome of patients was analyzed with Glasgow Outcome Score (GOS) at the time of discharge from the hospital. Results: A total of 53 patients with ruptured anterior circulation aneurysm underwent microsurgical clipping comprising 25 (47.2%) males and 28 (52.8%) females. The mean neck size of all aneurysms was 3.43 ± 1.66 mm. The mean hospital stay was longer in patients having preoperative intraventricular hemorrhage (IVH) (35.96 ± 27.27 days) and postoperative complications (43.36 ± 29.76 days) compared to patients who did not have IVH (21.10 ± 15.47 days) and postoperative complications (18 ± 6.54 days). P value was ≤0.05. Patients with preoperative hydrocephalus had GOS 3.44 ± 1.20 at discharge compared to nonhydrocephalus who had GOS 4.32 ± 1.07 (P = 0.009). Patients with Intracerebral Hemorrhage (ICH) and non-ICH had GOS 3.31 ± 1.38 and 4.28 ± 1.01, respectively (P = 0.009). Conclusion: Poor outcome at the time of discharge after the surgical treatment of anterior circulation aneurysms was associated with poor world federation of neurological surgeons grade on admission, presence of IVH, hydrocephalus, intracerebral hemorrhage, and postoperative cerebral infarcts.


Introduction
The prevalence of intracranial aneurysms is estimated to be from 1% to 5% of population, most of them are small and located in the anterior circulation. Anterior Circulation Aneurysms (ACA) arise from the internal carotid artery (ICA) or from any of its branches. The most common type is a saccular aneurysm, which is approximately 85% of ACA. Unruptured aneurysms may cause symptoms mainly due to mass effect, but the real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage (SAH). [1] The risk of rupture is around 1% per year. Size is a major risk factor for this complication, the rupture rate for ACA <7 mm was 0% per year in patients with no prior SAH and 0.3% per year in previous SAH; this risk rises considerably to 8% per year in patients with giant aneurysms. [1] Among ACA, the most frequent site is the anterior communicating artery (ACOM). [2] SAH is a catastrophic event with a mortality rate of 25% to 50%. Permanent disability occurs in nearly 50% of the survivors. Fifteen percent of patients expire before reaching the hospital and 25% die within 24 h. Only one-third of patients who suffer a SAH have a positive outcome. [3] Rebleed has a catastrophic morbidity from 48% to 78%. [4] Recent guidelines recommend early and ultra-early securing of the aneurysm by means of surgical clipping or endovascular coiling to avoid rebleeding. [5] However, this may not be possible for all patients, especially in developing countries due to late transportation to specialized neurosurgery units.
Late admission for patients with aneurysmal SAH during the period of vasospasm forced the neurosurgeons to secure the aneurysms during that period which historically carries a bad outcome. The purpose of our study is to report the clinicoradiological data and outcome of microsurgical clipping of ruptured anterior circulation aneurysms in our center.

Materials and Methods
A study of patients with ruptured anterior circulation aneurysms admitted to tertiary care hospital in northern India from January 2018 to June 2020 were enrolled after approval from the institutional ethical board.
The smallest size of aneurysmal neck was 1 mm and largest was 10 mm. The mean neck size of all aneurysms was 3.43 ± 1.66 mm, whereas the smallest aneurysmal sac was 2 mm and largest aneurysmal sac was 11 mm of size. The mean size of aneurysmal sac was 5.47 ± 2.11 mm. SAH was present in all patients. Intraventricular hemorrhage (IVH) was present in 23 (43.4%) patients. Preoperative hydrocephalus was found in 18 (36%) patients. Intracerebral hemorrhage (ICH) was seen in 13 (24.5%) patients.
Postoperatively, 12 (22.6%) patients had vasospasm that lead to cerebral infarcts in different territories. Ten (18.9%) patients had MCA infarcts. Among these, 6 (11.3%) patients were with left MCA territory infarcts and 4 (7.5%) patients developed right MCA territory infarcts. Anterior cerebral artery (Ant.CA) territory infarcts were seen in three patients(5.7%) , one each in Left Ant. CA and Right Ant.CA territory. Bilateral Ant. CA territory infarct was present in single patient. One patient had right posterior cerebral artery infarct. Postoperative hydrocephalus was present in 7 (13.2%) patients. Other rare complications such as meningitis, extradural hematoma, subgaleal hematoma, chronic subdural hematoma, and right lung empyema developed as single complication (1.9% each) in five different patients.
Decompressive craniectomy was done in 5 (9.4%) patients who had postclipping MCA territory infarcts. Of which 3 (5.7%) were with left MCA territory infarcts and 2 (3.8%) were with right MCA territory infarcts. Ventriculoperitoneal shunt was done in 6 (11.3%) patients for hydrocephalus during the hospital stay. Tracheostomy was done in 5 (9.4%) patients. Extradural hematoma and subgaleal hematoma evacuation each was done in two different patients.
The overall mean hospital stay was 27.55 ± 22.43 days. However, the mean hospital stay was longer in patients having preoperative IVH (35.96 ± 27.27 days) and postoperative complications (43.36 ± 29.76 days) compared to patients who do not have IVH (21.10 ± 15.47 days) and postoperative complications (18 ± 6.54 days). P value was ≤0.05 which was clinically significant. Similarly, the mean hospital stay was also longer in patients who had intraoperative aneurysm rupture (64.25 ± 33.02 days) compared to patients who did not have intraoperative aneurysm rupture (24.55 ± 18.86 days) with P ≤ 0.001.

