The thesis is devoted to the development of theoretical, scientific, and practical grounds for solving the urgent scientific and medical, as well as medical and social, problems of surgery of cerebral arterial aneurysms by applying the concept of individualizing surgical treatment based on deepening knowledge about separate components of pathogenesis at the stage of clinical manifestations of the disease.
A theoretical generalization and a new approach to solving the scientific problem of surgical treatment of cerebral aneurysms at the stage of clinical manifestations are presented in the thesis based on analyzing the retrospective cohort study of the comprehensive examination and surgical treatment of 547 (100%) patients with cerebral bifurcation and hemodynamic arterial aneurysms.
Clinical and neurological, instrumental (non-invasive and invasive), and neuroimaging examinations, as well as laboratory tests, were carried out, and statistical methods of information processing were used.
It was established that aneurysmal lesions of the cerebral arteries should be considered as a fast-moving pathological process, the transformation of which into a disease occurs stage by stage, clinically dividing into a latent (asymptomatic) period and a phase of clinical manifestations. It was found that the stage of clinical manifestations of the disease in most cases is associated with arterial rupture.
A combined effect of pathogenetic unmodified risk factors for the occurrence of bifurcation and hemodynamic aneurysms (gender and age of a patient) with hemodynamic aspects (functional asymmetry of the blood supply of the brain, atypical anatomical options of the structure of the cerebral arterial circle, as well as localization and number of aneurysms) was revealed at the stage of clinical manifestations of the disease in the form of increasing the aneurysm size and transforming its shape from saccular to “complex”.
It was found that hemorrhagic stroke due to rupture of a cerebral arterial aneurysm has specific clinical and neurological manifestations and features of the clinical progression depending on the aneurysm location and size.
The specificity of the clinical manifestations of cerebral aneurysms and surgical treatment of them was analyzed, and the factors that influence its results were determined. It was found that the results of surgical treatment of cerebral arterial aneurysms that were clinically manifested by rupture were not associated with the method of surgical treatment, but depending on the clinical and neurological state of the patient, the volume and localization of intracranial hemorrhage, as well as the surgical treatment duration since the aneurysm rupture.
It was determined that the choice of the duration and method of surgical treatment of cerebral aneurysms is carried out individually and is based on the character of the clinical progression of the disease, as well as localization and geometric, morphological, and hemodynamic parameters of cerebral aneurysms.
Increasing the efficiency of surgical treatment of cerebral arterial aneurysms is possible by carrying out combined operations with using intraventricular fibrinolysis in urgent indications for surgery.
A differentiated application of the multiple clip technique in combination with intraoperative contact Doppler sonography in urgent microsurgical operations for the rupture of cerebral bifurcation and hemodynamic aneurysms was proposed.
A method to optimize the craniotomy access and microsurgical corridor to the aneurysm and remodel the aneurysm neck with clips using preoperative virtual 3D modeling of the skull, cerebral arteries, and an aneurysm of the patient was developed. An individual 3D model is created by overlaying and combining neuroimaging data, followed by printing an individual model made of polylactide. This technique makes it possible to plan an operation (a micro-surgical stage of craniotomy), which has expanded the possibilities of microsurgical operations on “complex” cerebral aneurysms in the case of indications for a planned surgery.
The task of individualizing the surgical treatment of cerebral arterial aneurysms was solved by predicting the outcome of surgical treatment. An individualized formula for surgical treatment of a patient was created; a cluster analysis was carried out; the most informative signs and their diagnostic coefficients for building a forecasting system were identified, and the significance of the results was checked.
