Comparison of clinical efficacy and safety between interventional embolization and craniotomy clipping for anterior circulation aneurysms

Objective: To investigate the clinical efficacy and safety of interventional embolization in the treatment of anterior circulation aneurysms. Methods: Eighty patients with anterior circulation aneurysms admitted to People’s Hospital of Leshan from June 2019 to December 2021 were retrospectively analyzed. According to the different surgical methods, they were divided into two groups: the observation group and the control group. Patients in the observation group were given interventional embolization, while those in the control group were given craniotomy clipping. The surgical efficacy, postoperative neurological function and quality of life, surgical prognosis and surgical complications of the two groups were compared. Results: The intraoperative blood loss and hospitalization time in the observation group were lower than those in the control group (p<0.05). The scores of the Hunt-Hess and modified Rankin scale in the observation group were significantly lower than those in the control group three months after surgery (p<0.05). The good prognosis rate of the observation group was higher than that of the control group (p<0.05). Moreover, the complication rate of the observation group was 12.50%, which was significantly lower than 32.50% in the control group (p<0.05). Conclusion: Interventional embolization shows the advantages of minimally invasive procedures such as shorter operative times and shorter hospital stays. It has better clinical safety because it can significantly improve the neurological function and quality of life of patients, improve the prognosis of patients, and reduce the incidence of complications.


INTRODUCTION
Anterior circulation aneurysms are a common cerebral vascular disease in neurosurgery, which tends to make inroads in middle-aged and elderly people.It mostly occurs in abnormal bulging of the intracranial artery wall and is the primary cause of subarachnoid hemorrhage clinically. 1,2][5] Currently, anterior circulation aneurysms are generally treated by early surgery in principle 6 , and craniotomy clipping has long been the preferred surgical method. 7espite the classic operation and definite curative effect, this operation is characterized by large surgical trauma, many postoperative complications, and an unsatisfactory prognosis.With the rapid development of medicine and the appearance of all kinds of medical auxiliary materials, interventional embolization has been applied to the treatment of anterior circulation aneurysms.At present, certain differences still exist about how to choose the above two methods for the treatment of anterior circulation aneurysms in clinical practice.Based on this, in this study, eighty patients with anterior circulation aneurysms were selected as subjects to comprehensively compare the clinical effects of interventional embolization and craniotomy clipping in the treatment of anterior circulation aneurysms.

Exclusion criteria:
• Patients with cerebral infarction and brain trauma.
• Patients with abnormal coagulation function.
• Patients with severe systemic diseases, severe liver and kidney dysfunction, cardiopulmonary dysfunction, and difficulty in tolerating surgery.• Patients with disturbance of consciousness and mental illness.Surgical methods: Both groups of patients received basic treatment such as preventing vasospasm and relieving pain after admission, and their vital signs were closely monitored.Among them, the patients in the control group were treated with craniotomy clipping.After general anesthesia was successful, the patient's position was adjusted, the specific position of the aneurysm was located according to the preoperative angiographic results, the surgical area was disinfected, the tissues were separated layer by layer after incision, the bone flap was removed, the cerebral dura mater was cut open, the aneurysm was separated along the subarachnoid space, and the aneurysm was temporarily clipped with a vascular clip.After separation, an appropriate aneurysm clip was selected and clipped, and after hemostasis, the aneurysm was sutured layer by layer.The patients in the interventional group were treated with endovascular interventional embolization.The patient was under general anesthesia, heparinized during surgery, and blood pressure was controlled to maintain systolic blood pressure at 100-110 mmHg.Cerebral angiography was performed first to clarify the location, size and shape of anterior circulation aneurysms.Subsequently, the right femoral artery was punctured, the arterial sheath was indwelled, a super-sliding guide wire and a guide catheter were inserted, the stent catheter was delivered to the distal end of the aneurysm artery, and the microcatheter for embolization was successively reached into the aneurysm sac.According to the size of the aneurysm, the size and length of the coil were selected to effectively fill the aneurysm.

