Carotid Artery-posterior Communicating Artery Aneurysm Research Articles

Anatomical Justification of Extradural Resection of the Anterior Clinoid Process.

Objective The study aimed to provide neuroanatomical justification of the extradural resection of the anterior clinoid process (ACP). Material and Method Using a cross-sectional study design, 47 cranial computed tomography (CT) scans were examined. There were 31 (65.96%) females aged 28 to 79 years. The measured dimensions were ACP length and width, and optic strut (OS) width. Index (i acp ) was measured as the ratio of ACP width to ACP length. The ACP volume and working operating field (WOF) volume were measured using Syngo.via Siemens program. The percentage expansion of WOF after removal of the ACP was estimated on 5 fixed human cadaver heads with the exoscope VITOM 3D. The possibilities of the combined approach were demonstrated in a clinical case. Results The mean ACP lengths were 11.31 ± 2.76 and 11.54 ± 2.86 mm, on the right and left, respectively. The mean ACP widths were 7.70 ± 1.66 and 7.64 ± 1.67 mm, on the right and left, respectively. Average i acp was 0.67 (minimum 0.45; maximum 0.90). The width of the OS varied in the range from 1.37 to 4.75 mm. The average volume of right ACP was 0.71 ± 0.16 cm 3 , right WOF was 3.26 ± 0.74 cm 3 , left ACP was 0.71 ± 0.15 cm 3 , left and WOF was 3.20 ± 0.76 cm 3 . Removal of the right ACP expanded the right WOF by 22.21 ± 3.88%, and left ACP by 22.78 ± 5.50%. There was an approximately 25% increase in the WOF from the cadaveric dissections. Taking into account the variability of the ACP and OS, we proposed our own surgical classification of complicated (i acp ≥ 0.67; medium OS 2.5 mm ≤ 4.0 mm; wide OS ≥ 4.0 mm; ACP with pneumatization) and uncomplicated ACP (i acp 0.45 ≤ 0.67 mm; i acp ≤ 0.45; narrow OS ≤ 2.5 mm; ACP without pneumatization). Using this classification, we developed an algorithm for ACP dissection and removal. This was piloted in a clinical case of microsurgical clipping of a left internal carotid artery-posterior communicating artery aneurysm via the left minipterional approach. Conclusion Extradural removal of ACP expands the WOF by approximately 25%, it helps neurosurgeons to improve proximal vascular control and avoid complications, and expands the range of indications for neurosurgical interventions in the skull base area.

Presence of intra-aneurysmal thrombi with delayed coil migration after embolization of an aneurysmal subarachnoid hemorrhage: illustrative case.

Coil migration is a rare, but notable complication of endovascular treatment. Risk factors include communicating segment aneurysms, aneurysmal shape, and technical factors. Although cerebral blood flow obstruction caused by early coil migration requires urgent coil removal, delayed coil migration is often asymptomatic, making it difficult to determine a treatment strategy. A 47-year-old woman was referred to the institute with acute-onset headache. She was diagnosed with subarachnoid hemorrhage due to rupture of the right internal carotid artery-posterior communicating artery aneurysm and underwent endovascular coil embolization. Following the procedure, the patient showed no obvious complications; however, 14 days later, images showed coil migration to the distal side, leading to surgical removal. Right frontotemporal craniotomy was performed, and the remaining coil was removed. The aneurysm was clipped again, and blood flow was confirmed. The patient was discharged 12 days after the craniotomy with transient oculomotor nerve palsy. At the 15-month follow-up, there was no aneurysm recurrence and the oculomotor nerve palsy showed improvement. Retrieval of the migrated coil by craniotomy is an effective remedial measure; however, intraoperative complications are common. Early detection, established protocols, and prompt treatment decisions are important for preventing undesirable outcomes.

Endovascular Treatment for Posterior Communicating Artery Aneurysms with Oculomotor Nerve Palsy.

