Combined microscopic and neuroendoscopic treatment effects on psychological and cognitive outcomes in ruptured intracranial aneurysms

Abstract

BACKGROUND

Intracranial aneurysms, characterized by focal arterial wall dilation, pose significant neurosurgical challenges due to their potential for rupture and hemorrhage, leading to severe clinical outcomes, including fatality. Patients often experience profound psychological and social impacts, such as depression, anxiety, and cognitive impairment, affecting their quality of life. Rapid progression and high mortality necessitate timely intervention. Advances in neurosurgical techniques, including microscopic surgery and neuroendoscopy, offer distinct advantages. Microscopic surgery provides precision and direct visualization, while neuroendoscopy ensures minimally invasive access and reduced tissue trauma. Integrating these methods optimizes treatment efficacy and clinical outcomes.

AIM

To evaluate the impact of combined microscopic and neuroendoscopic techniques on psychological, cognitive outcomes, and quality of life in patients with ruptured intracranial aneurysms.

METHODS

The study focused on 189 patients with intracranial aneurysm rupture and hemorrhage from January 2020 to May 2024 as the objects of observation and analysis. They were randomly divided into a control group (treated with simple microscope surgery, n = 94) and an observation group (treated with microscope combined with neuroendoscopy, n = 95). The treatment effects of the two groups were observed, mainly including depression and anxiety scale scores, cognitive function assessment results and quality of life assessment data.

RESULTS

Before treatment, the depression and anxiety scale scores, cognitive function assessment results and quality of life assessment data of the two groups of patients at different time points were compared, and there was no statistically significant difference (P > 0.05). After microscope combined with neuroendoscopy treatment, the study revealed that the observation group surpassed the control group in alleviating depression and anxiety, accelerating cognitive function recovery, and enhancing quality of life, with these differences being statistically significant (P < 0.05).

CONCLUSION

Surgical treatment combined with microscopy and neuroendoscopy has a significant positive effect on the mental health, cognitive function and overall quality of life of patients with intracranial aneurysm rupture and bleeding, can shorten the operation time and treatment time, and provides a new strategic reference for clinical treatment.

Key Words: Microscope; Neuroendoscopy; Intracranial aneurysm; Depression and anxiety; Cognitive function; Quality of life

Core Tip: Surgical treatment combined with microscopy and neuroendoscopy has a significant positive effect on the mental health, cognitive function and overall quality of life of patients with intracranial aneurysm rupture and bleeding.

INTRODUCTION

Intracranial aneurysm, in short, refers to the localized abnormal expansion of the lumen of cerebral arteries. This expansion causes the arterial wall to form a tumor-like protrusion outward[1]. As one of the major challenges in the field of neurosurgery, its rupture and bleeding often lead to serious clinical consequences, including disability or even death[2]. Such patients not only suffer great physical pain, but their mental health and quality of life are also often seriously affected, especially depression, anxiety and cognitive dysfunction. The patient's condition progresses rapidly and the mortality rate is high. Treatment should be started as soon as possible[3]. At present, surgical operations under microscope and neuroendoscopy have become the two mainstream technologies in the field of neurosurgery. They each have unique advantages and limitations. However, by cleverly combining the two, it is possible to maximize the integration and give full play to their respective advantages[4]. Thanks to the rapid development of science and technology and the continuous improvement of microsurgery technology, coupled with the continuous progress in the field of medical imaging and the continuous innovation of surgical equipment, the success rate of microsurgery has been significantly improved. At the same time, endoscopic technology has been increasingly widely used in the field of minimally invasive neurosurgery, and the combination of microscopes and endoscopic technology has undoubtedly opened up an innovative and efficient new path for the treatment of intracranial aneurysms. During the operation, the microscope is used as the main treatment tool, but its field of view has certain limitations, namely the so-called "blind spot", which to a certain extent limits the accuracy and effect of surgical treatment. However, with the rapid rise and rapid development of neuroendoscopic technology, the clinical efficacy has been significantly improved[5]. It can reduce the need for exploration due to insufficient field of view of the microscope alone, resulting in postoperative vascular spasm, the aneurysm complex can be enlarged during surgery, and the incidence of misclipping and incomplete clipping can be reduced, thereby improving the quality of surgery and reducing the risk of surgical complications, which can promote the comprehensive recovery of patients[6]. At the same time, in addition to its significant efficacy, the improvement of people's treatment concepts has also led to the widespread application of neuroendoscopic technology in clinical practice[7]. To further confirm the application value of neuroendoscopy, this study aims to explore the effects of microscope combined with neuroendoscopy on depression, anxiety, cognitive function and quality of life in patients with intracranial aneurysm rupture and bleeding, and to understand the application effect of the combination of the two endoscopes in medical clinical practice.

