:Acta . . N urochlrurglca
Acta Neurochir (Wien) (1991) 108:22-29
9 Springer-Verlag 1991 Printed in Austria
Surgical Treatment of Multiple Intracranial Aneurysms T. Inagawa Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
Summary A retrospective review of 126 patients with multiple aneurysms seen over a 10 year period was undertaken. They had a total of 302 aneurysms. Thirty-seven percent of the patients were males, and 63% were females. Direct operations were performed on 97 cases. Both the ruptured and unruptured aneurysms were treated in 71% (69 of the 97 cases), and only the ruptured aneurysms were treated in 29% (28). In 69 cases in whom both ruptured and unruptured aneurysms were treated, one-stage operations were used for 48 cases, and twostage operations were used for 21 cases. Thirty-four of the 48 cases, who were treated in one-stage operations, were operated on by day 4 after subarachnoid haemorrhage. In 12 eases, a total of 13 small unruptured aneurysms, which had not been found by preoperative angiograms, were discovered during surgery, and 9 of the 13 were discovered while removing blood clots to reduce cerebral vasospasm. Regardless of the operative method selected and the timing of operations, the surgical outcome of patients with multiple aneurysms was comparable to that of the 228 cases with single aneurysms treated during the same period at the same hospital. The analysis of this study suggests that surgical results for multiple aneurysms are satisfactory, even for early operations. Further, the actual incidence of multiple aneurysms may be higher than has been reported to date because small unruptured aneurysms which have been discovered during clot removal may not have been reported. Keywords: Multiple intracranial aneurysms; early operation; unruptured aneurysm; surgical outcome.
O p i n i o n s r e g a r d i n g surgical i n d i c a t i o n for m u l t i p l e a n e u r y s m s have changed. M c K i o s s o c k e t al. a~ in 1964, a n d P a t e r s o n a n d B o n d 3~ in 1973 t h o u g h t t h a t opera t i o n s for u n r u p t u r e d a n e u r y s m s were n o t indicated. H e i s k a n e n a n d M a r t t i l a 9 in 1970 a d v o c a t e d t h a t only those u n r u p t u r e d a n e u r y s m s which c o u l d be reached t h r o u g h the s a m e a p p r o a c h as the r u p t u r e d a n e u r y s m s s h o u l d be o p e r a t e d on, a n d t h a t a second o p e r a t i o n w o u l d n o t be indicated. H a m b y 6 in 1959, P o p p e n a n d F a g e r 32 in 1959, M o y e s 27 in 1971, M o u n t a n d Brisman24, 26 in 1971 a n d in 1977, a n d S a m s o n e t a l . 36 in 1977 r e c o m m e n d e d t h a t if c o n d i t i o n s were satisfactory, all surgically accessible u n r u p t u r e d a n e u r y s m s s h o u l d be o p e r a t e d on. Suzuki a n d S a k u r a i 37 in 1979, a n d S a l a z a r 34' 35 in 1980 a n d in 1983 insisted t h a t all o f the m u l t i p l e a n e u r y s m s s h o u l d be c o n s i d e r e d for o p e r a t i o n , even if a second o p e r a t i o n were necessary to clip the u n r u p t u r e d aneurysms. T h e m a i n objectives o f this study were to assess the surgical results for patients with m u l t i p l e i n t r a c r a n i a l a n e u r y s m s , especially those w h o were o p e r a t e d on in the early stages after s u b a r a c h n o i d h a e m o r r h a g e (SAH).
