Surgical Treatment Of Unruptured Aneurysms Research Articles

Vasospasm Following Surgical Treatment of Unruptured Aneurysms

Vasospasm Following Surgical Treatment of Unruptured Aneurysms

Early versus Delayed Microsurgical Clipping of Additional Unruptured Aneurysms in Patients with Aneurysmal Subarachnoid Hemorrhage

The optimal timing for the surgical treatment of additional unruptured aneurysms in patients with multiple aneurysms and aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Therefore, we analyzed the results of early versus delayed microsurgical treatment of unruptured aneurysms when multiple aneurysms were present in the setting of aSAH. The medical records from a consecutive, single-surgeon, 19-year experience of all patients with aSAH and additional unruptured aneurysms treated with a second surgery were reviewed retrospectively. Early treatment was defined as treatment within 30 days and delayed treatment as treatment more than 30 days after the initial surgery for aSAH. A total of 85 patients with aSAH and multiple aneurysms were identified. Early (n= 55; 65%) or delayed (n= 30; 35%) clipping was performed for additional unruptured aneurysms. Intraoperative rupture (P= 0.028), higher Fisher grade (P= 0.046), multiple additional unruptured aneurysms (P= 0.04), and large aneurysm size of either the ruptured aneurysm (P= 0.034) or unruptured aneurysm (P= 0.022) were significant factors favoring early treatment. Significant differences were not observed with respect to outcome (modified Rankin scale), unfavorable modified Rankin scale changes between the first surgery and last follow-up, aneurysm occlusion, and shunt-dependent hydrocephalus. No ruptures of untreated aneurysms during the follow-up course were observed. Both early and delayed surgical treatment of unruptured aneurysms in the setting of aSAH are safe. Factors prompting earlier intervention might include multiple additional aneurysms, larger aneurysms, and intraoperative aneurysm rupture, which could suggest a destabilized arterial wall. Delayed treatment is advisable for patients with a poor clinical presentation, greater underlying brain injury, and a swollen brain requiring decompressive craniectomy to allow time for recovery.

Management of severe internal carotid stenosis with unruptured intracranial aneurysm

To investigate the safety and feasibility of endovascular treatment for severe internal carotid artery stenosis (≥70%) with unruptured intracranial aneurysms. We retrospectively reviewed 213 cases with severe stenosis or occlusion of internal carotid artery, and those patients had been treated at Peking University Third Hospital, between January 2012 and July 2015. In the study, 14 (6.6%) cases were coexistence with unruptured intracranial aneurysms. The medical records, imaging data, treatment and prognosis were analyzed. There were 15 aneurysms (11 after the stenosis, 1 before the stenosis, and 3 in the other drainage basin) in those 14 patients with severe stenosis or occlusion of internal carotid artery. One of the 14 patients underwent carotid endarterectomy, and the 11 patients were successfully implanted with an internal carotid stent (residual stenosis 0-30%, mean 6.4%). Two patients with internal carotid artery stenosis remained untreated. One of them had complete occlusion of the initial segment of the internal carotid artery and was not possible to be treated, and the other patient refused to treat with internal carotid stenosis. The sizes of aneurysms were 1.0-7.0 mm, with an average of (2.8±1.5) mm. Three cases were treated with stenosis and aneurysms treated at the same time, and stent assisted coil embolization was performed in all the aneurysms, including 1 case that treated aneurysm before the stenosis. One patient refused surgical treatment of unruptured aneurysm, and no treatment was given to 10 patients who had small unruptured aneurysms (<5.0 mm). No perioperative complications were observed during the perioperative period. Three cases were lost with the follow-up, and the other 11 patients were followed up for 15-55 months, with a median of 37 months, and had good prognosis. Our results suggest that patient coexistance with severe internal carotid stenosis and unruptured intracranial aneurysms should be treated individually according to the location and size of aneurysms. Moreover, the presence of a small intracranial aneurysm (<5.0 mm) does not seem to increase the risk of endovascular stenosis in patients with severe internal carotid stenosis.