MATERIALS AND METHODS

Patient selection

This study focused on individuals who were scheduled to receive treatment for ruptured intracranial aneurysm bleeding in our hospital between January 2020 and May 2024, and we strictly followed the following carefully formulated inclusion and exclusion criteria.

Inclusion criteria: (1) All patients were diagnosed with intracranial aneurysms and were willing to undergo single-microscope or combined neuroendoscopic surgery and subsequent research and investigation; (2) Patients were less than 80 years old; (3) Hunt-Hess grade was between I and IV; and (4) Voluntarily signed the informed consent form.

Exclusion criteria: (1) Patients with severe intracranial diseases such as cerebral hemorrhage and cerebral infarction; (2) Patients with cardiopulmonary dysfunction; (3) Individuals with coagulation dysfunction; or (4) Those with hereditary diseases or special personal history.

Medical ethics requirements: This research plan and the informed consent of the subjects have all been approved by the Medical Ethics Committee.

General information

A total of 189 patients with intracranial aneurysm rupture and bleeding were selected from January 2020 to May 2024 as the subjects of observation and analysis. Using the random number table method, they were segregated into a control group and an observation group. There were 95 cases were divided into the control group, including 49 males and 46 females, aged 36-73 (55.8 ± 8.0), and the amount of bleeding was 26-85 (62.14 ± 11.82). There were a total of 94 cases, comprising 51 males and 43 females, aged 38-75 (59.3 ± 12.4), and the amount of bleeding was 28-87 (65.34 ± 13.42). After statistical analysis, there was no statistically significant difference observed in the general data between the two patient groups (P > 0.05), ensuring that the two groups were comparable and could be compared in research (Table 1).

Table 1 Comparison of general data between the two groups.

Group	Number of cases	Gender (male/female, example)	Age (years old, mean ± SD)	Amount of bleeding (mL, mean ± SD)
Observation group	95	49/46	55.8 ± 8.0	62.14 ± 11.82
Control group	94	51/43	59.3 ± 12.4	65.34 ± 13.42
χ2/t		0.066	1.127	0.475
P value		0.798	0.228	0.643

Treatment methods

The control group was given simple microscopic treatment to routine patients. Under the microscope, the arachnoid membrane of the lateral fissure of the brain was separated to release cerebrospinal fluid, and the endplate pool was opened to fully release it. Separate the arachnoid membrane around the aneurysm during surgery, clamp it under direct visualization under a microscope, and adjust it under microscopic observation. Treat until the discharge criteria are met, conduct a follow-up examination 24 hours after surgery, and analyze the evaluation index data one month later. The observation group was treated with a combination of microscopy and neuroendoscopy surgery, both of which were performed under strict sterile conditions and performed by experienced neurosurgeons. According to the location of the hematoma, adopt a supine or lateral position, with the body slightly tilted forward in the lateral position, which is conducive to the use of microscopes and endoscopes. Firstly, perform routine microscopic operations to separate the arachnoid membrane of the lateral fissure and release cerebrospinal fluid. Open the internal carotid artery and chiasmatic cistern. If the decrease in cerebral pressure is not significant, the endplate cistern can be incised. Protect the surrounding brain tissue with a sponge, track the aneurysm along the artery, block the parent artery, expose the aneurysm neck and body, place a neuroendoscope to prevent damage to the surrounding tissue, clamp the aneurysm under the microscope, and ensure the patency of the parent artery. Later, important arterial branches and deep perforating arteries were observed through endoscopy, and adjustments were made for misclassification or incomplete occlusion. After clipping, high-definition vision using neuroendoscopy is used to assist in observing the clipping of the aneurysm, ensuring the accuracy and completeness of the aneurysm clipping.

