Long-term clinical outcomes of patients with aneurysmal subarachnoid hemorrhage in Yunnan Province / 南方医科大学学报

OBJECTIVE@#To investigate the clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) after surgeries in Yunnan Province.@*METHODS@#We retrospectively analyzed the demographic features, vascular risk factors, severity at admission, and aneurysm locations in 85 patients with aSAH receiving surgical interventions in Yunnan Province. All the patients were treated by aneurysm clipping or coiling and followed up for clinical outcomes and recovery of daily activities evaluated by modified Rankin Scale (mRS) and Activities of Daily Living (ADL) scale, respectively.@*RESULTS@#Thirty-four of the patients (40.0%) underwent aneurysm clipping and 51 (60.0%) underwent aneurysm coiling. During a median follow- up period of 66.23 months (IOR, 12.03 months), 84.7% of the patients had low mRS scores, and 78.8% lived independently. The WFNS grade at admission was significantly correlated with the follow-up mRS scores (95%: 1.48-19.09, =0.011) and ADL (95%: 2.55-28.77, 0.05), but the cost of hospitalization was significantly higher in coiling group than in the clipping group ( < 0.001).@*CONCLUSIONS@#Both aging and a high WFNS grade at admission are associated with a poor prognosis of aSAH, for which aneurysm clipping and coiling have similar long- term outcomes, but for patients with a high WFNS score, aneurysm clipping is favored over coiling in terms of health economics.

Clipado microquirúrgico de aneurisma asistido por endoscopia / Microsurgical clipping of aneurysm assisted by endoscopy

Introducción: Las complicaciones postoperatorias secundarias al compromiso inadvertido de una arteria normal durante el clipado de aneurismas son situaciones que pueden resultar catastróficas tanto para el paciente como para el neurocirujano tratante. El terreno de la neurocirugía vascular continúa siendo un desafío para la neuroendoscopia, sin embargo, al momento de realizar el control del clipado puede llegar a ser un elemento sumamente útil para evitar dichas complicaciones. Objetivos: El Objetivo del Trabajo es la presentación de un clipado de aneurisma coroideo anterior asistido mediante endoscopia. Materiales y métodos: Paciente femenina de 23 años que presenta hemorragia subaracnoidea (Fisher 2 y Hunt-Hess 2) secundaria a rotura de aneurisma comunicante anterior (ACA). En angiografía digital cerebral se evidencia a su vez aneurisma coroideo anterior derecho (ACoA). Mediante abordaje pterional derecho se realiza clipado microquirúrgico de ambos aneurismas. Para realizar revisión del clip en ACoA se utiliza endoscopio rígido de base de cráneo (0° y 45°). Se evidencia compromiso de arteria coroidea anterior por lo cual se realiza recolocación del mismo mediante guía endoscópica. Resultados: Se realizó clipado microquirúrgico asistido por endoscopia de ACA y ACoA. La paciente curso postoperatorio con vasoespasmo prolongado y tercer par derecho incompleto (ptosis y midriasis). Actualmente persiste solo la midriasis, resto del examen neurológico sin particularidades. Conclusión: El uso del endoscopio para control y asistencia durante el clipado microquirúrgico es una herramienta sumamente útil que permite realizar una revisión cercana y adecuada de la posición del clip.