Observation indicators:
The perioperative-related indicators of the two groups were observed, including operation time, intraoperative blood loss, intraoperative aneurysm rupture and hospital stay.Raymond-Roy grading was used to evaluate the curative effect of the operation, which was divided into four grades: Grade-I: complete embolism, no contrast agent filling in the tumor body and neoplasia neck; Grade-II: visible residues in the neoplasia neck, contrast agent filling showed "dog ear sign"; Grade-III: visible residue in the most of the neoplasia neck, and most of the contrast agent was filled; Grade-IV: visible residue in the tumor body, and the tumor cavity was filled with contrast agent.The National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale were used to evaluate the neurological function and quality of life of patients before and three months after surgery.The higher the NIHSS score, the more serious the neurological deficit of the patient is.The modified Rankin scale scores 0-6, the higher the score, the greater the impact on quality of life.After six months of treatment, Glasgow Outcome Scale (GOS) was used to evaluate the prognosis of the two groups, which were divided into five grades.Among them, 1-3 points

RESULTS
The intraoperative blood loss and hospitalization time in the observation group were significantly lower than those in the control group, with statistically significant differences (p<0.05).The proportion of postoperative Raymond-Roy Grade I and II in the observation group was 97.50% (39/40) and 2.50% (1/40), respectively, while that of postoperative Raymond-Roy Grade I and II in the control group was 92.50% (37/40) and 7.50% (3/40), respectively.The proportion in the observation group was slightly higher than that in the control group, but there was no statistically significant difference between the two groups (c²=1.053,P=0.305) Table-II Three months after surgery, the scores of the Hunt-Hess and modified Rankin scale in the two groups were significantly lower than those before surgery, and the degree of decrease in the observation group was significantly lower than that in the control group, with a statistically significant difference (p<0.05)Table -III The good prognosis rate of the observation group was higher than that of the control group, with a statistically significant difference between the two groups (p<0.05)Table -IV The incidence of complications in the observation group was 12.50%, which was significantly lower than 32.50% in the control group (p<0.05)Table-V.

DISCUSSION
In this study, the clinical effects of craniotomy and interventional embolization in the treatment of anterior circulation aneurysms were compared.The blood loss and hospitalization time of patients in the observation

Table-III: Comparison of the scores of Hunt-Hess and modified Rankin scale between the two groups (
).With the acceleration of the aging society in China, there is an obvious increase in the number of patients with anterior circulation aneurysms. 9,10Most scholars harbor the idea that the pathogenesis of anterior circulation aneurysms includes two factors: congenital factors such as hemodynamic changes and vascular wall lesions, and acquired factors such as atherosclerosis, vasculitis and severe hypertension. 11,12Once the aneurysm ruptures, it will cause subarachnoid hemorrhage and increase intracranial pressure.4][15][16] Therefore, it is of great significance to treat anterior circulation aneurysms early. 17urrently, craniotomy clipping and endovascular interventional embolization are the preferred options for the treatment of anterior circulation aneurysms.Specifically, craniotomy clipping can clip aneurysms under direct vision, which has a definite curative effect and a high success rate.However, this operation needs to be performed after the relatively stable condition of patients, with large surgical trauma, easy damage to the brain tissue around the tumor during the operation, and sequelae, which brings great pain to patients. 18In contrast, interventional embolization, as a minimally invasive operation, boasts the advantages of a small wound, light injury, quick recovery and good prognosis.It not only guarantees its safety but also has a high success rate.However, interventional embolization has its drawbacks such as being demanding, risky, expensive and poor operation timing.

Group
In recent years, more and more attention has been paid to the application of endovascular interventional embolization in the treatment of anterior circulation aneurysms, and it has become one of the important surgical methods for minimally invasive treatment of anterior circulation aneurysms. 19,20In this study, the good rate of GOS score in the observation group was significantly higher than the control group.The incidence of postoperative complications in the observation group was lower than that in the observation group.All these suggest that interventional embolization in the treatment of anterior circulation aneurysms can significantly improve the prognosis of patients and effectively reduce complications.By analyzing the reasons, we concluded that interventional embolization can effectively avoid brain tissue damage and reduce the risk of complications due to operation without direct contact with brain tissue.Moreover, interventional embolization is a minimally invasive operation that uses a special catheter system to place the coil into the artery cavity of the patient and fill it up, which improves the surgical effect.Supplemented with a short postoperative bedtime to promote early recovery of patients.
Limitations: It includes a single-center study with small sample size.There may be some selection bias and short follow-up time.To address this, further research is still needed on the long-term efficacy of interventional embolization and the long-term prognosis of patients.

CONCLUSION
Interventional embolization can significantly ameliorate the neurological function and quality of life of patients with the advantages of short operation time and short hospitalization time, and improve the prognosis of patients, and a low incidence of complications.It is worthy of vigorous promotion and application in clinical practice.

Table - I
: Comparison of perioperative indicators between the two groups.The good prognosis rate of the two groups was counted.Moreover, the complications of the two groups were observed, including cerebral vasospasm, rebleeding, cerebral infarction, neurological dysfunction and intracranial infection.The maximum follow-up time for patients in both groups was six months.And case data collection ceased in June 2022.The follow-up work of all patients was completed by the same group of surgeons.

Table - V
: Comparison of surgical complications between the two groups [n, (%)].