Observation indicators

(1) Depression and anxiety: Hamilton Depression Rating Scale and Self-Rating Anxiety Scale are used for scoring. The score of each item is usually 0 to 4 points or 0 to 5 points. The degree of depression and anxiety will be relieved as the score decreases; (2) Cognitive function: The Mini-Mental State Examination is used as an assessment tool to comprehensively assess the patient's cognitive function recovery; and (3) Quality of Life Assessment: The Short Form 36 quality of life questionnaire is employed as a tool to quantify and evaluate the patient's overall well-being and quality of life. The overall quality of life will become ideal as the score increases.

Statistical analysis

SPSS 28.0 statistical software was used for analysis. For continuous count data, we used mean ± SD to describe; for categorical measurement data, we used frequency (n) and percentage (%) to perform statistics. In order to compare the differences between different groups, we used the χ² test for analysis. In all statistical analyses, P < 0.05 was set as the standard for judging whether the difference was statistically significant.

RESULTS

Anxiety state scores between the two groups before and after treatment

Prior to treatment, no meaningful disparity was observed in the primary clinical symptom scores between the two groups (P > 0.05). Post-treatment, both groups demonstrated a marked reduction in their anxiety levels (P < 0.05). Intriguingly, the observation group's anxiety state was significantly lower than that of the control group after undergoing treatment (P < 0.05; Table 2).

Table 2 Comparison of anxiety status between the two groups of patients before and after treatment (mean ± SD, points).

Group	Number of cases	Before treatment	After treatment	t	P value
Observation group	95	55.44 ± 6.80	42.52 ± 4.92	14.417	< 0.01
Control group	94	55.40 ± 6.46	49.58 ± 5.48	6.360	< 0.01
t		1.022	9.471
P value		0.306	< 0.001

Comparison of depression status between the two groups

Before treatment, no significant variation was detected in the main clinical symptom scores between the two groups (P > 0.05). However, subsequent to treatment, both groups experienced a notable decline in their depression status (P < 0.05). Notably, the observation group exhibited a considerably lower level of depression compared to the control group post-treatment (P < 0.05; Table 3).

Table 3 Comparison of depression status between the two groups before and after treatment (mean ± SD, point).

Group	Number of cases	Before treatment	After treatment	t	P value
Observation group	95	24.38 ± 2.59	12.15 ± 2.37	35.554	< 0.001
Control group	94	24.29 ± 2.41	16.65 ± 2.19	21.044	< 0.001
t		0.049	-8.086
P value		0.962	0.001

Comparison of cognitive function status between the two groups

Before commencing treatment, there was no discernible difference in the primary clinical symptom scores between the two groups (P > 0.05). Nonetheless, after undergoing treatment, both groups showed substantial improvements in their cognitive function status (P < 0.05). Furthermore, the observation group outperformed the control group in terms of cognitive function status post-treatment (P < 0.05; Table 4).

Table 4 Comparison of cognitive function scores between the two groups before and after treatment (mean ± SD, point).

Group	Number of cases	Before treatment	After treatment	t	P value
Observation group	95	16.96 ± 3.16	28.64 ± 4.07	-20.815	< 0.001
Control group	94	17.09 ± 4.14	21.69 ± 2.56	-9.322	< 0.001
t		0.076	11.393
P value		0.940	< 0.001

Comparison of quality of life between the two groups

Prior to treatment, no statistically significant difference was observed in the primary clinical symptom scores between the two groups (P > 0.05). However, subsequent to treatment, both groups experienced marked improvements in quality of life (P < 0.05). Notably, the observation group demonstrated a superior quality of life compared to the control group post-treatment (P < 0.05; Table 5).