Background: Surgical complications secondary to undetected clipping of a main or perforator artery next to an aneurysm can lead to a catastrophic event for both the patient and vascular neurosurgeon. Neuro-endoscopy is difficult during vascular neurosurgery; however, for surgeons desiring a multi-modality check of vessels to ensure the patency of important arteries, endoscopy could be a very useful tool. Objective: The aim of the present report is to describe our results with endoscopy-assisted anterior choroidal aneurysm clipping in a single patient. Results: A 23-year-old female presented with a subarachnoid hemorrhage (SAH, Fisher 2, Hunt-Hess 2) secondary to a ruptured anterior communicating aneurysm (ACA). Digital angiography revealed an unruptured right anterior choroidal aneurysm (AChA). Surgical clipping via a right pterional approach was accomplished for both aneurysms. Clip position in the AChA was evaluated with a rigid skull-base endoscope (0° and 45°). It revealed accidental compromise of the AChA, so the clip was replaced under endoscopic guidance. Post-operatively, the patient experienced late vasospasm and a partial right third nerve palsy, manifested as ptosis and mydriasis. Currently, only the right mydriasis persists. Conclusions: In one patient with a SAH caused by a ruptured anterior communicating aneurysm, successful endoscopic-assisted surgical clipping of both the ruptured aneurism and an unruptured right anterior choroidal aneurysm was achieved.

A Meta-analysis of effect comparison between interventional embolization and surgical clipping in treatment of ruptured intracranial aneurysms / 重庆医学

Objective To compare the efficacies between interventional embolization and surgical clipping in treatment of ruptured intracranial aneurysms to provide an evidence‐based basis for selecting the clinical treatment scheme .Methods The related randomized controlled trail(RCT) literatures on the effects of interventional embolization and surgical clipping were retrieved from the databases of Pubmed ,Cochrane ,Medline and Embase .The screening was independently performed by two researchers according to the including and excluding criterion .The occurrence rate of adverse reactions ,postoperative 1‐year mortality rate ,re‐bleeding rate ,occurrence rate of vasospasm and ischemic cerebral infarction served as the measurement indicators .The data were extracted and performed the meta analysis by the RevMan5 .3 software .Results Sixteen RCT literatures were included for conducting analy‐sis ,involving 7 373 patients ,in which 3 092 cases adopted interventional embolization and 4 281 cases adopted surgical clipping .The occurrence rate of adverse events(OR=1 .25 ,95% CI ,1 .12-1 .40 ;P<0 .000 1) and re‐bleeding rate(OR=0 .43 ,95% CI ,0 .28 -0 .66 ;P=0 .000 1) in the interventional embolization group were lower than those in the surgical clipping group ;however ,there were no statistical differences between the interventional embolization group and surgical clipping group in the postoperative 1‐year mortality rate(OR=1 .13 ,95% CI ,0 .92-1 .39 ;P=0 .23) ,incidence rate of vasospasm (OR=1 .41 ,95% CI ,0 .99-2 .02 ;P=0 .06) and incidence rate of ischemic cerebral infarction(OR=0 .66 ,95% CI ,0 .42 -1 .05 ;P=0 .08) .Conclusion The current clinical re‐search evidences indicate that using the interventional embolization in treating ruptured intracranial aneurysms can obviously reduce the occurrence rate of adverse events than the surgical clipping ,but increases the re‐bleeding rate .The postoperative 1‐year mortali‐ty rate ,incidence rate of vasospasm and incidence rate of ischemic cerebral infarction have no obvious difference between these two kinds of operation .

Predicting Factors of Chronic Subdural Hematoma Following Surgical Clipping in Unruptured and Ruptured Intracranial Aneurysm

OBJECTIVE: The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA). METHODS: We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data. RESULTS: The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ≥5 mm and male sex in the UIA and A high HF unit for SFC and SFC ≥5 mm without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05). CONCLUSION: There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ≥5 mm were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ≥5 mm at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.

What Should Be Considered to Cause the Early Post-Craniotomy Seizure: Antibiotics (Cefazolin) Irrigation

