ACTA NEUROCHIRURGICA

Acta Neurochirurgica 46, 93--104 (1979)

9 by Springer-Verlag 1979

Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, Sendal, Japan

Early Intracranial Operations for Ruptured Aneurysms By

S. Hori and J. Suzuki With 5 Figures

Summary During the period between June 1961 and September 1975 320 patients with saccular aneurysms were operated on by intracraniaI procedures within 14 days of their last subarachnoid hemorrhages. Overall operative mortality rate for the 14 year period was 10.6~ being 18.9~ for 143 cases operated on within 7 days of rupture and 4.0~ for 177 cases operated on between the 8th and 14th days. The mortality was reduced to the zero level by 1.975 in the groups operated on within 48 hours and 8 to 14 days by selection of the patients as well as by improvements in surgical techniques and adjuncts, but did not reach a satisfactory level in the group operated on between th third and seventh days mainly because of fatality due to postoperative vasospasm. The quality of survival after surgery performed within seven days was better than that of surgery performed at eight days or later. Based on these results, the rationale for and technical problems concerning the early stage operations are discussed.

Introduction The surgical treatment of cerebral aneurysms has made striking progress. Although it has become widely accepted that intracranial direct surgery is the best treatment, there are a number of problems which still need to be solved, especially with regard to the surgical timing, which, although an extremely important problem, still remains a point of controversy among neurosurgeons. With regard to ruptured aneurysms, not only have we been trying to prevent rerupture, but we have also been actively pursuing a programme of early stage surgery 18 and making efforts to improve upon the results in order to reduce to a minimum the number of victims of post-rupture secondary intracranial phenomena. Based

0001-6268/79/0046/0093/$ 02.40

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upon our experience, a number of problem areas in early stage surgery have been investigated. Clinical Materials

During the 14 year period from June 1961 until September 1975, we performed direct surgery on 1,000 cases of intracranial saccular aneurysms 17, of which 980 had ruptured aneurysms. Since symptoms of cerebral infarction due to vasospasm, which is an important factor Table 1. Number of Aneurysm Patients Treated by Intracranial Operation Aneurysm site

Total No.

Patients operated on in the early stage * No. % of total

Anterior communicating Internal carotid Middle cerebral Anterior cerebral Vertebrobasilar Multiple

346 246 174 49 23 162

117 78 54 15 2 54

33.8 31.7 31.0 30.6 8.7 33.3

1,000

320

32.0

Total

* Within 14 days of the last bleed. in the results of early stage operations, are seldom seen after the 15th day following aneurysm rupture 15, we here tentatively define the early stage as the first 14 days. Until 1970 early stage operations were performed in only 200/0 of our cases, but thereafter the number gradually increased, and have comprised nearly half of our cases in recent years (Fig. 1). Thus, cases of surgery within two weeks of rupture numbered 320, or 32% of the total (Table 1). The long-term condition was investigated by close examination or questionnaires in 94.7% of the discharged patients after an average of three years and seven months (follow-up period ranging from six months to 14 years and 10 months). Intracranial surgery was carried out within two days of the last bleeding in 54 cases (16.9~ between 3 and 7 days in 89 cases (27.80/0), and between 8 and 14 days in 177 cases (55.30/0). Following Hunt's classification a concerned with preoperative condition, roughly half were Grade III or IV, but most cases operated on within two days had severe symptoms, 3/4 being Grade III or worse (Table 2).

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Results

With regard to the mortality rate irrespective of the cause of death, 34 cases, or 10.6~ of the 320 cases, died postoperatively while still in hospital. Indeed, the mortality rate was higher the 2W

IW

Non-rup,~ Total Op. I 379

3W-

122 132

\ ~

125 139

103

L 0

i 10

i 20.

I 30

i

J

40

50 %

i 60

i

r

I

i

70

80

90

100

Fig. 1. Annual incidence of aneurysm operation. 1 W Operations in the 1st week, 2 W in the 2nd week, 3 W in the 3rd week or later after rupture, and Non-rup in the non-ruptured cases. Note an incease in the incidence of the operations within two weeks since 1971 Table 2. Preoperative Grade and Operative Timing in 320 Patients Operated on

in the Early Stage Preoperative

Interval between last bleed and operation (days)

grade

0-2

3-7

8-14

I II III IV V

3 10 27 12 2

12 32 33 12 0

48 55 64 10 0

Total

54

89

177

Total (~ 63 97 124 34 2

(19.7) (30.3) (38.8) (10.6) (0.6)

320 (100.0)

earlier the surgery, there being 27 deaths in 143 cases (18.9~ operated on within 7 days of aneurysm rupture, and 7 deaths in 177 cases (4.0~ operated on between the 8th and 14th days. Incidentally, the mortality rate for the 660 cases operated on after 15 days was 3.8~ giving an average mortality rate of 6.0~ for the 980 surgical cases of ruptured aneurysms over the 14 year period.