Table 5 Comparison of quality of life between the two groups before and after treatment (mean ± SD, point).

Group	Time	General health	Social function	Physiological functions	Mental health
Observation group (n = 95)	Before treatment	40.22 ± 7.31	50.30 ± 8.86	60.64 ± 8.25	60.88 ± 4.92
	After treatment	51.99 ± 9.43	64.49 ± 10.13	74.83 ± 9.51	74.95 ± 7.36
Control group (n = 94)	Before treatment	41.01 ± 7.34	50.30 ± 8.90	60.1 8 ± 8.25	60.17 ± 5.03
	After treatment	47.22 ± 9.51	57.28 ± 9.29	67.21 ± 9.56	67.31 ± 6.24
Observation group value t/P value		10.403/< 0.001	12.945/< 0.001	10.230/< 0.001	12.310/< 0.001
Value within control group t/P value		5.354/< 0.001	6.339/< 0.001	5.067/< 0.001	9.472/< 0.001
The inter-group value t/P value after treatment		2.503/0.014	3.678/< 0.001	3.938/< 0.001	5.575/< 0.001

DISCUSSION

The specific effects of two different surgical methods, microscopy alone and microscopy combined with neuroendoscopy, on depression, anxiety, cognitive function and quality of life in patients with intracranial aneurysm rupture and bleeding. The results revealed the significant advantages of combined treatment. Intracranial aneurysms often appear as fusiform or saccular expansions[8,9], and are often found at the bifurcation of cerebral arteries and the main trunk of cerebral arteries. When the pressure on the intracranial artery wall increases sharply and the high pressure exceeds the upper limit (≥ 180 mmHg), intracranial aneurysms are most likely to rupture and bleed due to the degeneration and necrosis of the smooth muscle cells in the middle layer of the vascular wall[10,11]. Once rupture occurs, it will cause severe cerebral hemorrhage, the disease progresses rapidly, and the mortality rate is high[12]. Due to the pain of the disease, the probability of anxiety and depression in patients with ruptured intracranial aneurysms is relatively high. Although there is some improvement after treatment, it is still a topic worthy of attention. Microsurgery and intravascular intervention are commonly used treatment methods. In the application, it is found that the recurrence rate of interventional treatment is high and the cost is high[13]. Because traditional microscopic surgery has great limitations in treatment, it does not have a good impact on the patient's postoperative recovery and prognosis of psychological health. In addition, anxiety and depression during the operation will affect the patient's treatment cooperation and compliance, and will also reduce the prognosis[14]. Therefore, the field of neurosurgery faces a series of urgent and important challenges, including how to significantly improve the successful treatment rate of patients with aneurysm rupture and bleeding to prolong their postoperative survival; how to more effectively improve the mental health of patients and reduce the psychological burden caused by the disease; and how to improve the quality of life of patients after discharge, promote their better integration into society, and increase the rate of social return, etc[15]. When microsurgery is combined with neuroendoscopy to treat intracranial aneurysm rupture and bleeding, neuroendoscopy, as an effective auxiliary means of conventional microsurgery, can effectively make up for the shortcomings of the microscope in terms of function[16]. Neuroendoscopy can clearly display the blind areas that cannot be displayed by the microscope, and can also clearly display the anatomical structure, thereby reducing the traction on the patient's brain tissue during the operation, thereby improving the effectiveness and safety of the operation to a certain extent[17]. In this study, from the perspective of improvement in depression and anxiety, the depression and anxiety scores obtained by the observation group were notably lower in comparison to those achieved by the control group after receiving combined microscopy and neuroendoscopy. This result shows that combined treatment can not only effectively solve the patient's physiological disease, but also provide greater support to the patient at the psychological level, reducing the psychological burden caused by the disease. We speculate that this may be related to the fact that combined treatment improves surgical accuracy, reduces surgical trauma and complications, and thus enhances the patient's confidence in treatment and hope for recovery[18]. Studies have shown that the combination of microscopy and neuroendoscopy for surgical treatment of intracranial aneurysms can clearly observe and display the exact location of the aneurysm, the aneurysm-bearing artery, and the small perforating arteries during surgery, so that timely adjustments can be made during surgery[19], which can reduce vasospasm caused by repeated exploration, improve