OBJECTIVE: Post-craniotomy seizure (PCS) is reported only rarely. However, our department noted a 433% increase in PCS for a year beginning September 2010, especially after cerebrovascular surgery. Our goal was to identify the cause of our unusual outbreak of PCS. METHODS: For almost one year after September 2010, cases of PCS increased significantly in our department. We analyzed 973 patients who had received a major craniotomy between January 2009 and November 2011. We included seizures that occurred only in the first 24 postoperative hours, which we defined as early PCS. After verifying the presence of PCS, we analyzed multiple seizure-provoking factors and their relation to the duration and character of seizure activity. RESULTS: Overall PCS incidence was 7.2% (70/973). Cefazolin (2 g/L saline) was the antibiotic drug used for intraoperative irrigation in 88.4% of the operations, and no PCS occurred without intraoperative cefazolin irrigation. When analyzed by operation type, clipping surgery for unruptured aneurysms was the most frequently associated with PCS (80%). Using logistic regression, only 2 g cefazolin intraoperative irrigation (p=0.024) and unruptured aneurysm clipping surgery (p<0.001) were associated with early PCS. The seizure rate of unruptured aneurysm clipping surgery using 2 g cefazolin intraoperative irrigation was 32.9%. CONCLUSION: Intraoperative cefazolin irrigation must be avoided in patients undergoing craniotomy, especially for clipping of unruptured aneurysms, because of the increased risk of early PCS.

The Effectiveness of Lumbar Cerebrospinal Fluid Drainage to Reduce the Cerebral Vasospasm after Surgical Clipping for Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: Removal of blood from subarachnoid space with a lumbar drainage (LD) may decrease development of cerebral vasospasm. We evaluated the effectiveness of a LD for a clinical vasospasm and outcomes after clipping of aneurysmal subarachnoid hemorrhage (SAH). METHODS: Between July 2008 and July 2013, 234 patients were included in this study. The LD group consisted of 126 patients, 108 patients in the non LD group. We investigated outcomes as follow : 1) clinical vasospasm, 2) angioplasty, 3) cerebral infarction, 4) Glasgow outcome scale (GOS) score at discharge, 5) GOS score at 6-month follow-up, and 6) mortality. RESULTS: Clinical vasospasm occurred in 19% of the LD group and 42% of the non LD group (p<0.001). Angioplasty was performed in 17% of the LD group and 38% of the non LD group (p=0.001). Cerebral infarctions were detected in 29% and 54% of each group respectively (p<0.001). The proportion of GOS score 5 at 6 month follow-up in the LD group was 69%, and it was 58% in the non LD group (p=0.001). Mortality rate showed 5% and 10% in each group respectively. But, there was no difference in shunt between the two groups. CONCLUSION: LD after aneurysmal SAH shows marked reduction of clinical vasospasm and need for angioplasty. With this technique we have shown favorable GOS score at 6 month follow-up.

Comparison of surgical clipping and intravascular interventional therapy in treatment of intracranial wide-necked aneurysm / 中国医师进修杂志

Objective To compare the clinical effects and safety of surgical clipping and intravascular interventional therapy in treatment of intracranial wide-necked aneurysm.Methods The clinical data of 158 patients with intracranial wide-necked aneurysm from February 2010 to February 2013 were retrospectively analyzed,all patients were divided into two groups:surgical clipping group with 92 cases and intravascular interventional therapy group with 66 cases,the postoperative curative effects,treatment time,hospital stay,hospital expenses and postoperative complications between two groups were compared.Followed up for 10-46 months,the recurrence rate were compared.Results The good prognosis and defective rates between surgical clipping group and intravasular interventional therapy group had no significant difference [90.2％(83/92) vs.90.9％(60/66),9.8％(9/92) vs.9.1％ (6/66)] (x2 =0.298,P ＞ 0.05).The preoperative Hunt-Hess classification and CT Fisher classification between two groups had no significant difference (P ＞ 0.05).Six months after discharge,mRS score was used to evaluate the curative effect,the defective rates in same level patients between two kinds of treatment methods had no significantdifference (P ＞ 0.05).The treatment time,hospital stay in surgical clipping group were significantly longer than those in intravascular interventional therapy group [(4.03 ± 1.01) h vs.(1.61 ± 0.98) h,(15.90 ± 2.03) dvs.(13.20 ± 1.95) d],hospital expenses was significantly lower than that in intravascular intervention therapy group [61 829.4 ±320.6) yuan vs.(99 876.2 ±371.5) yuan] (P ＜0.05).The postoperative complications rate between two groups had no significant difference (P ＞ 0.05).Followed up for 31.3 (10-46) months,the recurrence rate in surgical clipping group was significantly lower than that in intravascular intervention therapy group [1.1％ (1/94) vs.8.8％ (6/68)] (P ＜ 0.05).Conclusion Surgical clipping and intravascular interventional therapy in treatment of intracranial wide-necked aneurysm has their own different characteristics,so patients' treatment methods should be based on their preoperative status (especially preoperative Hunt-Hess and Fisher classification) and patients' economic conditions.