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A comparison of the mortality rates by year shows a yearly decrease particularly in surgery within the early stage of 14 days; the 18.7~ mortality rate in 1970 fell significantly to 4.8~ by 1975. The mortality rate in surgery in the chronic stage following the 14th day had also improved from 5.1 to 1.7% during these years % 20

15

10 5 i

0i

15days~(660Cases) ~'70 '71 '72 73 '74

'75

~5

% 4~

2days(54Cases)

4[ 35 30 25 20

%%"'~.~--~ ~

15

5,

.~

3~Tdays(71Cases) I.~

10 8~14days ~ \ 0 ~'70

'71

//~ '72

'73

'74

'75

Fig. 2, Annual operative mortality rate. Upper: The yearly decrease in the cases operated on within 14 days than in the cases operated on after 15 days. Lower: Among the cases operated on within 14 days, the fall was most remarkable in the cases operated on within 2 days

(Fig. 2, upper). Furthermore, a subclassification according to surgical period of the cases operated on within 14 days shows, first of all, that the mortality rate for surgery on the first or second day, that is within 48 hours of aneurysm rupture, dropped remarkably to the point where in 1972 it reached zero. In 1974, two patients died postoperatively, but both cases had preoperative reruptures, so that, strictly speaking, they should not be counted among the cases operated on in this acute stage. Next, with regard to the 177 cases

Early Intracranial Operations for Ruptured Aneurysms

97

operated on in the second week, that is between the 8th and the 14th days from aneurysm rupture, the mortality rate again fell yearly until 1974 when it reached zero. Among the first week cases, the 71 cases operated on between the third and seventh days also showed a yearly decrease in mortality rate to the point where it was somewhat less than 20% (Fig. 2, lower). Among the cases of postoperative death in hospital (Table 3), the greatest number were patients now thought not to have been suitable for surgery because they were in coma or were in a deteriorating Tabie 3. Main Cause of Postoperative Death During Hospitalization Preoperative grade I II III IV V Total

Misindication

Operative procedure

Postoperative vasospasm

1 9 9 2

3 2

2 4

21

5

6

Other complications

Total

1 1

1 6 16 9 2

2

34

state of consciousness. The two Grade V cases could not have been saved on any account. The next most common cause of death was severe postoperative vasospasm--frequently found in the group operated on between the third and the seventh days and including patients in a relatively good preoperative state. Vasospasm was consequently the most important cause of death in patients in that surgical stage. Next most important in the discussion of surgical results is the quality of life for survivors. We found that 77% of the 286 patients discharged following early stage surgery were found at follow-up to have returned to a normal social life. The rate of return to social life was studied both in terms of the surgical stage and the year of surgery (Fig. 3). For both the group operated on within 48 hours and the group operated on between the third and seventh days, a yearly improvement was seen until 1975 when 100% of the survivors of both groups returned to normal life. On the other hand, for cases operated on in the second week (between the 8th and 14th days) no improvement in the rate of return to normal life has been seen, although a minimum of 70% were found capable. With regard to the rate of return to social life for patients operated on in the chronic period following 15 days, a steady levelling tendency was seen at the 90~ mark. 7 Acta Neurochirurgica, Vo]. 46, Fasc. 1 ~

S. Hori and J. Suzuki:

98

Discussion

The Rationale

for Early Stage Operations

Once an intracranial aneurysm has ruptured, it may easily rerupture, resulting in death within three years in about 60% of such cases ~. According to Locksley 6, such rerupture is apt to occur in a concentrated period around one week from the initial rupture. After four weeks the rate of rerupture decrease considerably. Deterioration in the acute stage is, however, not only due to rerupture, but also to cerebral ischaemia, oedema, intracranial hyper-

%

1,2days

3~Tdays

100

8~14days

15days~

72

90

~

77

80 70

60 50

i;

40 30 20 10 O'