Aneurysms of the pericallosal artery (literature review)

The study objective is to analyze scientific sources describing features of surgical treatment of aneurysms of the pericallosal artery (APcA) and unfavorable outcome risk factors.Materials and methods. The analysis included 4 russian and 57 foreign sources.Results and conclusion. Conservative treatment of patients with ruptured APcAs yields unsatisfactory results due to high mortality. Data on surgical outcomes of ruptured APcAs are contradictory: per some sources, they do not differ from results of treatment of cerebral aneurysms of other locations; another sources state that they are worse. The main risk factors are severity per the Hunt–Hess scale ≥IV, large size of intracranial hematoma. Outcomes of surgical treatment of unruptured aneurysms are mostly favorable. Microsurgical clipping allows to achieve favorable results both for ruptured and unruptured APcAs. Due to deep APcA localization, the majority of revascularization surgeries can be performed only using intracranial-to-intracranial bypass. Extracranial-intracranial bypass in the anterior cerebral artery system is rarely performed. For surgical treatment, choice of its timeframe in critically ill patients (grade IV–V by the Hunt–Hess scale) causes difficulties: early surgery prevents repeated hemorrhages, while postponed surgeries eliminate the possibility of affecting this and other factors. There are arguments for preventive exclusion of APcA from blood flow even if its size is &lt;5 mm because of high frequency of APcA ruptures and more severe consequences. For combination of an unruptured APcA with a ruptured aneurysm in another location, either simultaneous exclusion of all aneurysms is performed or two-stage surgery with primary exclusion of the ruptured aneurysm, but the first approach is not always possible. Selection of optimal approach depends on the location of the aneurysm: pterional approach is used for clipping infracallosal aneurysms, variations of interhemispheric accesses – for exclusion of supracallosal aneurysms and aneurysms located at the genu of corpus collosum. Temporary pharmacological cardioplegia is considered a promising method which potentially can replace temporary APcA clipping.

Circumferential wall enhancement in evolving intracranial aneurysms on magnetic resonance vessel wall imaging.

Recent MR vessel wall imaging studies have indicated intracranial aneurysms in the active state could show circumferential enhancement along the aneurysm wall (CEAW). While ruptured aneurysms frequently show CEAW, CEAW in unruptured aneurysms at the evolving state (i.e., growing or symptomatic) has not been studied in detail. The authors quantitatively assessed the degree of CEAW in evolving unruptured aneurysms by comparing it separately to that in stable unruptured and ruptured aneurysms. A quantitative analysis of CEAW was performed in 26 consecutive evolving aneurysms using MR vessel wall imaging. Three-dimensional T1-weighted fast spin echo sequences were obtained before and after contrast media injection, and the contrast ratio of the aneurysm wall against the pituitary stalk (CRstalk) was calculated as the indicator of CEAW. Aneurysm characteristics of evolving aneurysms were compared with those of 69 stable unruptured and 67 ruptured aneurysms. The CRstalk values in evolving aneurysms were significantly higher than those in stable aneurysms (0.54 vs 0.34, p < 0.0001), and lower than those in ruptured aneurysms (0.54 vs 0.83, p < 0.0002). In multivariable analysis, CRstalk remained significant when comparing evolving with stable aneurysms (odds ratio [OR] 12.23, 95% confidence interval [CI] 3.53-42.41), and with ruptured aneurysms (OR 0.083, 95% CI 0.022-0.310). The CEAW in evolving aneurysms was higher than those in stable aneurysms, and lower than those in ruptured aneurysms. The degree of CEAW may indicate the process leading to rupture of intracranial aneurysms, which can be useful additional information to determine an indication for surgical treatment of unruptured aneurysms.