Temporary Semi-Jailing Technique for Coil Embolization of Wide-Neck Aneurysm with Small Caliber Parent Artery Following Incomplete Clipping

The authors describe the use of a self-expandable stent in a temporary deployment for treatment of a very wide-neck A1 segment of anterior cerebral artery (ACA) aneurysm following incomplete clipping. A 39-year-old hypertensive man presenting with seizure-like movement underwent computed tomography, which showed acute subarachnoid hemorrhage and an A1 segment of ACA aneurysm with superior and inferior projection. He underwent surgical clipping of the aneurysm, but superior and posterior portion of wide-neck aneurysm remained. We decided to treat the remnant aneurysm using an endovascular modality. After selection of the aneurysm, coil packing was performed assisted by the temporary semi-jailing technique. The Enterprise stent (Cordis Neurovascular, Miami, FL, USA) was deployed and recaptured repeatedly for angiography to ensure safety of the small caliber parent artery. Successful semi-deployment and recapture of the stent allowed subtotal coil occlusion of the aneurysm with good anatomic and clinical results. No complications were encountered. The stent could be recaptured up to the point where the proximal end of the stent marker was aligned with distal marker band of the microcatheter, approximately 70% of the stent length. The temporary semi-jailing technique is feasible for wide-neck aneurysm with small caliber parent artery.

Surgical Results of Unruptured Intracranial Aneurysms in the Elderly : Single Center Experience in the Past Ten Years

OBJECTIVE: As medical advances have increased life expectancy, it has become imperative to develop specific treatment strategies for intracranial aneurysms in the elderly. We therefore analyzed the clinical characteristics and outcomes of the treatment of unruptured intracranial aneurysms in patients older than 70 years. METHODS: We retrospectively reviewed the medical records and results of neuroimaging modalities on 54 aneurysms of 48 consecutive patients with unruptured intracranial aneurysms. (mean+/-SD age, 72.11+/-1.96 years; range, 70-78 years) who underwent surgical clipping over 10 years (May 1999 to June 2010). RESULTS: Of the 54 aneurysms, 22 were located in the internal carotid artery, 19 in the middle cerebral artery, 12 in the anterior cerebral artery, and 1 in the superior cerebellar artery. Six patients had multiple aneurysms. Aneurysm size ranged from 3 mm to 17 mm (mean+/-SD, 6.82+/-3.07 mm). Fifty of the 54 aneurysms (92.6%) were completely clipped. Three-month outcomes were excellent in 50 (92.6%) aneurysms and good and poor in 2 each (3.7%), with 1 death (2.0%). Procedure-related complications occurred in 7 aneurysms (13.0%), with 2 (3.7%) resulting in permanent neurological deficits, including death. No postoperative subarachnoid hemorrhage occurred during follow-up. The cumulative rates of stroke- or death-free survival at 5 and 10 years were 100% and 78%, respectively. CONCLUSION: Surgical clipping of unruptured intracranial aneurysms in elderly group could get it as a favorable outcome in well selected cases.