~'70 71 '72 73 74 '75

~'70 71 '72 '73 74 75

--'70 71 72 73 74 '75

t

~'70 71 '72 73 '74 '75

Year Fig. 3. Survivors who returned to normal life in terms of the operative timing and the year of operation. The rate increased to 100~ by 1975 in both groups operated on within 2 days and 3 - - 7 days. On the other hand, the rate was lower, even in cases operated on in recent years, in both groups operated on at 8-14 days and following 15 days mainly because of persisting neurological deficits already present preoperatively

tension due to intracranial hematoma, disturbances of CSF circulation, and cerebral vasospasm, following successively upon the initial rupture. Most important is vasospasm which brings about cerebral infarction and can be fatal as often as rerupture itself. The symptoms of cerebral infarction occur at roughly the same period as that in which rerupture is likely 6 (Fig. 4), and frequently their onset is sudden and severe, making it possible to mistake infarction for aneurysm rerupture. Furthermore, the statistics a. t9 from conservative treatment generally show that the survival rate for patients with ruptured cerebral aneurysms drops sharply for the first four weeks and drops more gradually thereafter and that the long-term survival rate of those

Early Intracranial Operations for Ruptured Aneurysms

99

patients who survive the first four weeks following rupture is quite good. In other words, the mortality rate is highest in the first four weeks (Fig. 5). The above facts all indicate that in order to save a greater number of ruptured aneurysm patients, surgical efforts not only to occlude Rupture Associated with Unconsciousness

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14 15

16

17

18

19

20

21

16

17

18

19

20

21

Rupture Unassociated with Unconsciousness I

I

2

3

4

5

6

7

8

9

10

II

12

13

14

15

Days after Rupture Fig. 4. Relapses following aneurysm rupture. When the initial bleeding is of such severity that it is associated with unconsciousness, a relapse is most likely due to infarction occurring exclusively between the 4th and 14th days, while a relapse due to rerupture occurs usually within the first 3 days or after the 15th day (upper). When the initial bleeding is not associated with unconsciousness, a relapse is more likely due to rerupture occurring at any time in the subsequent days, and infarction may also occur, though less frequently, in the 4-14th day period (lower)

the aneurysm but also to alleviate the propagation of further intracranial processes secondary to rupture should be directed toward the patients in this early stage, and that surgery in the chronic stage may be of little additional help as far as mortality is concerned. However, it has been widely accepted that intracranial surgery at an early stage following rupture, particularly for patients with impaired consciousness, does not produce good results even in skilled hands, whereas the results of surgery in the chronic stage are generally good. According to the Cooperative Study 2, the mortality rate 7*

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S. Hori and J. Suzuki:

in surgery within two weeks, even in cases in relatively good preoperative condition, reaches 37% and, in cases with severe symptoms, reaches 600/0. Consequently, an approach has been considered whereby drug-induced hypotension it or the administration of antifibrinolytic agents s is relied upon for a few weeks following rupture in the hope of preventing until the chronic stage when surgery is performed. However, with this technique it has been difficult completely to prevent rerupture, and there is the danger that these conservative measures can have a deleterious effect 4 upon cerebral infarction when vasospasm exists.

~sten('Tl)

I00

80> >

{/1 o

6o4020i

~J/,

Weeks

'//r

Months

Years

Fig. 5. Long-term survival curves of non-surgically treated cases. Generally, the survival rate drops steeply for the first four weeks following aneurysm rupture and drops more gradually thereafter. On the other hand, the iong-term survival rate for the survivors from this early stage is quite good (modified from Hunt 3)

Our surgical results in the last few years reveal that, in the so-called early stage, considerable differences in survival and prognosis are found depending upon the number of days from aneurysm rupture to surgery. For surgery in the second week the mortality rate is relatively low, but neurological deficits already present before surgery tend to remain, and the rate of return to social life decreases. On the other hand, the rate of return in the survivors who had been operated on within one week is favourable and, especially for those operated on within one or two days, the surgical mortality rate is also low. Indeed, with surgical treatment of aneurysms in this acute stage, the development of secondary intracranial processes is kept to a minimum, allowing good results. Needless to say, surgery at an early stage would be dangerous if performed indiscriminately; a mature surgical technique and much pre- and postoperative planning and efforts such as described below are necessary.