Coil embolization for the treatment of internal carotid artery-posterior communicating artery aneurysms (PComAAn) associated with oculomotor nerve palsy (ONP) remains controversial in terms of the therapeutic effect to improve ONP. Patients with PComAAn treated in our hospital were retrospectively analyzed to evaluate the effectiveness of coil embolization on ONP. Twenty-three patients who had coil embolization for PComAAn with ONP were included in the analysis. In the evaluation of postoperative outcome of ONP, complete resolution of all symptoms was considered as a total recovery. ONP with a few residual symptoms that are stable and not disabling was considered as a subtotal recovery and that with only a slight improvement as a partial recovery. Preoperative ONP was complete palsy in 14 and partial palsy in nine cases. The mean maximum diameter of the aneurysms was 9.1 ± 3.5 mm (3-17 mm), and the mean time from the onset to treatment was 46.3 ± 98.4 days (0-300 days). The embolization state immediately after the procedure was complete occlusion in seven, neck remnant in eight, and body filling (BF) in eight cases. Total recovery was observed in nine, subtotal recovery in 11, and partial recovery in three cases. The mean time to any improvement in ONP was 6.0 ± 6.0 months (0.5-25 months). Comparing 20 cases with total plus subtotal recovery and three cases with partial recovery, five (25.0%) and three (100%) cases showed BF immediately after the procedure, respectively, which was statistically significant (P = 0.015). The analysis indicated that coil embolization for the treatment of PComAAn with ONP resulted in satisfactory recovery of ONP in 87% of the cases and the outcome of aneurysm embolization was related to improvement in ONP.

Risk factors for recurrence after coil embolization for internal carotid artery-posterior communicating artery aneurysms

BackgroundUse of coil embolization for internal carotid artery-posterior communicating artery aneurysms (IC-PC ANs) has been increasing. However, the recurrence rate after embolization is rather high compared to that after surgery. The aim of this study was to evaluate the factors related to recurrence after coil embolization for IC-PC ANs. MethodsA total of 69 patients with IC-PC ANs treated with coil embolization between 2013 and 2019 were retrospectively enrolled, and we evaluated whether the aneurysms recurred after embolization. The patients were divided into two groups (no-recurrence group and recurrence group), and the relationships of several patient or aneurysm characteristics and treatment-related information with aneurysm recurrence were examined. ResultsTwenty patients (29%) developed aneurysm recurrence. There were significant differences in dome size (5.19 mm/6.48 mm, p = 0.01), neck width (3.25 mm/4.23 mm p = 0.009), aneurysm volume (47.5 mm3/120 mm3, p = 0.003), and Pcom diameter (1.11 mm/1.96 mm p = 0.005) between the two groups. Pcom diameter was the independent risk factor for recurrence (odds ratio: 3.52, 95%CI 1.43–8.69, p = 0.006). The cutoff for Pcom diameter as the factor related to recurrence was 1.79 mm, with sensitivity of 60% and specificity of 83.7%. ConclusionIn this study, dome size, neck width, aneurysm volume, and Pcom diameter were associated with recurrence after coil embolization for IC-PC ANs. In particular, Pcom diameter could be an independent risk factor for recurrence.

Surgical Technique for Tentorium Resection and Oculomotor Nerve Mobilization during Internal Carotid Artery-Posterior Communicating Artery Aneurysm Clipping

Introduction: Internal carotid artery-posterior communicating artery aneurysms (ICPCANs) are occasionally located under the anterior petroclinoid fold (tentorium). The tentorium must be resected to achieve safe and secure clipping of the ICPCAN. The surgeon performing the procedure must be careful not to damage the oculomotor nerve, which is usually located behind the aneurysm, to ensure that the patient's oculomotor function is preserved. In this article, we presented a surgical technique for the tentorium resection and oculomotor nerve mobilization during an ICPCAN clipping intervention. Additionally, the clinical features of the patients who underwent the procedure have been described.

The Hybrid Neurosurgeon: The Japanese Experience.