Unruptured cerebral aneurysms

The problem of high disability and mortality due to subarachnoid hemorrhage (SAH) from cerebral aneurysms has led to the fact that surgical treatment of unruptured aneurysms has been considered in Western Europe, Japan, and the United States as a method for prevention of subarachnoid hemorrhage for many years. The introduction of the so-called surgical SAH prophylaxis in Russia is a challenge that requires defining the principles of patient selection and choosing a treatment technique for unruptured cerebral aneurysms. The article highlights the modern approaches to treatment of asymptomatic unruptured cerebral aneurysms based on the concepts of aneurysm epidemiology and natural progression.

Surgical Treatment of Unruptured Aneurysms Reduces Mortality But Long-Term Follow-Up Needed

Surgical Treatment of Unruptured Aneurysms Reduces Mortality But Long-Term Follow-Up Needed

Impact of Surgical Treatment of Unruptured Aneurysms

To the Editor: In the June 2004 issue of Stroke , Britz et al1 provide us with a clear example of misleading information and nonscientific analysis. The credibility and authority enjoyed by Stroke , combined with a craving for any possible enlightenment on the management of unruptured intracranial aneurysms, strengthen the impact of such a publication and justify the necessity to critically review this work. I would like to rephrase the problem on which the authors focused: My hypothesis is that physicians tend to offer a preventive but risky treatment to patients who are most likely to benefit. I believe this hypothesis to be reasonable; in fact, this is all that was shown by the study. If we are to retrospectively compare patients who underwent operation to those who were denied surgery for the same condition, we may end up …

Intracranial vascular surgery

To review the recent literature on intracranial vascular surgery, to summarize the main findings, and to discuss the impact of these findings on clinical practice. Three areas of vascular neurosurgery literature have recently generated significant interest, controversy and heated debate: (1) The International Study of Unruptured Intracranial Aneurysms studied the natural history and treatment options of unruptured aneurysms, and reported surprisingly low aneurysm rupture rates for small asymptomatic aneurysms. The study also reported favorable morbidity rates for endovascular treatment compared with surgical treatment of unruptured aneurysms. (2) The International Subarachnoid Aneurysm Trial compared endovascular and surgical treatments for ruptured intracranial aneurysms. The study concluded that the outcome in terms of survival free of disability at one year was significantly better with endovascular coiling. (3) The Intraoperative Hypothermia for Aneurysm Surgery Trial compared intraoperative hypothermia and normothermia for potential neuroprotection during neurovascular procedures. Preliminary results suggest no difference between the treatments. The International Study of Unruptured Intracranial Aneurysms and the International Subarachnoid Aneurysm Trial have provided data on the natural history of unruptured intracranial aneurysms and on the morbidity and mortality of surgical and endovascular treatments for intracranial aneurysms. Although morbidity rates of endovascular therapy compare favorably with those of surgery, long-term data on the efficacy of endovascular coiling of aneurysms are needed to assess the overall risk-benefit ratio of these therapies.

Stratification of outcome for surgically treated unruptured intracranial aneurysms.

The combination of low anticipated rupture rates for many unruptured aneurysms, better delineation of treatment risks, and the availability of alternative modalities of treatment have led to heightened scrutiny of the surgical management of unruptured intracranial aneurysms. Most reports to date have provided aggregate data concerning surgical treatment risks. This study was performed to better delineate risk estimates for the surgical treatment of patients with unruptured intracranial aneurysms according to a patient's risk profile with regard to age, aneurysm location, and aneurysm size. We studied 493 patients who were treated with surgical clipping of 604 unruptured saccular aneurysms. Information regarding aneurysm size, location, patient age, and 6-month or greater outcome were gathered prospectively from 1992 to 1999. Multivariate analysis was performed to identify independent risk factors for outcome. On the basis of the model, risk stratification curves were generated. In our series, the mean patient age was 53 years, and the mean lesion size was 8.8 mm. Lesion locations included the internal carotid artery (n = 259, 43%), the middle cerebral artery (n = 174, 28%), the anterior cerebral artery (n = 99, 17%), and the vertebrobasilar artery (n = 67, 11%). Multivariate analysis revealed that aneurysm size (beta = 0.122, P < 0.001), patient age (beta = 0.0308, P < 0.05), and vertebrobasilar location (beta = 1.37, P = 0.0080) were independently associated with high risk of poor outcome or death. Small aneurysms in the anterior circulation in young patients carry a very low treatment risk (approximately 1%), and treatment in elderly individuals (ages 70 years and older) with large lesions (greater than 10 mm), carries a significant risk of poor outcome (5% in the anterior circulation, 15% in the posterior circulation). The nomograms generated by this study should be particularly useful in discussing with patients the risks and benefits of surgical treatment of unruptured aneurysms.