Predicting Factors Affecting Clinical Outcomes for Saccular Aneurysms of Posterior Inferior Cerebellar Artery with Subarachnoid Hemorrhage

OBJECTIVE: The aim of this study is to investigate the clinical outcomes of surgery and coiling and analyze the predicting factors affecting the clinical outcomes of ruptured posterior inferior cerebellar artery (PICA) aneurysms. METHODS: During the last 15 years, 20 consecutive patients with ruptured PICA aneurysms were treated and these patients were included in this study. The Fisher's exact test was used for the statistical significance of Glasgow Outcome Scale (GOS) according to initial Hunt-Hess (H-H) grade, treatment modalities, and the presence of acute hydrocephalus. RESULTS: Eleven (55%) and nine (45%) patients were treated with surgical clipping and endovascular treatment, respectively. Among 20 patients, thirteen (65.0%) patients had good outcomes (GOS 4 or 5). There was the statistical significance between initial poor H-H grade, the presence of acute hydrocephalus and poor GOS. CONCLUSION: In our study, we suggest that initial H-H grade and the presence of acute hydrocephalus may affect the clinical outcome rather than treatment modalities in the ruptured PICA aneurysms.

Microsurgical clipping in forty patients with unruptured anterior cerebral circulation aneurysms: an investigation into cognitive outcome / Clipagem microcirúrgica em 40 pacientes com aneurisma de circulação cerebral anterior não-roto: uma investigação cognitiva

OBJECTIVE: It is a consensus that most unruptured intracranial aneurysms (UIA) can be treated with acceptably low morbidity. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributable to surgical damage. Our goal is to evaluate cognitive function before and after microsurgical clipping in patients with UIA. METHOD: A consecutive series of 40 patients who underwent microsurgical clipping for UIA were studied. The cognitive assessment (Mini Mental State Examination, MMSE) was performed immediately before and at least one month after surgery. Paired Student's "t" test and analysis of variance (ANOVA) were used for statistical purposes. RESULTS: The mean MMSE score in the preoperative analysis was 28.12 (SD, 1.34). In the postoperative period the mean MMSE score was 28.40 (SD, 1.46). Paired Student's "t" test was applied to the scores and no significant difference was found (p=0.315). ANOVA did not find independent associations between MMSE scores and age, hypertension, smoking, dyslipidemia, education, aneurysm location, number, laterality or size. CONCLUSION: The present study suggests that microsurgical clipping for UIA does not result in major cognitive dysfunction as determined by the MMSE.

OBJETIVO: É consenso que a maioria dos aneurismas intracranianos não-rotos (AINR) podem ser tratados com aceitável taxa de morbidade. Entretanto, alguns estudos reportaram déficits cognitivos no pós-operatório, sugerindo que poderiam ser atribuídos ao dano cirúrgico. O objetivo desse estudo é avaliar a função cognitiva antes e após clipagem microcirúrgica em pacientes com AINR. MÉTODO: Uma série de 40 pacientes com AINR submetidos à clipagem microcirúrgica foi estudada. A avaliação cognitiva (Mini Exame do Estado Mental, MEEM) foi realizada antes e após a intervenção cirúrgica. A análise estatística foi realizada com teste "t" de Student e análise de variância (ANOVA). RESULTADOS: A média dos escores do MEEM na análise pré-operatória foi 28,12 (DP, 1,34). No período pós-operatório, a média dos escores foi 28,40 (DP, 1,46). Não houve diferença estatística (teste "t" de Student; p=0,315). A ANOVA não encontrou associações independentes entre os escores de MEEM e idade, hipertensão, tabagismo, dislipidemia, educação e características dos aneurismas (topografia, número, lado e tamanho). CONCLUSÃO: O presente estudo sugere que a clipagem microcirúrgica não está associada a danos cognitivos maiores em pacientes com AINR.