In Japan, hybrid neurosurgeons who perform both open surgical clipping as well as endovascular embolization for the treatment of intracranial aneurysms are common. Although many Japanese neurosurgeons can perform surgical clipping of middle cerebral artery aneurysms or internal carotid artery-posterior communicating artery aneurysms and coil embolization of cerebral aneurysms using simple techniques-only a limited number of neurosurgeons are able to perform surgical clipping and endovascular procedures for anterior communicating artery aneurysms, paraclinoid, or posterior circulation aneurysms using both treatment modalities equally and safely. The senior author's personal experience of more than 500 cases each of surgical clipping and endovascular embolization over the past 25years included 110 cases of basilar tip aneurysms and 104 cases of paraclinoid internal carotid artery (ICA) aneurysms. The safety and efficacy of both treatments appears to be the same, while the durability of surgical clipping is superior to that of endovascular embolization. Among the 110 basilar tip aneurysms, 18 patients were treated by surgical clipping and 94 were treated by endovascular embolization. The initial results of endovascular therapy seemed to be better than those of surgical clipping, although the rate of retreatment was higher. Among the 104 cases of paraclinoid ICA aneurysm, 23 patients were treated by surgical clipping and 81 were treated by endovascular embolization. The results of both treatments seemed to be same, while surgical clipping had apparently good long-term durability. Over the past 15years, the frequency of surgical clipping for basilar tip aneurysms has decreased, and the procedure may eventually be abandoned for this type of aneurysm. However, surgical clipping still offers several advantages in the treatment of paraclinoid aneurysms. Hybrid neurosurgeons can make reasonable decisions concerning the choice of treatment for cerebral aneurysms, as they perform both treatments and understand the benefits and drawbacks of each modality.

A Comparative Study of Intraoperative Application of Fluorescein and Indocyanine Green Videoangiography in Intracranial Aneurysm Clipping Surgery

To compare the application of fluorescein videoangiography (FL-VA) and indocyanine green videoangiography (ICG-VA) in intracranial aneurysm surgery. A total of 65 patients who underwent aneurysm clipping in our hospital from January 2019 to January 2020 were included in the study. FL-VA and ICG-VA were used during the surgery to determine whether the aneurysm is completely clipped and the artery bearing the aneurysm and the perforating artery around the aneurysm are unobstructed. All 65 patients underwent both FL-VA and ICG-VA intraoperatively after aneurysm clipping. FL-VA was applied first. In 30 cases, FL-VA and ICG-VA provided the same results. In 10 cases, FL-VA performed obviously better over ICG-VA in visualizing small perforating arteries (2 cases of internal carotid artery-posterior communicating artery aneurysms and 3 cases of anterior communicating artery aneurysm) and evaluating whether the aneurysm was completely clipped (3 cases of middle cerebral artery aneurysm, 1 case of internal carotid artery-posterior communicating artery aneurysms and 1 case of distal anterior cerebral artery aneurysm). In the remaining 25 cases, ICG-VA was repeatedly applied in a short period of time due to quick clearance of indocyanine green from the blood vessels, but this couldn't be done with FL-VA. Compared with ICG-VA, FL-VA can provide better visualization of perforating artery, and can determine whether the aneurysm was completely clipped more accurately. However FL-VA couldn't be repeatedly applied during a short period of time.

Evaluation of magnetic resonance angiography as a possible alternative to rotational angiography or computed tomography angiography for assessing cerebrovascular computational fluid dynamics.

The aim of this study was to conduct a flow experiment using a cerebrovascular phantom and investigate whether magnetic resonance angiography (MRA) could replace three-dimensional rotational angiography (RA) and computed tomography angiography (CTA) to construct vascular models for computational fluid dynamics (CFD). We performed MRA and 3D cine phase-contrast (PC) MR imaging with a silicone cerebrovascular phantom of an internal carotid artery-posterior communicating artery aneurysm with blood-mimicking fluid, and controlled flow with a flowmeter. We also obtained RA and CTA data for the phantom. Four analysts constructed vascular models based on the three different modalities. These 12 constructed models used flow information based on 3D cine PC MR imaging for CFD. We compared RA-, CTA-, MRA-based CFD results using the micro-CT-based CFD result as the criterion standard to investigate whether MRA-based CFD was not inferior to RA- or CTA-based CFD. We also analyzed the inter-analyst variability. Wall shear stress (WSS) distributions and streamlines of RA- or MRA-based CFD and those of micro-CT-based CFD were similar, but the vascular models and WSS values were different. Accuracy in measurements of blood vessel diameter, cross-sectional maximum velocity, and spatially averaged WSS was the highest for RA-based CFD, followed by MRA-based and CTA-based CFD using micro-CT-based CFD result as the reference. Except maximum velocity from CTA, all other parameters had good inter-analyst agreement using different modalities. The results demonstrated that non-invasive MRA can be used for cerebrovascular CFD models with good inter-analyst agreements.