Stratification of Outcome for Surgically Treated Unruptured Intracranial Aneurysms

OBJECT The combination of low anticipated rupture rates for many unruptured aneurysms, better delineation of treatment risks, and the availability of alternative modalities of treatment have led to heightened scrutiny of the surgical management of unruptured intracranial aneurysms. Most reports to date have provided aggregate data concerning surgical treatment risks. This study was performed to better delineate risk estimates for the surgical treatment of patients with unruptured intracranial aneurysms according to a patient’s risk profile with regard to age, aneurysm location, and aneurysm size. METHODS We studied 493 patients who were treated with surgical clipping of 604 unruptured saccular aneurysms. Information regarding aneurysm size, location, patient age, and 6-month or greater outcome were gathered prospectively from 1992 to 1999. Multivariate analysis was performed to identify independent risk factors for outcome. On the basis of the model, risk stratification curves were generated. RESULTS In our series, the mean patient age was 53 years, and the mean lesion size was 8.8 mm. Lesion locations included the internal carotid artery (n = 259, 43%), the middle cerebral artery (n = 174, 28%), the anterior cerebral artery (n = 99, 17%), and the vertebrobasilar artery (n = 67, 11%). Multivariate analysis revealed that aneurysm size (β = 0.122, P < 0.001), patient age (β = 0.0308, P < 0.05), and vertebrobasilar location (β = 1.37, P = 0.0080) were independently associated with high risk of poor outcome or death. CONCLUSION Small aneurysms in the anterior circulation in young patients carry a very low treatment risk (approximately 1%), and treatment in elderly individuals (ages 70 years and older) with large lesions (greater than 10 mm), carries a significant risk of poor outcome (5% in the anterior circulation, 15% in the posterior circulation). The nomograms generated by this study should be particularly useful in discussing with patients the risks and benefits of surgical treatment of unruptured aneurysms.

Surgical management of unruptured aneurysms: prognostic indicators

BACKGROUND The treatment of unruptured aneurysms (UA) remains controversial. Therefore, it has become necessary to define various prognostic indicators in the surgical treatment of unruptured aneurysms not associated with previously ruptured aneurysms. METHODS During a 6-year period, 78 unruptured aneurysms were managed. The results of management were retrospectively reviewed to define the prognostic indicators. RESULTS There were 104 patients with unruptured aneurysms who underwent surgical treatment. Seventy-five patients without previous subarachnoid hemorrhage (SAH) were selected for data analysis. Eighty-seven percent of the aneurysms were on the anterior circulation. The most common location was the middle cerebral artery (MCA) followed by the posterior communicating artery (PCom), ophthalmic artery, and anterior communicating artery (ACom). Six percent were found on the basilar artery. The mean size of aneurysms was 12.5 mm (range = 3–30 mm, SD = 7.4). At surgery, rupture of the aneurysm was encountered in eight cases with temporary control of the parent vessel being required in 31 procedures. In four cases, intraoperative angiography warranted clip reapplication. The Glasgow Outcome Scale (GOS) was used as an outcome measure. Surgical treatment resulted in good outcome (GOS 1) in 87% and 10.7% had fair outcome; 2.3% were in GOS 3 (severe disability) at 6 month follow-up. There was no mortality. Logistic regression identified significant relationships between GOS and intraoperative rupture ( p < 0.0002), rupture and size ( p < 0.003), and size and age ( p < 0.01). CONCLUSIONS Large size aneurysms were associated with intraoperative rupture, which had a strong correlation with poor outcome. Increased age showed a linear relationship with the size of the aneurysm. Overall results of treatment for UA are gratifying. There was no mortality. Early diagnosis and surgical extirpation of UA may reduce both intraoperative difficulties as well as poor outcome probability.