Early Intracranial Operations for Ruptured Aneurysms

101

The Techniques in Early Stage Surgery Immediately following aneurysm rupture, the brain often becomes swollen due to subarachnoid haemorrhage. However, in cases where preoperative consciousness is improving and for which intracranial surgery is indicated we have usually been able to treat aneurysms despite such swelling. Nonetheless, continuous ventricular drainage should be used in order to remove bloody CSF and clots and make the brain volume less bulky so that the surgical procedures become easier. This drainage is maintained postoperatively allowing for the control of cerebral pressure and brain oedema. In cases where intracranial hypertension tends to continue for several days, the drainage is then replaced by a shunt system. Furthermore, this type of ventricular drainage has also been proved to be an effective method for improving the condition of patients with symptoms previously too severe to allow surgery to a point where surgery becomes possible 14. Indeed, we have experienced a number of cases who were brought out of a coma through this method and could even respond to questions; aneurysm surgery was then performed, resulting in favourable postoperative courses. In cases where the patient remains in a comatose state or deteriorates during drainage, it is thought that life cannot be preserved and that the patient is not suitable for surgery. Secondly, in the early stage following aneurysm rupture, the aneurysm walls are extremely thin and often at the point of rupture. Since rupture during surgery greatly complicates the surgical operation, and frequently makes the result worse, it is necessary to lessen the intra-aneurysm pressure so that rupture will seldom occur. Hypotensive agents 10 are being used by some for this purpose, but we have been utilizing a method whereby temporary occlusion is performed on afferent and sometimes efferent arteries, and subsequently complete occlusion of the aneurysm neck is carried out. Previously we have used hypothermic anaesthesia in order to allow the longest possible occlusion period, but this is associated with various complications 5. Consequently, we currently administer mannitol, which is also effective in prolonging the allowable occlusion time, immediately before craniotomy by intravenous drip and perform surgery under normothermic anaesthesia with normotension 1~, ~o Thirdly, the greatest problem preventing improvement in the results of surgery on aneurysms in an early stage is that of vasospasm. As described above, when an aneurysm ruptures, the subarachnoid spaces become filled with clots and from around the third

102

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day vasospasm of the basal arteries can be produced. When direct surgery on the aneurysm is performed at this time, even if the operation itself is successful, severe postoperative vasospasm often leads to bad results. The fact that the results of our early period surgery are worst during the third to seventh day period is due primarily to vasospasm. Currently the mechanisms of cerebral vasospasm are not welt known and no countermeasures have yet become established. At this point, it can only be said that it is important to perform surgery at as early a period as possible to extirpate as much of the clot in the subarachnoid spaces as possible in order that the development of vasospasm can be reduced to a minimum. We believe that one cause of the good results obtained with the 48 hour period after rupture is that considerable efforts have been made at clot removal. Yet, since it is technically impossible to remove all clots from the deeper portions of the basal cisterns, it is not always possible to avoid the development of postoperative vasospasm. In such cases, we have been performing cervical sympathectomy i6, based upon the fact that the cerebral arterial walls are rich in sympathetic nerves from the superior cervical ganglion. This method is effective--its mechanism of action aside--in cases of cerebral ischaemia, provided that surgery is performed before the occurrence of grave cerebral infarction. Recently, some progress in research on the physical basis of cerebral vasospasm has been made. Particularly noteworthy is the strong spasmogenic effect of oxyhaemoglobin in clots. According to our experiments 1~, oxyhaemoglobin is released from the third day in incubated mixtures of blood and cerebrospinal fluid and reaches a peak at seven days. Thereafter, until the 15th day the oxyhaemoglobin is transformed into methaemoglobin, which does not have conspicuous spasmogenic capability. This in vitro course is identical with the pattern of cerebral infarction due to vasospasm which is seen clinically 15. Finally, agents which deactivate oxyhaemoglobin, such as sodium nitrite 12 and haptoglobin v, have been proposed for clinical use, but this research is currently limited to a few institutions; further developments are eagerly awaited. Conclusion

As discussed above, in the hope of saving the lives of a greater number of ruptured aneurysm patients and improving their functional prognosis as well, we have been performing surgery at an early stage. In fact, we have obtained favourable results, but the results of surgery between the third and seventh days after rupture, particu-

Early Intracranial Operations for Ruptured Aneurysms

103

larly in severe cases, are still not satisfactory. It appears that great improvements in the results during this stage will only be obtainable once a method for dealing with cerebral vasospasm has been established; currently, it is desirable to perform surgery within one or two days of rupture before the appearance of vasospasm. In patients who died of massive haemorrhage when surgery was not performed, nearly all had experienced minor bleedings previously 9. Therefore, if soon after the development of minor haemorrhages a diagnosis had been made and the patients rushed to surgery, there is a chance that many such cases could have been saved. In the light of these considerations, it is evident that treatment of ruptured cerebral aneurysms is essentially a matter of emergency medical care. Provided that close cooperation between physicians and surgeons is possible and appropriate facilities are available for treatment at an early stage following rupture, more patients than ever can be expected to return to normal social life. References