Recurrent Risk of Posterior Communicating Artery-preserving Coil Embolization for Internal Carotid Artery-Posterior Communicating Artery Aneurysm

Recurrent Risk of Posterior Communicating Artery-preserving Coil Embolization for Internal Carotid Artery-Posterior Communicating Artery Aneurysm

Abstract WP75: Enhancement of Disturbed Flow is Involved in Recanalization After Complete Endovascular Coil Embolization of Internal Carotid Artery-Posterior Communicating Artery Aneurysms

Background and purpose: Although it is thought that hemodynamics is closely involved in recanalization after endovascular coil embolization of cerebral aneurysms, details are still not clear. Using computational flow dynamic (CFD) analysis, the aim of this study was to identify hemodynamic predictors specific to recanalization after complete coil embolization. Methods: We used patient-specific arterial geometries of 14 internal carotid artery-posterior communicating artery (ICPC) aneurysms after coil embolization. Pulsatile blood flow was simulated using ANSYS-CFX, based on the Navier-Stokes equations for incompressible fluid. As the pulsatile inlet boundary condition, we used a typical flow velocity waveform of internal carotid artery that was scaled based on the patient-specific mean velocity. In order to eliminate the influence due to aneurysm size between both groups, multivariate logistic regression analysis was performed using aneurysm size and each hemodynamic metric as independent variables to find hemodynamic predictors for recanalization after coil embolization. Results: With a follow-up of >1 year, 6 aneurysms were recanalized, and 8 cases were stable. Significant hemodynamic risk factors specific to recanalization were high values of metrics in association with disturbed flow, i.e. oscillatory shear index (OSI) [odds ratio (OR), 0.00115; 95% confidence interval (CI), 0.00102-0.00144; p = 0.017] and normalized transverse WSS (NtransWSS) (OR, 0.00103; 95%CI, 0.0010-0.00179; p = 0.043), but not flow rate of parent artery, aneurysmal mean velocity, or WSS magnitude-based metrics, including WSS and normalized WSS. Conclusions: These data suggest that enhanced disturbed flow plays a central role in recanalization after complete coil embolization of ICPC aneurysms. Imaging examinations at shorter intervals may be necessary if strong disturbed flow is observed in the aneurysm before surgery.

Bypass Revascularization Applied to the Posterior Cerebral Artery

The application of bypass procedures to the posterior cerebral artery (PCA) in combination with proximal clipping or trapping is a useful option for the treatment of complex posterior circulation aneurysms, especially those of the PCA. Because of its course around the midbrain through various cisterns, different approaches are required to access the PCA. The presented study analyzes a retrospective case series of bypass procedures to the PCA to investigate the relevant treatment strategies and their outcomes. Seven patients with bypass procedures to the PCA bypass were analyzed. The location of the aneurysms, approaches, site of anastomosis, bypass patency, pre- and postoperative modified Rankin Scale scores, and transient and permanent morbidity were assessed. Analyzed patients were treated for intracranial aneurysm located on the P2 (n= 3) or P3 (n= 2) of the PCA, bilateral vertebral artery dissecting aneurysm (n= 1) or internal carotid artery-posterior communicating artery aneurysm (n= 1). The following approaches were used: anterior temporal approach (n= 2), anterior temporal approach combined with subtemporal approach (n= 2), combined transpetrosal approach (n= 1), posterior interhemispheric approach (n= 1), and posterior interhemispheric approach with subtemporal approach (n= 1). All bypasses were patent. Permanent morbidity occurred in 2 patients via cognitive dysfunction (n= 1) and hemiparesis (n= 1). Bypass revascularization of the PCA territory is effective for the treatment of complex vascular lesions affecting the posterior circulation. To address the various surgical segments of the PCA, different approaches are required. Combined approaches allow access to the PCA proximal and distal from the lesion.