Basal brain injury in aneurysm surgery.

The goal of this study was to determine the frequency of lesions in the basal frontotemporal area that were related to surgical damage to the brain tissue. A prospective series of 101 patients with ruptured intracranial aneurysms were examined with high-field magnetic resonance imaging, 2 to 6 years (mean, 3.3 yr) after early surgery. Lesions in the basal frontotemporal region, on the side of the pterional approach, were observed for 36 patients. These lesions were not visible in computed tomographic scans obtained pre- or postoperatively or 3 months after subarachnoid hemorrhage. Patients with ruptured aneurysms in the anterior communicating artery exhibited fewer of these lesions than did patients with aneurysms in the internal carotid artery or middle cerebral artery; this difference was not statistically significant. The age of the patient, the duration and depth of hypotension, the amount of blood or ventricular enlargement in pre- and postoperative computed tomographic scans, and the incidence and severity of angiographic vasospasm in pre- and postoperative angiograms did not predict the existence of these lesions. The clinical conditions of the patients, as assessed using the Glasgow Outcome Scale, at 3 months after surgery and at the time of magnetic resonance imaging did not predict the existence of these lesions. Nine of the 10 patients who underwent surgical treatment of unruptured aneurysms on the contralateral side exhibited no signs of tissue damage. Surgical treatment of ruptured intracranial aneurysms seems to cause damage in the basal frontotemporal region in one-third of patients. The significance of these lesions remains unclear.

The detection and management of unruptured intracranial aneurysms.

The incidence of subarachnoid haemorrhage (SAH) is 6-8 per 100 000 person years, peaking in the sixth decade. SAH, mostly due to rupture of an intracranial aneurysm, accounts for a quarter of cerebrovascular deaths. Aneurysms increase in frequency with age beyond the third decade, are 1.6 times more common in women and are associated with a number of genetic conditions. Prospective autopsy and angiographic studies indicate that between 3.6 and 6% of the population harbour an intracranial aneurysm. Studies have found an increased rate of SAH in first degree relatives of SAH patients (relative risk 3.7-6.6). In affected families, the most frequent relationship between sufferers is sibling to sibling. The rupture rate of asymptomatic aneurysms was thought to be 1-2% per annum, but the recent International Study of Unruptured Intracranial Aneurysms found that the rupture rate of small aneurysms was only 0.05% per annum in patients with no prior SAH, and 0.5% per annum for large (>10 mm diameter) aneurysms and for all aneurysms in patients with previous SAH. Non-invasive tests such as magnetic resonance angiography (MRA), computed tomographic angiography (CTA) and transcranial Doppler (TCD) have been advocated as alternatives to intra-arterial digital subtraction angiography to screen for aneurysms. Although all are promising techniques, the quality of data testing their accuracy is limited. Overall reported sensitivity for CTA and MRA (TCD is poorer) was 76-98% and specificity was 85-100%, but many subjects had an aneurysm or recent SAH, which could overestimate accuracy. CTA and MRA are much poorer methods for the detection of aneurysms <5 mm diameter, which account for up to one-third of unruptured aneurysms. Elective surgical clipping of asymptomatic aneurysms has a morbidity of 10.9% and mortality of 3. 8%. Treatment of aneurysms by Guglielmi coils, for which there is less long-term follow-up available, has a 4% morbidity and 1% mortality, but only achieves complete aneurysm occlusion in 52-78% of cases. There has been interest in screening for aneurysms, but the indication for, and cost effectiveness of screening are unclear because aneurysm prevalence varies, rupture rate is low, non-invasive imaging tests are not yet accurate enough to exclude small aneurysms and the morbidity and mortality for elective surgical treatment of unruptured aneurysms is high. There may be a limited role for investigation of high risk subgroups. Ideally, screening in such subgroups should be tested in a randomized trial. The avoidance of risk factors for aneurysms such as smoking, hypertension and hypercholesterolaemia should be part of the management of at-risk subjects.

