Neurological Research A Journal of Progress in Neurosurgery, Neurology and Neurosciences
ISSN: 0161-6412 (Print) 1743-1328 (Online) Journal homepage: https://www.tandfonline.com/loi/yner20
Effect of circulating pattern and complicating factors on outcome for ruptured anterior communicating artery aneurysms G. Üzdemir, S. Torun & J.R. Bradshaw To cite this article: G. Üzdemir, S. Torun & J.R. Bradshaw (1992) Effect of circulating pattern and complicating factors on outcome for ruptured anterior communicating artery aneurysms, Neurological Research, 14:2, 197-200, DOI: 10.1080/01616412.1992.11740051 To link to this article: https://doi.org/10.1080/01616412.1992.11740051
Published online: 23 Jul 2016.
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Citing articles: 2 View citing articles
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Effect of circulating pattern and complicating factors on outcome for ruptured anterior communic ating artery aneurysms G. Ozdemir, S. Torun and j.R. Bradshaw Department of Neurology, Anadolu University, Eskisehir, Turkey and *Department of Neuro radiology, Frenchay Hospital, Bristol, UK
We reviewed outcome for ruptured anterior communicating artery ( ACoA ) aneurysm in 40 patients and attempted to establish its relationships with circulating pattern and complicating factors. Circulation Type-1 and Type-2 were associated with a better outcome than Type-3 and Type-4. Apart from arterial hypertension and cerebral infarction, all the complicating factors, i.e., vasospasm, brain oedema, intraparanchymal and I or intraventricular haemorrhage and hydrocephalus were related with an increased risk for poor outcome, but the broad outcome was more depended on circulating pattern fo r anterior cerebral territories. Keywords :Circulating pattern; anterior communicating artery aneurysms; outcome
INTRODUCTION ACoA is the most common site for intracranial aneurysms resulting in subarachnoid haemorrhage1 . The morbidity and mortality for ruptured aneurysms is well known , but reports confined to outcome in patients with ruptured ACoA aneurysms are less common. The aim of the present study was to establish broad outcome in patients with ruptured ACoA aneurysm and its relationships particularly with circulation types.
MATERIALS AND METHODS We reviewed clinical records of the patients attending to Frenchay Hospital in Bristol over a 20 months period, and selected the cases of ruptured ACoA aneurysms. The following data were compiled for each patient where available: (1) Clinical condition on admission according to Hunt and Hess Classification 1 . The patients in Grade-l and Grade-11 were taken into account as in the same group, and also the patients in Grade-Ill, IV and V were combined. (2) Presence and distribution of complicating factors : arterial hypertension, subarachnoid and / or intraventricular haemorrhage, intracerebral haematoma, cerebral infarction, brain oedema, vasospasm and hydrocephalus. The diagnosis of these complicating factors was based on angiographic, computerized tomographic and if appropriated, surgical findings. Circulating patterns for the anterior cerebral territories were classified into four types according to schema (Table 1) proposed by Sengupta and MacAIIister3 . Circulation Type-1 and Type-2 were considered together, and also Type-3 and Type-4. To determine the broad outcome, data were gathered from clinical records and other sources regarding
the patients' physical, neurological, psychological and social well-being at the time of their fo llow-up, i.e., 4-24 months. The patients were divided into two groups : group A (good outcome): independent or capable of full employment; group B (poor outcome): dependent o r uncapable of employment or w ith physical / neurological deficit (sequel hemiparesis or Barthel score < 10) or with cognitive dysfunction (according to the notes of psychologists, some patients who have poor memory were -retired but independent, the remaining patients with cognitive dysfunction worked part-time ) or vegetative state or deceased. X2 and the Student' s-t test (one-tailed ) were used to compare group A and group B on the various dependent factors.
RESULTS Characteristics of the patients Qur study group co nsisted of 23 men and 17 women with a mean age of 48.5 years (ranging fro m 24 to 68 years ). M ale to female ratio was 1.3. Almost all of the patients were treated with the same procedure (primary surgical clipping of the aneurysm ).