Anatomic Study of Posterior Communicating Artery in Computed Tomographic Image.

This study aims to provide an anatomic data of posterior communicating artery (PComA) and its anatomic relationship to the adjacent structures, so as to guide surgeons in the surgery of internal carotid artery-posterior communicating artery aneurysm clipping and sellar tumors resection without injuring the PComA. Computer topographic angiography images of 123 individuals were reviewed, and the measurements were done on coronal, sagittal, axial, and other user-defined planes after multiplanar reconstruction. Posterior communicating artery was classified in the reconstructed three-dimensional image, measured in proper planes, and located by the structures such as anterior clinoid process (ACP), posterior clinoid process (PCP), and sagittal midline. Six types of PComA were identified in this study based on its existence and origin. The initial part of PComA can be located by ACP, PCP, and sagittal midline based on some particular angles and distances. Posterior communicating artery varies in different individuals, and the radiologic study of it is an optimal way to analyze the variances. The anatomic relations between PComA and basic skull structures such as the ACP and PCP are especially important for neurosurgeons.

Generalized Auditory Agnosia following a Subarachnoid Hemorrhage; A case report

A 65-year-old male developed a subarachnoid hemorrhage(SAH) caused by a ruptured right internal carotid artery-posterior communicating artery aneurysm. Clipping of the aneurysm, removal of the hematoma, and external decompression were performed. Thereafter, he developed a bacterial meningitis after a spinal lumbar drainage that was done for the treatment of hydrocephalus. He was admitted to our hospital for rehabilitation 4 months after the onset of the SAH. He was still lethargic and delirious at the time of admission. He could not recognize spoken words, environmental sounds or music one month later, but was able to speak and understand the written words. He was diagnosed to have generalized auditory agnosia, based on almost normal pure tone audiometry, otoacoustic emission test, and ABR. Brain CT disclosed a right temporal and frontal lesions, but not in the left side. The eZIS and vbSEE analysis of the SPECT images disclosed a lesion in the left Heschl's transverse gyrus that could not be detected on CT. We emphasized that the detailed analysis of the SPECT images is useful to demonstrate the lesions that can not be detected by CT. ACTA MEDICA NAGASAKIENSIA 57: 99－103, 2012