Unruptured Intracranial Aneurysms with Oculomotor Nerve Palsy : Clinical Outcome between Surgical Clipping and Coil Embolization

OBJECTIVE: To evaluate the clinical outcome of coil embolization for unruptured intracranial aneurysm (UIA) with oculomotor nerve palsy (ONP) compared with surgical clipping. METHODS: A total of 19 patients presented with ONP caused by UIAs between Jan 2004 and June 2008. Ten patients underwent coil embolization and nine patients surgical clipping. The following parameters were retrospectively analyzed to evaluate the differences in clinical outcome observed in both coil embolization and surgical clipping : 1) gender, 2) age, 3) location of the aneurysm, 4) duration of the symptom, and 5) degree of ONP. RESULTS: Following treatment, complete symptomatic recovery or partial relief from ONP was observed in 15 patients. Seven of the ten patients were treated by coil embolization, compared to eight of the nine patients treated by surgical clipping (p = 0.582). Patient's gender, age, location of the aneurysm, size of the aneurysm, duration of symptom, and degree of the ONP did not statistically correlate with recovery of symptoms between the two groups. No significant differences were observed in mean improvement time in either group (55 days in coil embolization and 60 days in surgical clipping). CONCLUSION: This study indicates that no significant differences were observed in the clinical outcome between coil embolization and surgical clipping techniques in the treatment of aneurysms causing ONP. Coil embolization seems to be more feasible and safe treatment modality for the relief and recovery of oculomotor nerve palsy.

Treatment Outcome of Ruptured Cerebral Aneurysms in the Elderly / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to assess the results of surgical and endovascular treatments in aneurysmal subarachnoid hemorrhage (SAH) patients older than 70 years. METHODS: This study included 18 patients, more than 70 years of age, treated for ruptured cerebral aneurysms between April 2004 and March 2009. In most cases, patients underwent the early obliteration procedure for each aneurysm, and we compared the clinical results according to the obliteration method (clipping or coiling). We assessed neurological outcomes at 6 months post-procedure according to the modified Rankin Scale (mRS): favorable (mRS score > 2) or unfavorable (mRS score > 2). RESULTS: Of the 18 patients, 12 (66.6%) underwent obliteration of the aneurysm sac via microvascular clipping patients, and 6 (33.3%) underwent endovascular coiling. At 6 months post-procedure, the clinical outcomes were favorable in 6 patients (33.3%), 5 (41.7%) who received microvascular clipping and 1 (16.7%) who underwent endovascular coiling. Unfavorable outcome was not statistically associated with poor initial clinical state, poor Fisher grade, occurrence of stroke, or hydrocephalus, although we frequently noted these variables in the unfavorable outcomes. CONCLUSIONS: In this study, aneurysm obliteration method (microvascular clipping vs. endovascular coiling) did not seem to significantly affect clinical outcomes. A poor initial clinical state, poor Fisher grade, occurrence of stroke, and hydrocephalus seemed to be associated with poor clinical outcomes.

Analysis of Clinical Outcome and Complications After Microsurgical Clipping of Unruptured Paraclinoid Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The study reports the clinical outcomes and complication rates of microsurgical clipping of unruptured paraclinoid aneurysms. METHODS: From July 1997 to December 2008, 61 patients underwent microsurgical clipping for 61 unruptured paraclinoid aneurysms in our institute. Entire medical records, radiographic data, and operation records were reviewed retrospectively. RESULTS: After the microsurgical clipping, complete obstruction was achieved in 56 patients (91.8%). Visual disturbance (nine cases, 14.8%) was the most frequent complication. Overall, 59 patients (96.7%) had a good long-term outcome (Glasgow outcome scale score of 4-5 3 months post-operatively). CONCLUSION: For patients with paraclinoid aneurysms, satisfactory outcomes can be achieved by microneurosurgical management. These results will be useful when considering treatment of an unruptured paraclinoid aneurysm.

Recent Trends in the Treatment of Cerebral Aneurysms: Comparison between Endovascular Coil Embolization and Surgical Clipping / 신경중재치료의학

Surgical clipping has been the gold standards in the treatment of cerebral aneurysms. In 1990, Guglielmi detachable coil was introduced into clinical use, and was approved by FDA in 1995. After the ISAT results in 2002, endovascular coil embolization of cerebral aneurysms has been accepted and regarded as equal or better alternative. From 2003 to 2007, numbers of endovascular coil embolization of cerebral aneurysms has increased two-fold while surgical clipping has remained stable in Korea. Total numbers of aneurysm treatment has been increased by 40%, endovascular coil embolization has been increased by 229% (p < 0.001), but surgical clipping has been increased by 5.6%. This result suggests there is paradigm shift in the treatment of cerebral aneurysms.