surgical quality, and reduce the risk of complications[20]. This is consistent with our research speculation. There are also literature reports that traditional microsurgery often requires grinding of the anterior clinoid process to obtain a larger field of view, but at the same time increases the risk of surgery. If a neuroendoscope is used to assist, it can avoid blind grinding of the anterior clinoid process that leads to aneurysm rupture, which in turn causes irreparable damage[21]. The study of Ferreira et al[22] also proved that neuroendoscopes can be widely used in various hemorrhagic cerebrovascular diseases, and have obvious advantages in the treatment of hypertensive cerebral hemorrhage. Neuroendoscopes can be used directly for clipping in some aneurysms, but in complex aneurysms, microscopes are still needed. In terms of cognitive function, the assessment scores of cognitive function for the observation group were significantly elevated compared to those of the control group, reinforcing the beneficial impact of the combined treatment regimen on enhancing cognitive abilities among patients suffering from intracranial aneurysm rupture and subsequent bleeding. The placement of a neuroendoscope can better observe the important arterial branches and deep perforating arteries, and timely detect misclipping or incomplete clamping and make adjustments[23]. Our analysis shows that microscope combined with neuroendoscopic treatment can more clearly display the lesion site and its surrounding structures, which helps the surgeon to operate more accurately during the operation[24], reducing damage to the surrounding normal brain tissue, thereby protecting the patient's cognitive function. Even more accurate studies have shown that neuroendoscopy combined with a microscope can not only separate the lateral fissure under the microscope to reduce damage, but also make up for the blind spot of the microscope field of view, observe the hematoma cavity and brain tissue under direct vision, and remove the hematoma as much as possible without damaging the brain tissue[25]. From the perspective of improving the quality of life, after undergoing treatment, the observation group exhibited notably higher scores on the quality of life assessment compared to the control group, underscoring the positive influence of the treatment on enhancing the patients' quality of life. This shows that combined treatment can not only effectively control the disease, but also significantly improve the patient's daily living ability and social function, and improve their overall quality of life. We believe that this is mainly due to the combined effects of combined treatment in reducing surgical trauma, shortening recovery time, and improving the patient's psychological state[26,27]. Through appropriate treatment, patients can gradually return to a normal rhythm of life, participate in meaningful activities, and increase the joy and satisfaction of life[28]. The reason why neuroendoscopy can play a huge and unique advantage is that some studies believe that with the improvement of surgeons' skills and experience, the continuous expansion of endoscopic three-dimensional field of view, the continuous innovation of endoscopic aneurysm clipping devices, and the widespread promotion of endoscopic fluorescein angiography and simulated endoscopy, etc[29], neuroendoscopy is showing more and more potential and advantages in the field of microsurgical treatment of aneurysms. For patients with good general physical condition, it is particularly important to actively adopt microsurgical treatment in the early stage, which can effectively prevent the re-rupture and bleeding of cerebral aneurysms[30]. The combined surgery of microscopy and neuroendoscopy has shown obvious advantages in the treatment of patients with intracranial aneurysm rupture and bleeding. It can not only control the disease more effectively, but also give patients greater improvements in depression and anxiety, cognitive function and quality of life. Therefore, we recommend that in clinical practice, for patients with intracranial aneurysm rupture and bleeding who meet surgical indications, the treatment plan of microscopy combined with neuroendoscopy should be given priority. Of course, further research is still needed in the future to explore the long-term effects and possible risks of this treatment method.

CONCLUSION

Surgical treatment combined with microscopy and neuroendoscopy has a significant positive effect on the mental health, cognitive function and overall quality of life of patients with intracranial aneurysm rupture and bleeding, can shorten the operation time and treatment time, and provides a new strategic reference for clinical treatment.