Table 1: Circulation patterns for the anterior cerebral territories. (from Sengupta and MacAIIister3 )
Type-1 : The aneurysm and distal anterior cerebral artery (ACA) fill from only one proximal ACA Type-2: The aneurysm arises {rom the origin of the dominant ACA and contralateral ACA is hypoplastic Type-3: The aneurysm and both ACA's fill from a carotid injection on either side
Correspondence to: Prof. Dr Gazi Ozdemir, 2 Eylul cad.Yediler sok.1 / 11, 2601 0- Eskisehir /Turkey. Accepted for publication December 1991.
© 1992 Forefront Publishing Group 0161 - 6412 / 92/ 020197-04
Type-4: Similar to Type-3, but there is associated foetal posterior cerebral artery, other anomaly of the circle of Willis
Neurological Research, 1992, Volume 14, Suppl
197
Effect of ruptured anterior communicating artery aneurysms: C. Ozdemir et al.
Outcome Nineteen patients (47.5%) were considered to have 'good' outcome at the time of their follow-up. The broad outcome was 'poor' in 21 patients (52.5% ). Of these, five had died and 16 had an evidence of significant physical / neurological or cognitive disability.
.•.-. .
Admission grade There were 16 patients in grades HI and 24 patients in grades IIHV-V. Circulating pattern Twenty patients had circulation Type 1-2 (Figure 1). The aneurysm was on the left in seven and on the right in 12 of the cases of Type-1. No lateralization was observed in the single Type-2 case. Circulation Type 3-4 (Figure 2) were seen in 20 patients. The majority of ACoA aneurysms were on the left in this group (15 versus 5 ). Complicating factors . Only one patient did not show evidence of any complicating factor. The remaining 39 patients had one or more complicating factors. Table 2 shows the comparison of group A and group Bon admission grade, circulation types and complicating factors. It can clearly be seen that outcome is associated with admission grade, circulation type and presence of brain oedema, intracerebral haematoma, intraventricular haemorrhage or hydrocephalus. Circulation Type 3-4 was more common in patients who were in grade 111-IV-V on admission, suggesting a causal relationship between admission grade and circulation type. Whereas, circulation Type 1-2 was associated with better admission grades (Table 3).
DISCUSSION It is well recognized that the incidence of ACoA aneurysm is slightly higher in men than in women. Male to female ratio, mean age and age range in our series are similar to the reports of the previous studies 3 - 5 . The outcome for ruptured intracranial aneurysms is generally accepted to be poor, but carefully selected operative series 2 show consistently better result? and the outcome for ruptured ACoA aneurysm is broadly similar. There is, however, no uniform method to assess the outcome, and many reports have not taken into account the .considerable cognitive dysfunction which is some patients' experience. We have used an outcome classification similar to that of Rosenorn 2 • Overall, 19 (47.5%) of our patients were independen t at follow-up. In Rosenorn' s series of 383 patients with ACoA aneurysm, 29% fell into this category. Two other studies 3•6 record better outcome as 78% and 75% respectively. These higher values seem to be likely due to differences in assessment procedures. It is widely accepted that the outcome has a bearing on the patient' s condition on admission. In his series of 371 operated cases of ACoA aneurysm, Yasargil 4 found an overall good outcome in 88% of grades HI and 31 .5% of grade IIHV-V. This result is probably comparable to ours (63.1% for grade 1-11 and 36.8% for grade III-IV-V). Reports citing the incidence of variations in the circle of Willis vary. An autopsy series reported by Wilson et
198
Neurological Research, 1992, Volume 14, Suppl
A
B Figure 1:
Angiographic view of circulation Type-1 (A ) and Type-2
(B)
aC recorded
hypoplasia of one anterior cerebral artery A1 sefment in 85% of cases of ACoA aneurysms. Kirgis et a/. reported a similar rate, whereas Sengupta and MacAIIister3 found only 28% of 100 patients with ACoA aneurysms to have hypoplasia of an anterior cerebral
Effect of ruptured anterior communicating artery aneurysms: C. Ozdemir et al.