Clinical Analysis of Cerebral Aneurysms of Posterior Circulation / 대한뇌혈관외과학회지

OBJECTIVES: We sought to examine the diverse factors associated with aneurysms of the posterior circulation. In addition, the results of conventional craniotomy were compared with those of endovascular treatment. METHODS: One hundred and one patients with posterior circulation aneurysms were selected for study inclusion. The factors that might affect the clinical outcomes were studied , such as the initial Hunt-Hess (H-H) grade, aneurysm location, size of the aneurysm, and therapeutic modalities. In addition, the morbidity and mortality rates were analyzed. The treatment outcomes were evaluated using the Glasgow Outcome Scale (GOS) 6 months after the initial insult. RESULTS: The patient population consisted of 67 women and 34 men, with a mean age of 52 (range 28-81 years). The overall morbidity and mortality rates at 6 months were 13.9% (14/101) and 17.8% (18/101), respectively. Sixty-one operations (60.3%) were performed, and 32 patients were treated with endovascular therapy. Forty-two (85.7%) of the 49 patients that had initial H-H grades of I and II had a better prognosis (GOS more than 4) than those with poor H-H grades (P<0.001). Patients that underwent endovascular treatment had better outcomes than those that had clipping (P=0.032). There was no significant difference in outcome according to the size of the aneurysm, location of the aneurysm, or the age of the patients. CONCLUSIONS: The results of this study showed that the factors affecting the prognosis were the initial HH grade and treatment modality. Considering the very high mortality rate in patients with rebleeding, early management may help improve the prognosis of patients with posterior circulation aneurysms. Endovascular therapy should be considered the primary treatment modality in patients with posterior circulation aneurysms.

Surgical Outcome of Aneurysmal Subarachnoid Hemorrhage of Elderly Patients / 대한뇌혈관외과학회지

OBJECTIVE: The number of elderly patients with cerebral aneurysm has markedly increased. We investigated the clinical characteristics and the surgical outcomes of cerebral aneurysms among elderly patients more than 65 years of age compared to a control group including patients less than 65. MATERIALS AND METHODS: From March 2001 to May 2007, 590 patients with aneurysmal subarachnoid hemorrhage (SAH) were treated; among them, 88 patients (14.9%) more than 65 were candidates for this study. The variables included in the analysis were: age, gender, size and site of the aneurysm, the Hunt-Hess grade, size of the hematoma on the CT scan, and comorbidities. RESULTS: The mean age was 69 (range 65-84 years), 72 patients (81%) were female, 72 of the patients had a Hunt-Hess grade of I-III, 37 patients (42%) had anterior communicating artery bleeds, and 13 patients (16.7%) had multiple aneurysms. The treatments consisted of neck clipping for 77 aneurysms and endovascular therapy for 11 aneurysms. Fifty eight patients (65.9%) had a favorable outcome and the overall mortality was 11.4%. The main causes of unfavorable outcomes among the elderly patients included a poor Hunt-Hess grade on admission and a concurrent intracerebral hematoma. CONCLUSIONS: The results of this study showed that advanced age was not a contra-indication to aneurysm surgery and early craniotomy can lead to a better outcome in elderly patients.

