Abstract
Compared with endovascular techniques, clipping of ruptured cerebral aneurysms has been shown to associate with increased morbidity in several studies. Despite this, clipping remains the preferred option for many aneurysms. The objective of this study is to describe the reported adverse events of open repair of ruptured cerebral aneurysms and their impact on patient outcome. The PubMed, Embase and Cochrane databases were searched between June 1999 and June 2019 to identify original studies of at least 100 patients undergoing surgical repair of ruptured cerebral aneurysms and in which adverse event rates were reported. Thirty-six studies reporting adverse events in a total of 12,410 operations for repair of ruptured cerebral aneurysms were included. Surgical adverse events were common with 36 event types reported including intraoperative rupture (median rate of 16.6%), arterial injury (median rate of 3.8%) and brain swelling (median rate 5.6%). Only 6 surgical events were statistically shown to associate with poor outcomes by any author and for intraoperative rupture (the most frequently analysed), there was an even split between authors finding a statistical association with poor outcome and those finding no association. Even with modern surgical techniques, the technical demands of surgical aneurysm repair continue to lead to a high rate of intraoperative adverse events. Despite this, it is not known which of these intraoperative events are the most important contributors to the poor outcomes often seen in these patients. More research directed towards identifying the events that most drive operative morbidity has the potential to improve outcomes for these patients.
Highlights
Patients with ruptured cerebral aneurysms which are suitable for endovascular repair have been shown to have a reduced risk of death and dependency at 1 year when treated endovascularly compared with open surgical techniques [1, 2]
Whilst endovascular techniques have become increasingly used in open aneurysm surgery, open surgical repair remains the preferred modality for many aneurysms [2, 3]
Compared with the fast pace of innovation seen in endovascular techniques for coiling, only a small number of new technologies have been adopted in open aneurysm surgery since Yasargil developed the microscopic approaches used by the majority of surgeons today [61]
Summary
Patients with ruptured cerebral aneurysms which are suitable for endovascular repair have been shown to have a reduced risk of death and dependency at 1 year when treated endovascularly compared with open surgical techniques [1, 2]. As many as 43% of patients undergoing surgery for ruptured cerebral aneurysms will experience an immediate postoperative neurological deterioration [4] and in one series of subarachnoid haemorrhage treated with surgical clipping, 36% of the deaths and permanent disabilities were attributed to technical intraoperative complications [5]. The profile of adverse events is very different for surgery for unruptured cerebral aneurysms which have much lower morbidity due to more favourable operating conditions [6]. The aim of this review is to better describe the adverse intraoperative events that occur, in surgery for ruptured cerebral aneurysms which appear to cause significant morbidity for this group
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