Table 2: Comparison of 'good' and 'poor' outcome groups on various associated factors Factors associated with broad outcome Grade 1-11 Grade 11!-IV-V Hypertension Cerebral infarct ion Vasospasm Brain oedema Intracerebral haematoma Intraventricular haemorrhage Hydrocephalus Circulation Type 1-2 Circulation Type 3-4
Table 3: grades
Group B
Group A (n = 19)
(n = 21 )
p
12 7 12 3 8 3 1 2 6 13 6
4 17 12 6 15 11 6 11 15 7 14
0.05 >0.05
ISSN: 0161-6412 (Print) 1743-1328 (Online) Journal homepage: https://www.tandfonline.com/loi/yner20
Effect of circulating pattern and complicating factors on outcome for ruptured anterior communicating artery aneurysms G. Üzdemir, S. Torun & J.R. Bradshaw To cite this article: G. Üzdemir, S. Torun & J.R. Bradshaw (1992) Effect of circulating pattern and complicating factors on outcome for ruptured anterior communicating artery aneurysms, Neurological Research, 14:2, 197-200, DOI: 10.1080/01616412.1992.11740051 To link to this article: https://doi.org/10.1080/01616412.1992.11740051
Published online: 23 Jul 2016.
Submit your article to this journal
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=yner20
Effect of circulating pattern and complicating factors on outcome for ruptured anterior communic ating artery aneurysms G. Ozdemir, S. Torun and j.R. Bradshaw Department of Neurology, Anadolu University, Eskisehir, Turkey and *Department of Neuro radiology, Frenchay Hospital, Bristol, UK
We reviewed outcome for ruptured anterior communicating artery ( ACoA ) aneurysm in 40 patients and attempted to establish its relationships with circulating pattern and complicating factors. Circulation Type-1 and Type-2 were associated with a better outcome than Type-3 and Type-4. Apart from arterial hypertension and cerebral infarction, all the complicating factors, i.e., vasospasm, brain oedema, intraparanchymal and I or intraventricular haemorrhage and hydrocephalus were related with an increased risk for poor outcome, but the broad outcome was more depended on circulating pattern fo r anterior cerebral territories. Keywords :Circulating pattern; anterior communicating artery aneurysms; outcome
INTRODUCTION ACoA is the most common site for intracranial aneurysms resulting in subarachnoid haemorrhage1 . The morbidity and mortality for ruptured aneurysms is well known , but reports confined to outcome in patients with ruptured ACoA aneurysms are less common. The aim of the present study was to establish broad outcome in patients with ruptured ACoA aneurysm and its relationships particularly with circulation types.
MATERIALS AND METHODS We reviewed clinical records of the patients attending to Frenchay Hospital in Bristol over a 20 months period, and selected the cases of ruptured ACoA aneurysms. The following data were compiled for each patient where available: (1) Clinical condition on admission according to Hunt and Hess Classification 1 . The patients in Grade-l and Grade-11 were taken into account as in the same group, and also the patients in Grade-Ill, IV and V were combined. (2) Presence and distribution of complicating factors : arterial hypertension, subarachnoid and / or intraventricular haemorrhage, intracerebral haematoma, cerebral infarction, brain oedema, vasospasm and hydrocephalus. The diagnosis of these complicating factors was based on angiographic, computerized tomographic and if appropriated, surgical findings. Circulating patterns for the anterior cerebral territories were classified into four types according to schema (Table 1) proposed by Sengupta and MacAIIister3 . Circulation Type-1 and Type-2 were considered together, and also Type-3 and Type-4. To determine the broad outcome, data were gathered from clinical records and other sources regarding
the patients' physical, neurological, psychological and social well-being at the time of their fo llow-up, i.e., 4-24 months. The patients were divided into two groups : group A (good outcome): independent or capable of full employment; group B (poor outcome): dependent o r uncapable of employment or w ith physical / neurological deficit (sequel hemiparesis or Barthel score < 10) or with cognitive dysfunction (according to the notes of psychologists, some patients who have poor memory were -retired but independent, the remaining patients with cognitive dysfunction worked part-time ) or vegetative state or deceased. X2 and the Student' s-t test (one-tailed ) were used to compare group A and group B on the various dependent factors.
RESULTS Characteristics of the patients Qur study group co nsisted of 23 men and 17 women with a mean age of 48.5 years (ranging fro m 24 to 68 years ). M ale to female ratio was 1.3. Almost all of the patients were treated with the same procedure (primary surgical clipping of the aneurysm ).
Table 1: Circulation patterns for the anterior cerebral territories. (from Sengupta and MacAIIister3 )
Type-1 : The aneurysm and distal anterior cerebral artery (ACA) fill from only one proximal ACA Type-2: The aneurysm arises {rom the origin of the dominant ACA and contralateral ACA is hypoplastic Type-3: The aneurysm and both ACA's fill from a carotid injection on either side
Correspondence to: Prof. Dr Gazi Ozdemir, 2 Eylul cad.Yediler sok.1 / 11, 2601 0- Eskisehir /Turkey. Accepted for publication December 1991.