Discussion
Endovascular intervention may not be applicable in many centers in developing countries due to expensive supplies that make surgical clipping the standard treatment modality for ruptured aneurysms in developing countries like India. Rinkel et al. found that the incidence of intracranial aneurysms increased with age, and the majority of cases occur among patients in their 50s. [6] Similarly, in our study, most of the patients were from 51 to 60 years of age group. Samandouras G found that females are more affected than males. [7] Our study also had more females (52.8%) compared to males (47.2%). Schöller et al. reported that outcomes clearly worsened with increasing age, and age was one of the strongest predictors of mortality and a poor outcome. [8] A multivariate regression analysis showed the independent effects of gender on the outcome at discharge in 108 young adult patients. [9] There are some reports suggesting that age and sex have no prognostic value [10,11] . In our study age and sex were not found to be predictors of poor outcome and mortality (p >_0.05). The presence of hypertension as a comorbid illness was a major risk factor in our study. It was present in approximately 85% of patients. Hypertension is associated with increased risk of SAH and is also associated with poor outcomes in patients of a SAH. Feigin et al. in their study concluded that smoking, hypertension, and excessive alcohol remain the most important risk factors for SAH. [12] WFNS grade at presentation is the most important predictor of outcome, and this held true in our study. Orakdogen and others reported that WFNS grade and clinical vasospasm were the most important prognostic factors of outcome in patients with ruptured cerebral aneurysms. [13] Chiang et al. on studying 56 consecutive patients for prediction of outcome in a SAH found the patient's worst clinical grade to be most predictive of the outcome, especially when the patient is assessed using the WFNS or GCS. [14] In our study, patients with good WFNS grades at presentation had good outcomes (P = 0.001). In our study, mortality occurred in 3.8% of patients with WFNS Grade V only, which was statistically significant.
In the present study, the relation of size of a ruptured aneurysm to the final outcome of the patient was not found in contrary to Shiue et al., who pointed out that the size of a ruptured aneurysm is an important determinant of outcome in SAH and should be used as a prognostic parameter in directing management. [16] We divided patients into three groups according to the size of aneurysm (≤4 mm, 5-7 mm and ≥7 mm) to compare outcomes and found P value statistically insignificant (P = 0.45). Chotai et al. also found that the size of the aneurysm and the presence of multiple aneurysms were associated with unfavorable outcomes. [9] Various projections of anterior circulation aneurysms and their relation to the outcome of patients were not found in our study (P ≥ 0.05). In the study done by Orz and AlYamany, [17] the mean size of rupture was different for different locations of aneurysms. Sixty-three percent of ruptured aneurysms were smaller than 7 mm in diameter in their study. Seventy-three percent of ruptured ACOM aneurysms were <7 mm in diameter in their study. Forget et al. [18] also found that 44% and 94.4% of ruptured ACOM aneurysms were <5 mm and 10 mm in diameter in their study. In a study done by Joo et al., [19] 71.8% of aneurysms ruptured before reaching a size of 7 mm. These studies are in concordance with our findings.
Schöller et al. reported hydrocephalus to be the weakest predictor of outcome, while Lagares et al. reported that the presence of hydrocephalus was related to a poor outcome. [8,20] In our study, we found that preoperative IVH and hydrocephalus were significant predictors of poor outcome (P ≤ 0.05). Intracerebral hematoma (ICH) due to rupture of aneurysm was also found to be a predictor of poor outcome in the present study (P ≤ 0.05). Bohnstedt et al. in their study concluded that Hunt and Hess (HH) grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH Grade IV and V expired during their hospital course despite the best treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH Grade IV-V. [10] IVH, hydrocephalus, and ICH were predictors of poor outcome in our study.
Sandalcioglu et al. concluded that intraoperative aneurysm rupture has no impact on the outcome neither in patients with good initial condition nor for poor grade patients. [21] The results of our study coincided with that as in our study, GOS difference at the time of discharge from hospital in patients with intraoperative ruptured aneurysm and in unruptured patients was not statistically significant (P = 0.066), although the length of hospital stay was quite longer in intraoperative ruptured aneurysm patients (P = 0.001).

Conclusion
This study has concluded that hypertension was the most common risk factor among the patients. Poor outcome at the time of discharge after the surgical treatment of anterior circulation aneurysmal was associated with poor WFNS grade on admission, presence of IVH, hydrocephalus, intracerebral hemorrhage, and postoperative cerebral infarcts, whereas other factors such as age, sex, diabetes mellitus, size and projection of aneurysmal sac, and intraoperative rupture of aneurysm were not associated with poor outcome of patients. The limitation of our study is the small number of patients; hence, further studies with a greater number of patients are required to corroborate our findings.

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Conflicts of interest
There are no conflicts of interest.