A comparative analysis of the outcome of surgical clipping and endovascular treatment in the ruptured posterior circulation aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Posterior circulation aneurysms are difficult lesions to treat surgically because they have a potential for high morbidity and mortality. We have used both surgical clipping and endovascular coiling techniques to treat posterior circulation aneurysms and report the comparative results of these two treatment modalities. METHOD: Of 999 patients with intracranial aneurysms admitted between January 1996 and May 2005, 77 (7.7%) had aneurysms of the posterior circulation. Forty-three cases of posterior circulation aneurysms (43/77 [55.8%]) who were treated with clipping or coiling were included in this study. These aneurysms were located in the following sites: 20 cases (46.5%) in the basilar bifurcation artery (BBA), 9 cases (20.9%) in the superior cerebellar artery (SCA), 7 cases (16.7%) in the vertebral artery (VA), 4 cases (9.5%) in the distal posterior inferior cerebellar artery (PICA), and 4 cases (9.5%) in the posterior cerebral artery (PCA). Fourteen (31%) aneurysms were treated with surgical clipping and 29 (69%) aneurysms were treated with endovascular coiling. The treatment outcomes from outpatient follow-up 12 months after treatment were analyzed according to Glasgow outcome scale (GOS). RESULT: Overall, 10 patients who were treated with surgical clipping and 22 (74.4%) patients who were treated with endovascular therapy had good outcomes (GOS, 4~5). The mortality of surgical treatment and endovascular coiling was approximately 7.1% (1/14) and 6.9% (2/29), respectively. The postoperative complications included two transient cranial nerve deficits in the patients who underwent surgical treatment, whereas the patients who underwent endovascular treatment had more serious complications (two intra-operative aneurysm ruptures and three embolic infarctions). CONCLUSION: Patients treated with endovascular coiling had more severe intra-procedure rebleeding than patients treated with surgical clipping; however, there was no statistical significant difference in overall outcome between the two treatment groups. Both surgical and endovascular approaches to posterior circulation aneurysms can achieve good outcomes, and appropriate choice depends on the judgment of the surgeon and neurointerventionist based on angiographic findings. More cautious judgment according to patient factors and angiographic findings can improve the final results.

Guideline for Management of Unruptured Intracranial Aneurysms: Preliminary Report / 신경중재치료의학

Over the past decade, development of noninvasive diagnostic modalities for the diagnosis of intracranial aneurysms have led to a dramatic change in the management in which patients with unruptured intracranial aneurysms are diagnosed and treated. A patient with an unruptured intracranial aneurysm has three treatment options: endovascular coiling, surgical clipping, and observation. The decision making about management of intracranial aneurysms should be based on the risk of rupture and risks associated with surgical or endovascular treatment. In this report, we review the recent published articles pertaining to diagnositic modalities, natural history, management, and follow-up of unruptured intracranial aneurysms.

Surgical Experiences of Unruptured Intracranial Aneurysms / 대한뇌혈관외과학회지

Object : This study was conducted to evaluate the surgical results of the active treatment of unruptured intracranial aneurysms (UIAs) and to suggest treatment indications. METHODS: Operations were performed on 49 patients with 52 UIAs between 1999 and 2005. Medical records and radiologic studies of the patients with UIAs were retrospectively reviewed. The clinical outcomes were evaluated in each patient by the modified Glasgow Outcome Scale (m-GOS) one month after operation. RESULTS: UIAs had a high frequency of a middle cerebral artery (MCA) and an internal carotid artery (ICA) aneurysm. Forty-four UIAs (84.6%) ranged between 5 mm to 15 mm in diameter. Fortysix UIAs were treated by clipping, 2 by wrapping, and coil embolization was used in 3 UIAs. In one patient, which had only one UIA, one procedure and one operation was performed. There was no surgical mortality. In most patients, surgical complications or neurological deteriorations were not found. In three patients, minor neurological deficits of ptosis (2 patients) and spinal subdural hematoma (1 patient) were newly developed after operation. However the patients completely recovered within 3 months after operation. Finally, the surgical mortality and morbidity rate was 0%. CONCLUSION: If the UIAs are larger than 5 mm in diameter and located in a susceptible area for rupture, surgical treatment should be considered for the UIAs. If operation is performed by an expert neurosurgeon, surgical clipping is one of the best treatment modalities with or without endovascular treatment.