1. Graf, G.J., Prognosis for patients with nonsurgically treated aneurysms. Analysis of the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. J. Neurosurg. 35 (1971), 438--443. 2. Graf, G. J., Nibbelink, D. W., Cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Report on a randomized treatment study. III. Intracranial surgery. Stroke 5 ((1974), 559--601. 3. Hunt, W.E., Grading of risk in intracranial aneurysms. In: Recent progress in neurological surgery (Sano, K., Ishii, S., eds.). Excerpta Medica ICS 320, pp. 169--175. New York: American Elsevier. 1974. 4. K~gstr/Sm, E., Palma, L., Influence of antifibrinolytic treatment on the morbidity in patients with subarachnoid hemorrhage. Acta Neurol. Scand. 48 (1972), 257--258. 5. Kwak, R., Okudaira, Y., Suzuki, J., et aI., Problems in hypothermic anesthesia for direct surgical treatment of intracranial aneurysms, with special reference to ventricular fibrillation. Brain Nerve (Tokyo) 24 (1972), 403--410. 6. Locksley, H. B., Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V, Part II. Natural history of subarachnoid hemorrhage. Intracranial aneurysms and arteriovenous malformations. J. Neurosurg. 25 (1966), 321--368. 7. Miyaoka, M., Nonaka, T., Watanabe, H., et aI., Etiology and treatment of prolonged vasospasm--Experimental and clinical studies. Neurol. Med. Chir. (Tokyo) 16 Part II (1976), 103--114. 8. Mullah, S., Dawley, J., Antifibrinolytic therapy for intracranial aneurysms. J. Neurosurg. 28 (1968), 21--23. 9. Nishijima, Y., Yoshimoto, T., Hori, S., Suzuki, J., Postmortem examination of patients with nonsurgically treated ruptured aneurysms. Neurol. Med. Chir. (Tokyo) 16 Part I (1976), 97--104. 10. Rollason, W. N., Cerebral complications of hypotensive anaesthesia. Brit. Med. J. 2 (1963), 402--403.

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11. Slosberg, P.S., Medical treatment of intracraniaI aneurysm: an analysis of 15 cases. Neurology 10 (1960), 1085--1089. 12. Sonobe, M., Hori, S., Suzuki, J., Effect of spasmogenic substances on cerebral arteries. X. International Congress of Angiology, Tokyo, Aug. 31, 1976. 13. Suzuki, J., A method of prolongation of temporary stopping of the cerebral blood flow. (Presidential Address) XXXIII. Annual Meeting of the Japan Neurosurgicat Society, Sendal, Oct. 22, 1974. 14. Suzuki, J., Yoshimoto, T., Hori, S., Continuous ventricular drainage to lessen surgical risk in ruptured intracranial aneurysms. Surg. Neurol. 2 (1974), 87--90. 15. Suzuki, J., Hori, S., Prediction of reattacks following rupture of intracranial aneurysms. Neurol. Med. Chir. (Tokyo) 18 Part I (1975), 35--39. 16. Suzuki, J., Iwabuchi, T., Hori, S., Cervical sympathectomy for cerebral vasospasm after aneurysms rupture. Neurol. Med. Chir. (Tokyo) 15 Part I (1975), 41--50. 17. Suzuki, J., Direct surgery of intracranial aneurysms: Experience with over 1,000 cases. Inst. Neurol. Madras Proc. 6 (1976), 15--23. 18. Suzuki, J., Yoshimoto, T., Early operation for the ruptured intracranial aneurysms--Especially the cases operated on within 48 hours after the last subarachnoid hemorrhage. Neurol. Surg. (Tokyo) 4 (1976), 135--141. 19. Yamaguchi, T., Nagaki, J., Omae, T., et al., Long-term results of non-surgically treated ruptured cerebral aneurysms. II. Annual Meeting of the Japan Stroke Society. Fukuoka, Feb. 2, 1977. 20. Yoshimoto, T., Suzuki, J., Intracranial definitive aneurysm surgery under normothermia and normotension utilizing temporary occlusion of brain artery and preoperative mannitol administration. Neurol. Surg. (Tokyo) 4 (1976), 775--783. Authors' address: S. Hori, M.D., J. Suzuki, M.D., Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, 5-13-I, Nagamachi, Sendal, Japan 982.

Early intracranial operations for ruptured aneurysms.

ACTA NEUROCHIRURGICA Acta Neurochirurgica 46, 93--104 (1979) 9 by Springer-Verlag 1979 Division of Neurosurgery, Institute of Brain Diseases, Tohok...
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