Use of Prophylactic Decompressive Craniectomy in Middle Cerebral Artery Aneurysmal Subarachnoid Hemorrhage Patients Presenting with Associated Large Hematoma / 대한뇌혈관외과학회지

OBJECTIVE: Patients who present with a poor Hunt-Hess grade (IV or V) after aneurysmal subarachnoid hemorrhage (SAH) often have a poor prognosis. However, there may be subgroups of these patients for whom the sustained increased intracranial pressure predominates due to a large sylvian hematoma and for which rapid decompression of these predominant pathological processes may result in an improved outcome. We report here on the use of prophylactic decompressive craniectomy in patients who present in a poor neurological condition or they have a focal neurologic deficit, such as motor aphasia, after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. METHODS: Twelve patients (mean age: 52yr, age range: 13-71yr) presented with middle cerebral artery (MCA) aneurysmal SAH (one with Hunt-Hess grade III, five with Hunt-Hess grade IV and six Hunt-Hess grade V). They all had large hematomas (mean hematoma volume: 70ml, range: 30-120ml). All the patients underwent emergency operation. One patient whose Hunt-Hess grade was III underwent decompressive craniectomy because she had motor aphasia due to a focal mass effect of the hematoma. Five of them underwent operation without conventional angiography. All the patients were treated with large craniectomy and duraplasty. RESULTS: All patients underwent craniectomy without operative complications. The results for this study demonstrated that craniectomy patients had a remarkably high rate of good recovery or they had moderately disabled outcomes. The outcomes of the craniectomy patients were three grade 5s, four grade 4s, one grade 3 and four grade 1s for the GOS. CONCLUSION: The data in this study showed that decompressive craniectomy can be performed safely as part of the initial management for patients with SAH and who also present with large hematomas. We suggest decompressive craniectomy when patients with a large hematoma present not only with deteriorated mentality due to the increased intracranial pressure, but also with focal neurologic deficits such as motor aphasia due to the local mass effect.

Middle Cerebral Artery Aneurysm Operation through Minicraniotomy (Minimized Pterional Approach): Technical Note

Since Yasargil's report, most neurosurgeons operate on middle cerebral artery(MCA) aneurysms through frontotemporal(pterional) bone flap under large skin incision which could result avoidable complications of facial nerve damage, temporal muscle atropy, paresthesia along incision scar and cosmetic bony defect. After careful review of detailed facial nerve anatomy, the author has developed a less invasive approach involving 8cm mini skin incision starting from 1.5cm above zygomatic arch, 1.5cm inside the anterior temporal hair line to upward 4-5cm and then curving forward 3cm length around 2cm above supraorbital ridge. Then, about 2.5cm mini-bone flap centered on pterion is made. After reflection of round dural flap, dissection of sylvian fissure was proceeded from just lateral end of limen insula, where middle cerebral artery(MCA) bifurcation or M2 segment was deeply located. The author has operated on consecutive 18 cases of MCA aneurysms using this minicraniotomy from 1996 to 1998 which provided sufficient working area enough not only for surgeon's free hand motion including multiple temporary clippings at one field but also inspection for other anterior circulation and posterior circulation systems. Hunt-Hess Grade for these patients were 17 cases of Grade II and 1 case of Grade I. Mean age of patients was 52.9 years old. There were 15 males and 3 females. Excellent postoperative neurological conditions were achieved without any morbidity or mortality. This approach is especially recommendable for patients with good neurological status for being less invasive and more convenient method.

Complications in Middle Cerebral Artery Aneurysm Surgery

Middle cerebral artery aneuryms account for aporoximately 20 percent of all intracranial aneurysms. The majority are located at the bbifurcation of M1 segment insylvian fissure. Incidence of formation of intracerebral hematoma with ruptured aneurysm and giant and infectious aneurysms are more common than with aneurysm in other locations. Clinical presentation of the MCA aneurysms are associated with symptoms of subarachnoid hemorrhage and mass effect. Symptoms of subarachnoid hemorrhage such as headache are indistinguishable from that associated with SAH from rupture of an aneurysm in any other location. But mass effect of large aneurysm, temporal lobe epilepsy and transient ischemic attack occur more frequently with aneurysms of the MCA. Complications of MCA aneurysm surgery can be divided into two group, one related to subarachnoid hemorrhage with aneurysmal rupture and the other to surgical procedure. Vasospasm is major cause of morbiduty and medical complications such as hypertension, cardiac arrhythmia, pneumonia and GI bleeding are frequently encountered. Operative complications include occlusion of MCA branch by improperly placed clip, retraction injury, intraoperative rupture.