O-10-137 - Surgical treatment of unruptured aneurysms during the past 20 years

Analyser, à partir d’une série rétrospective de 48 patients présentant des crises d’épilepsie associées à un ou plusieurs cavernomes supratentoriels, l’histoire des crises et leur devenir en fonction de la prise en charge médicale et chirurgicale.Les patients ont été divisés en 2 groupes, selon les données cliniques : 21 patients présentaient une crise unique ou des crises rares (groupe A) et 27 patients une épilepsie pharmacorésistante (groupe B). Tous les patients ont reçu un traitement antiépileptique et 35 patients ont été opérés : 12 patients du groupe A et 23 patients du groupe B. Une exploration SEEG a été réalisée chez 8 patients du groupe B. Ont été réalisées une lésionectomie seule (16 cas), une résection élargie au tissu périlésionnel (7 cas) ou une résection associée à une cortectomie (12 cas).L’histoire naturelle des crises différait d’un groupe à l’autre : l’âge moyen au début des crises était de 25 ans chez les patients du groupe B et 33 ans chez ceux du groupe A (p < 0,05), les crises étaient partielles chez tous les patients du groupe B et chez 8 des patients du groupe A (p < 0,05). La fréquence et la périodicité des crises étaient également variables chez un même patient. Des rémissions de plusieurs années sous traitement médical étaient observées. Le cavernome était de localisation temporale chez 17 patients du groupe B et chez 4 patients du groupe A (p < 0,01).Chez les patients du groupe A, l’évolution des crises était favorable après chirurgie ou après traitement médical seul (disparition des crises chez 7 des 12 patients opérés, et chez 5 des 7 patients non opérés). Chez ceux du groupe B, le devenir des crises était meilleur après chirurgie qu’après traitement médical seul (17 des 23 patients opérés étaient en classe I d’Engel, alors que chez 3 des 4 patients non opérés les crises persistaient malgré une polythérapie médicamenteuse).La variabilité de la gravité des crises d’un patient à l’autre et chez un même patient suggère une attitude adaptée. En cas de crise unique ou de crises rares, la résection du cavernome est justifiée mais son bénéfice sur les crises ne paraît pas supérieur à celui du traitement médical seul. En cas d’épilepsie partielle pharmacorésistante, une exploration préopératoire spécialisée suivie d’une exérèse élargie ou d’une cortectomie associée, surtout en région temporale, est suivie de très bons résultats sur les crises. Mais l’évaluation des résultats doit tenir compte à la fois des modalités chirurgicales, du traitement médical et de l’histoire individuelle des crises.To review, from a retrospective series of 48 patients presenting with seizures associated with one or more supratentorial cavernoma(s), the natural history of the seizures and outcome according to medical and surgical treatment.Patients were divided into two groups: group A included patients presenting with a single seizure or rare seizures (n = 21), and group B patients having intractable epilepsy (n = 27). All received antiepileptic drugs and 35 were operated on (12 in the group A and 23 in the group B). Stereo-EEG was performed in 8 patients in group B. Surgery included lesionectomy alone (n = 16), resection of the cavernoma and perilesional tissue (n = 7) or tailored corticectomy including the cavernoma (n = 12).The natural history of seizures was different in the two groups: mean age at seizure onset was 25 years in group B and 33 years in group A (p < 0.05), seizures were partial in all patients in group B and 8 patients in group A (p < 0.05). Seizure frequency and periodicity also varied. Prolonged seizure-free periods were observed. The cavernoma was temporal in 17 patients in group B and 4 patients in group A (p < 0.01).In group A, seizure outcome was favorable following surgery or with antiepileptic medication only (7 patients out of 12 operated were seizure-free, as were 5 out of 7 non-operated). In group B, seizure outcome was better after surgery than with medication only (17 patients out of 23 operated were in Engel's Class I, while 3 patients of 4 non-operated patients had persisting seizures despite antiepileptic polytherapy).Variations in seizure severity in patients harboring cavernomas suggest different therapeutic approaches. In case of unique or rare seizures, surgical resection of the cavernoma is appropriate, but benefits of surgery over antiepileptic medication in terms of seizure control remains unclear. Intractable epilepsy associated with cavernomas is better controlled after surgery rather than with medication only. In these patients, a detailed preoperative work-up is necessary and should be followed by wide resection associated or not with corticectomy, especially in the temporal lobe. Evaluation of outcome after surgery should consider the surgical strategy, antiepileptic medications and the patient's seizure history.

Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system

Surgical treatment of unruptured aneurysms is gaining increased support owing to the recently defined poor long-term natural history of these aneurysms. The benefit of treatment ultimately depends on the relative risk of subsequent aneurysm rupture in untreated patients versus the risk of surgery. To identify those patients at a higher risk from surgery, the authors reviewed the management of 172 patients with unruptured intracranial aneurysms treated at their institution. The size of the aneurysms ranged from 3 to 45 mm (mean 13.7 mm). Twenty-two patients (12.8%) had aneurysms in the posterior circulation, and 32 (18.6%) of these were giant aneurysms. Major morbidity occurred in 12 patients (6.9%) and five patients (2.9%) died. Multivariate logistic analysis of several risk factors revealed that aneurysm size and location had an independent correlation with surgical outcome and that patient age approached statistical significance. Patients presenting with ischemic cerebrovascular disease, in particular, did not have a higher risk of a poor outcome. A simple classification for predicting patients at high risk from surgical morbidity and mortality is proposed. Preoperative grading is based on the size and location of the aneurysm and patient's age. The lowest grade is given to young patients with small anterior circulation aneurysms, and the highest grade includes elderly patients with complex giant posterior circulation aneurysms. A retrospective analysis of this classification demonstrated a strong correlation with postoperative outcome. The incidence of poor outcome progressively increased with a higher grade, ranging from 0% in Grade 0 to 66.6% in Grade VI. An analysis of this classification on 50 consecutive surgically treated patients with unruptured aneurysms not included in the analysis also validated the predictive value of this system. Along with predicting outcome, this classification should provide a standardized format for comparison of results from different clinical centers as well as different therapeutic techniques (surgical vs. endovascular) without omission of significant risk factors found to influence outcome.

Patients with ruptured intracranial saccular aneurysms: clinical features and outcome according to the size.

In the prospective consecutive Danish Aneurysm Study 192 patients (19%) had a ruptured intracranial aneurysm (RA) with a maximum diameter < 5 mm (small). In 524 (51%) and 306 patients (30%) the size was 5-10 mm (medium) and 11-24 mm (large), respectively. More patients with large RA (35%) were unconscious more than 1 h after the bleeding and had more CT-visualized haematomas (49%) compared with the patients with small RA (28 and 34%) and medium RA (27 and 37%). After 2 years, more patients with small RA and medium RA had resumed their previous occupation (49 and 49%), regained a normal daily functional capacity (55%, 55%) and normal mental outcome (29 and 32%) compared with the patients with large RA (34, 44 and 23%). The mortality was 47, 39 and 51% for patients with small, medium and large RA, respectively. With also a very serious prognosis after rupture of aneurysms of 10 mm or less and even less than 5 mm we also recommend surgical treatment of unruptured aneurysms of these sizes.

Surgical management of unruptured intracranial aneurysms. Personal experience with 37 cases and discussion of the indications.

