Kazantseva V. Individualization of microsurgical treatment tactics in the acute period of rupture of cerebral arterial aneurysms

The dissertation study concentrates on refining approaches to improving the outcomes of microsurgical treatments. This will enable the selection of the optimal timing for microsurgical intervention in each individual case during the acute phase of cerebral artery aneurysms (CAAs) rupture, which remains one of the most pressing and contentious issues in contemporary vascular neurosurgery. The study explores a comprehensive set of well-known predictors for evaluating patients' demographic, clinical, and neurological status, incorporating clinical scales and instrumental parameters from supportive neuroimaging techniques, all considered collectively. This approach enabled the identification of the most impactful among these criteria/predictors in predicting the outcomes of microsurgical intervention (MSI) and in the construction of a prognostic model, which also takes into account the individual timing for MSI during the acute phase of CAA rupture. The prognostic value of these risk factors for patients with CAA rupture in determining favourable MSI outcomes has been determined. Based on the research conducted, a prognostic model in the form of a logistic regression equation was developed. This model made it possible to influence the efficacy of microsurgical tactics and allowed the categorising of patients according to diagnostic criteria for performing a surgical intervention with successful outcomes. The dissertation work is based on the results of a retrospective analysis of medical histories (n=391) of patients with clinical manifestations of CAA rupture and a prospective study of the microsurgical treatment results in the clinical group of patients (n=89) aged 18 to 85 years, sharing the same pathology, who were treated in the setting of the Vascular Neurosurgery Center of the Communal Enterprise "Dnipropetrovsk Regional Clinical Hospital n.a. I.I. Mechnykov" of the Dnipropetrovsk Regional Council (KP "DOKLM" DOR). The retrospective analysis included patients (n=329) who were microsurgically operated in the acute period of CAA rupture at different terms and patients (n=62) who died without surgery from 2013 through 2017. The study of the prospective group was conducted throughout 2018, with the introduction of a prognostic model in the MSI tactics, which took into account the influence of the identified significant criteria/predictors for a favourable clipping result. The clinical outcome of MSI in patients was determined using the Glasgow Outcome Scale (GOS), and in cases of an unfavourable outcome, the reason was analysed. The studied clinical groups were comparable by the selected data, which indicates the compatibility of both groups and the possibility of comparing the results. Scientific novelty of the obtained results. The first study of multiple predictors of the unfavourable MSI outcomes taken together, using statistical analysis, gave us the opportunity to identify the most important of them, which, when evaluated together, allowed predicting the MSI outcomes with the maximum probability. A prognostic model, useful for clinical application in vascular neurosurgery, was developed and scientifically substantiated, which made it possible to influence the efficacy of microsurgical tactics and to categorise patients, taking into account the main predictors of the development of complications of microsurgical treatment of CAA in the acute period of rupture. This evidence-level prognostic model made it possible to avoid the probable development of unfavourable consequences and to optimally approach the choice of MSI timing. Based on the conducted logistic regression analysis, a prognostic model has been developed that statistically significantly predicts the actual belonging of the patient to one or another group (favourable or unfavourable MSI prognosis) with an accuracy of 83.01%, sensitivity of 61.04%, and specificity of 83.28% (AUC=0.757, p<0.001).