© 1992 Forefront Publishing Group 0161 - 6412 / 92/ 020197-04
Type-4: Similar to Type-3, but there is associated foetal posterior cerebral artery, other anomaly of the circle of Willis
Neurological Research, 1992, Volume 14, Suppl
197
Effect of ruptured anterior communicating artery aneurysms: C. Ozdemir et al.
Outcome Nineteen patients (47.5%) were considered to have 'good' outcome at the time of their follow-up. The broad outcome was 'poor' in 21 patients (52.5% ). Of these, five had died and 16 had an evidence of significant physical / neurological or cognitive disability.
.•.-. .
Admission grade There were 16 patients in grades HI and 24 patients in grades IIHV-V. Circulating pattern Twenty patients had circulation Type 1-2 (Figure 1). The aneurysm was on the left in seven and on the right in 12 of the cases of Type-1. No lateralization was observed in the single Type-2 case. Circulation Type 3-4 (Figure 2) were seen in 20 patients. The majority of ACoA aneurysms were on the left in this group (15 versus 5 ). Complicating factors . Only one patient did not show evidence of any complicating factor. The remaining 39 patients had one or more complicating factors. Table 2 shows the comparison of group A and group Bon admission grade, circulation types and complicating factors. It can clearly be seen that outcome is associated with admission grade, circulation type and presence of brain oedema, intracerebral haematoma, intraventricular haemorrhage or hydrocephalus. Circulation Type 3-4 was more common in patients who were in grade 111-IV-V on admission, suggesting a causal relationship between admission grade and circulation type. Whereas, circulation Type 1-2 was associated with better admission grades (Table 3).
DISCUSSION It is well recognized that the incidence of ACoA aneurysm is slightly higher in men than in women. Male to female ratio, mean age and age range in our series are similar to the reports of the previous studies 3 - 5 . The outcome for ruptured intracranial aneurysms is generally accepted to be poor, but carefully selected operative series 2 show consistently better result? and the outcome for ruptured ACoA aneurysm is broadly similar. There is, however, no uniform method to assess the outcome, and many reports have not taken into account the .considerable cognitive dysfunction which is some patients' experience. We have used an outcome classification similar to that of Rosenorn 2 • Overall, 19 (47.5%) of our patients were independen t at follow-up. In Rosenorn' s series of 383 patients with ACoA aneurysm, 29% fell into this category. Two other studies 3•6 record better outcome as 78% and 75% respectively. These higher values seem to be likely due to differences in assessment procedures. It is widely accepted that the outcome has a bearing on the patient' s condition on admission. In his series of 371 operated cases of ACoA aneurysm, Yasargil 4 found an overall good outcome in 88% of grades HI and 31 .5% of grade IIHV-V. This result is probably comparable to ours (63.1% for grade 1-11 and 36.8% for grade III-IV-V). Reports citing the incidence of variations in the circle of Willis vary. An autopsy series reported by Wilson et
198
Neurological Research, 1992, Volume 14, Suppl
A
B Figure 1:
Angiographic view of circulation Type-1 (A ) and Type-2
(B)
aC recorded
hypoplasia of one anterior cerebral artery A1 sefment in 85% of cases of ACoA aneurysms. Kirgis et a/. reported a similar rate, whereas Sengupta and MacAIIister3 found only 28% of 100 patients with ACoA aneurysms to have hypoplasia of an anterior cerebral
Effect of ruptured anterior communicating artery aneurysms: C. Ozdemir et al.
Table 2: Comparison of 'good' and 'poor' outcome groups on various associated factors Factors associated with broad outcome Grade 1-11 Grade 11!-IV-V Hypertension Cerebral infarct ion Vasospasm Brain oedema Intracerebral haematoma Intraventricular haemorrhage Hydrocephalus Circulation Type 1-2 Circulation Type 3-4
Table 3: grades
Group B
Group A (n = 19)
(n = 21 )
p
12 7 12 3 8 3 1 2 6 13 6
4 17 12 6 15 11 6 11 15 7 14
0.05 >0.05