The authors report a series of 37 cases of unruptured aneurysms, admitted and operated upon over a 5 year period (1985-1990), which represents an incidence of 18% of the total number of aneurysm patients operated upon during this period. These unruptured aneurysms were discovered in 4 types of circumstances: 1) Associated with a ruptured aneurysm but treated in a second procedure (9 cases); 2) After a transient ischaemic attack (6 cases); 3) After a cerebral haemorrhage of a different origin (3 cases), 4) After the onset of various neurological symptoms other than SAH (19 cases). Giant aneurysms (over 2.5 cm in diameter) are excluded from this series. Overall these 37 patients harboured 52 aneurysms, and 1 patient was operated upon on both sides. 27 aneurysms (52%) were located on the right side, 15 (29%) on the left side, and 10 (19%) on the midline. In the immediate post operative period, 1 patient died (2.6%) and 8 patients (21%) presented various complications. The outcome at 6 months was: death 2.6%, moderately disabled 8%, good recovery 89%. The arguments in favour of, or against, the surgical treatment of unruptured aneurysms are discussed in view of the literature. In favour of prophylactic surgery are: 1) The rather poor overall outcome following aneurysm rupture (including deaths before admission); 2) The rather good outcome of surgery in published series of unruptured aneurysms. The data of the natural history of the unruptured aneurysm are more questionable: in this view, surgery seems to be recommended in young patients with an easily accessible aneurysm and being in a good clinical condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Rotatostereoradiography: A New Radiodiagnostic Method

The rotatostereoradiographic device uses an x-ray tube coupled with an image intensifier rotating through a 180 degree arc in 2.25 seconds. The rapidly rotating x-ray tube allows 180 degree-arc angiograms to be obtained with a single injection of contrast medium. Subtracted fluoroscopic angiograms can be viewed immediately after injection of the contrast medium with digital recording. These three-dimensional images are displayed on side-by-side monitors stereoscopically. The mortality and morbidity of subarachnoid hemorrhage can only be greatly reduced by surgical treatment of unruptured aneurysms and arteriovenous malformations detected by a wide survey of subarachnoid hemorrhage. Such a wide survey would be possible utilizing intra-arterial digital subtraction angiography via the ascending aorta and this new three-dimensional radiodiagnostic method. A fluoroscopic device must be used to allow easier manipulation of the catheter from the axillary or brachial artery.

Surgical treatment of unruptured aneurysms of the posterior circulation

With the ever-increasing number of intact aneurysms revealed by modern imaging, the options for their management are assuming great importance. While some knowledge has emerged as to their natural history and the results of surgical treatment of those in the anterior circulation, little information has been published concerning unruptured aneurysms arising from the posterior circulation. The authors report their experience since 1971 with 167 patients operated on for 179 unruptured vertebrobasilar aneurysms up to 25 mm in diameter. Overall, 160 aneurysms were treated by direct clip obliteration, while 19 were managed by alternative methods. Fifty-three patients (32%) had solitary aneurysms and the other 114 patients (68%) had multiple aneurysms or an associated arteriovenous malformation, which were commonly treated concurrently. Many of these coexisting vascular anomalies had ruptured in the recent or remote past, adding to the complexity of management and interpretation of specific surgical results related to the intact posterior circulation aneurysm. There were 78 documented postoperative complications including 23 systemic complications, seven postoperative hematomas, six brain injuries from retraction, five cases of aseptic meningitis, three instances of seizures, three wound infections, and three patients with hydrocephalus. Multiple complications occurred in 23 patients. Seventy-one of the patients with these untoward events recovered, without disability, with time or treatment. There were only six poor results and one death in the series, resulting in a 4.2% combined morbidity/mortality rate. However, since two of these poor outcomes and the single death were attributable to a coexisting aneurysm, the actual surgical morbidity related specifically to the posterior circulation aneurysm was only 2.4%. This experience suggests that non-giant, intact vertebrobasilar aneurysms can be obliterated surgically at a very low risk, and this treatment should eliminate the greater lifetime risk related to an unsecured aneurysm.