THE “NO-DRILL” TECHNIQUE OF ANTERIOR CLINOIDECTOMY

A high-speed power-drilling technique of anterior clinoidectomy has been advocated in all publications on paraclinoid region surgery. The entire shaft of the power drill is exposed in the operative field; thus, all neurovascular structures in proximity to any portion of the full length of the rotating drill bit are at risk for direct mechanical and/or thermal injury. Ultrasonic bone removal has recently been developed to mitigate the potential complications of the traditional power-drilling technique of anterior clinoidectomy. However, ultrasound-related cranial neuropathies are recognized complications of its use, as well as the increased cost of device acquisition and maintenance. A retrospective review of a cerebrovascular/cranial base fellowship-trained neurosurgeon's 45 consecutive cases of anterior clinoidectomy using the "no-drill" technique is presented. Clinical indications have been primarily small to giant aneurysms of the proximal internal carotid artery; however, in addition to ophthalmic segment aneurysms, selected internal carotid artery-posterior communicating artery aneurysms and internal carotid artery bifurcation aneurysms, and other large/giant/complex anterior circulation aneurysms, this surgical series of "no-drill" anterior clinoidectomy includes tuberculum sellae meningiomas, clinoidal meningiomas, cavernous sinus lesions, pituitary macroadenomas with significant suprasellar extension, other perichiasmal lesions (sarcoid), and fibrous dysplasia. A bony opening is made in the mid-to posterior orbital roof after the initial pterional craniotomy. Periorbita is dissected off the bone from inside the orbital compartment. Subsequent piecemeal resection of the medial sphenoid wing, anterior clinoid process, optic canal roof, and optic strut is performed with bone rongeurs of various sizes via the bony window made in the orbital roof. No power drilling was used in this surgical series of anterior clinoidectomies. Optimal microsurgical exposure was obtained in all cases to facilitate complete aneurysm clippings and lesionectomies. There were no cases of direct injury to surrounding neurovascular structures from the use of the "no-drill" technique. The surgical technique is presented with illustrative clinical cases and intraoperative photographs, demonstrating the range of applications in anterior and central cranial base neurosurgery. Power drilling is generally not necessary for removal of the anterior clinoid process, optic canal roof, and optic strut. Rigorous study of preoperative computed tomographic scans/computed tomographic angiography scans, magnetic resonance imaging scans, and angiograms is essential to identify important anatomic relationships between the anterior clinoid process, optic strut, optic canal roof, and neighboring neurovascular structures. The "no-drill" technique eliminates the risks of direct power-drilling mechanical/ thermal injury and the risks of ultrasound-associated cranial neuropathies. The "no-drill" technique provides a direct, time-efficient, and efficacious approach to the paraclinoid/ parasellar/pericavernous area, using a simplified mechanical route. This technique is applicable to any neurosurgical diagnosis and approach in which anterior clinoidectomy is necessary. It is arguably the gentlest and most efficient method for exposing the paraclinoid/parasellar/pericavernous region.

Operative strategy of complex internal carotid artery-posterior communicating artery aneurysms: Defensive effect on perioperative nerve injury

Background The two problems in treating intracranial aneurysm are the vascular reconstruction and brain protection, especially for complex internal carotid artery-posterior communicating artery (ICA-PComA) aneurysms. Objective To analyze the anatomic features and operative technique of complex ICA-PComA aneurysms, and investigate how to better protect the brain tissue. Design A retrospective case analysis. Setting Department of Neurosurgery, Dalian Central Hospital. Participants Totally 154 inpatients with ICA-PComA aneurysms were selected from the Department of Neurosurgery, Dalian Central Hospital from January 1998 to December 2006, including 19 cases (12.3%) of complex ICA-PComA aneurysms, 8 males and 11 females, 38-67 years of age. Informed contents for surgery and observation were obtained from all the patients or their relatives. Methods The clinical manifestations, including initial symptoms and Hunt&Hess grading, were observed. Corresponding strategies were selected for different types of ICA-PComA aneurysms. The patients were followed up at 3 months postoperatively. According to the results of Glasgow scoring, the curative effects were classified as good (4-5 points), bad (2-3 points) and dead (1 point). The results at discharge were taken as early results, whereas the follow-up results as late results. Main outcome measures Clinical manifestations and curative effects of the patients. Results All the 19 patients with ICA-PComA were involved in the analysis of results. For clinical manifestations, the initial symptoms were subarachnoid hemorrhage ( n =15), paralysis of oculomotor nerve ( n =3), and occasional attack ( n =1); The Hunt&Hess grading was grade ? in 4 cases, grade ? in 6 cases, grade ? in 6 cases, grade ? in 2 cases, and grade ? in 1 case. The curative effects were that aneurysm breakage and bleeding occurred in 6 cases perioperatively, uncomplete clipping of aneurysm in 2 cases and constriction of parent artery in 1 case. The complications were nervous and ischemic ones. The early outcome was good in 12 cases and bad in 7 cases, no one died. The late outcome was good in 17 cases and bad in 2 cases. Conclusion Complex ICA-PComA aneurysm is a particular aneurysm, thus different operative strategies should be adopted according to the conditions to improve the operative outcome and reduce ischemic and nervous injuries.

Application of keyhole approach in operation of intracranial aneurysms

To explore the operative technique and evaluate the effect of intracranial aneurysms via keyhole approach. Fifty-six intracranial aneurysm patients, 23 with anterior communicating artery (AcomA) aneurysm, 29 with posterior communicating artery (PcomA) aneurysm, and 4 with internal carotid artery-posterior communicating artery aneurysm, totally with 58 lesions, were treated by microsurgery, via supraorbital keyhole approach in 22 cases, pterional approach in 18, and transorbital approach in 16. Adjuvant endoscopy was used in 33 patients. Fifty-eight lesions of aneurysm were clipped in all the patients and no one died. No approach-related severe complication occurred. Bilateral PcomA aneurysms in 2 cases were clipped via unilateral keyhole approach. It is workable to treat intracranial aneurysms via keyhole approach. Keyhole approach not only reduces the operation-related trauma and shorten the operation time, but also obtains ideal results.

Surgical Indications to Maintain Quality of Life in Elderly Patients with Ruptured Intracranial Aneurysms

We performed a retrospective study to assess long-term outcomes in very old patients with ruptured intracranial aneurysms. The aim of the study was to develop guidelines for choosing surgical or conservative treatment with the goal of maintaining patients' quality of life. Between 1996 and 1999, 76 consecutive patients, aged 80 to 89 years, with ruptured intracranial aneurysms were treated at 18 participating centers. They were divided retrospectively into operated and nonoperated groups, and their preoperative characteristics and treatment outcomes were analyzed. Their Glasgow Outcome Scale and Barthel Index scores at least 2 years after the insult were recorded and analyzed from the perspective of their admission Hunt and Hess grade. Our retrospective review encompassed 5.9 years. Of the original 76 patients, 54 (71.1%) died, 13 (17.1%) had a good outcome (Barthel Index >or=60), and 9 (11.8%) had a poor outcome (Barthel Index <60). All patients with Hunt and Hess grades of III or higher at admission had poor outcomes irrespective of treatment. Of 32 patients with an initial Hunt and Hess grade of I or II, 19 (59.4%) underwent surgery; 9 of these patients (47.4%) had good outcomes. Conversely, of 13 nonoperated patients (40.6%), only 2 (15.4%) experienced good outcomes. In seven of the nine operated patients with good outcomes, the aneurysm was small (<12 mm) and located at the internal carotid artery-posterior communicating artery junction. Our results suggest that patients in the 9th decade of life with ruptured intracranial aneurysms can be considered for surgical treatment if they have a Hunt and Hess grade of I or II. The highest rate of favorable results was achieved in patients with small internal carotid artery-posterior communicating artery aneurysms.

Surgical Indications to Maintain Quality of Life in Elderly Patients with Ruptured Intracranial Aneurysms

We performed a retrospective study to assess long-term outcomes in very old patients with ruptured intracranial aneurysms. The aim of the study was to develop guidelines for choosing surgical or conservative treatment with the goal of maintaining patients' quality of life.Between 1996 and 1999, 76 consecutive patients, aged 80 to 89 years, with ruptured intracranial aneurysms were treated at 18 participating centers. They were divided retrospectively into operated and nonoperated groups, and their preoperative characteristics and treatment outcomes were analyzed. Their Glasgow Outcome Scale and Barthel Index scores at least 2 years after the insult were recorded and analyzed from the perspective of their admission Hunt and Hess grade.Our retrospective review encompassed 5.9 years. Of the original 76 patients, 54 (71.1%) died, 13 (17.1%) had a good outcome (Barthel Index >or=60), and 9 (11.8%) had a poor outcome (Barthel Index <60). All patients with Hunt and Hess grades of III or higher at admission had poor outcomes irrespective of treatment. Of 32 patients with an initial Hunt and Hess grade of I or II, 19 (59.4%) underwent surgery; 9 of these patients (47.4%) had good outcomes. Conversely, of 13 nonoperated patients (40.6%), only 2 (15.4%) experienced good outcomes. In seven of the nine operated patients with good outcomes, the aneurysm was small (<12 mm) and located at the internal carotid artery-posterior communicating artery junction.Our results suggest that patients in the 9th decade of life with ruptured intracranial aneurysms can be considered for surgical treatment if they have a Hunt and Hess grade of I or II. The highest rate of favorable results was achieved in patients with small internal carotid artery-posterior communicating artery aneurysms.