Material and Methods Introduction W h i l e there are different o p i n i o n s r e g a r d i n g the app r o p r i a t e n e s s o f direct surgery on incidental u n r u p t u r e d a n e u r y s m s in p a t i e n t s w i t h m u l t i p l e a n e u r y s m s , surgery for such a n e u r y s m s is g r a d u a l l y b e c o m i n g the a c c e p t e d practice as the result o f i m p r o v e d operative, anaesthetic, a n d m a n a g e m e n t techniques. R e c e n t p a pers on surgical t r e a t m e n t o f u n r u p t u r e d a s y m p t o m a t i c a n e u r y s m s have d e m o n s t r a t e d excellent surgical results; i.e., several series have r e p o r t e d o p e r a t i v e m o r talities o f zero o r o n l y a few p e r c e n t 8' 24, 2s, 34, 36, 44
During the 10 year period from 1979 to 1988, 478 patients who had suffered aneurysmal SAH were admitted to the Department of Neurosurgery of Shimane Prefectural Central Hospital. The subjects of the present study are 435 consecutive patients in whom the exact location of the ruptured aneurysm could be confirmed. With the calendar day of initial SAH considered as day 0, 59% (258) of the patients were admitted on day 0 and 88% (381) were admitted by day 7 (Fig. 1). Of the total 435 patients, 29% (126) had multiple aneurysms, and 71% (309) had single aneurysms. Of the 126 patients with multiple aneurysms, 37% (46) were males, and 63% (80) were females. The mean age was 60 years for the 126 patients, 53 years for males, and 64 years for females. The 126 patients with multiple aneurysms had 302 aneurysms. Ninety-one patients had 2 aneurysms,
T. Inagawa: Surgical Treatment of Multiple Intracranial Aneurysms 300 with multiple aneurysms with single aneurysms re
200
Q
*8 ..Q
E 100 z
1
2 3 4
5
6 7
8-14 15~ Day
Fig. 1. Day of admission in relation to the initial subarachnoid haemorrhage, with the day of haemorrhage considered as day 0 150 ~ll
with single aneurysms
I
O9
o~100 ..~ O_
with multiple aneurysms
~s ..Q
50
z
0
2
3
4 5
6 7
"/---8-I-4
15~Day
Fig. 2. Timing of first operation in relation to the initial subarachnoid haemorrhage, with the day of haemorrhage considered as day 0
24 had 3 aneurysms, 8 had 4 aneurysms, 2 had 5 aneurysms and I had 6 aneurysms. The percentage of the patients with 3 or more aneurysms were 28% for both males and females (13 of 46 patients and 22 of 80 patients). Of the 309 patients with single aneurysms, 45% (139) were males and 55% (170) were females. The mean age was 59 years for the 309 patients, 55 years for males, and 6l years for females. In accordance with a policy of early operation for ruptured intracranial aneurysms of the anterior circle I~' ~2, ~s, ~6, direct operations were performed on 75% of the 435 patients (325). This included 77% of 126 cases with multiple aneurysms (97) and 74% of 309 cases with single aneurysms (228). Figure 2 shows the interval between the initial SAH and the first surgery. Of the 325 surgical patients, 66% (214) were operated on by day 4 after the initial SAH. Each patient's preoperative clinical condition was graded according to Hunt and Hess 1~ without modification. The 97 patients with multiple aneurysms, who were operated upon, were classified into three groups. Group 1 comprised 48 patients whose ruptured and unruptured aneurysms were treated by one-stage operations. Group 2 included 21 patients whose multiple aneurysms were treated by two-stage operations, i.e., initially, the ruptured aneurysms were
23 operated upon, and then the unruptured aneurysms were treated by a second operation. Group 3 included 28 patients in whom only the ruptured aneurysms were operated upon. Group 1 patients were subdivided into three subgroups: (group l-A) had unruptured aneurysms which were discovered fortuitously during surgery and treated; (group l-B) had unruptured aneurysms which were discovered by preoperative angiograms, and were treated by the same approach as used for the ruptured aneurysms; and (group l-C) had unruptured aneurysms which were discovered by preoperative an~ograms, and treated by a different approach to that used for the ruptured aneurysms. A study was made of the following two points: (1) relationships of the site of ruptured aneurysms to the site ofunruptured aneurysms in groups 1 to 3, and (2) outcome at 1 year after the initial SAH. The outcome was classified according to the Glasgow Outcome ScaleTM. Statistical analyses were done using the chi-square test.
Results T a b l e 1 shows the age d i s t r i b u t i o n o f patients with m u l t i p l e or single a n e u r y s m s w h o were o p e r a t e d upon. T h e m e a n age was higher in g r o u p 3 t h a n in the o t h e r groups; that is, 56 years for g r o u p 1, 59 years for g r o u p 2, 64 years for g r o u p 3, a n d 57 years for the p a t i e n t s with single aneurysms. F u r t h e r , the rate o f elderly p a tients aged 70 years or older was higher in g r o u p 3 t h a n in the o t h e r groups. There were no significant differences between these g r o u p s in the p r e o p e r a t i v e clinical grades (Table 2).
1. Relationships of Site of Ruptured Aneurysms to Site of Unruptured Aneurysms in Groups 1 to 3 T a b l e s 3 a n d 4 shows the r e l a t i o n s h i p s o f the site o f r u p t u r e d a n e u r y s m s to the site o f u n r u p t u r e d aneurysms in g r o u p s 1 to 3. In the 12 cases in g r o u p l - A , 13 u n r u p t u r e d aneurysms were discovered d u r i n g surgery. M o s t o f these were tiny a n e u r y s m s a few m m in d i a m e t e r on m a i n t r u n k s o f the cerebral arteries. Therefore, while it was possible to clip 5 o f the aneurysms, 8 o f t h e m were t o o small to clip a n d were w r a p p e d or c o a t e d instead. N i n e o f the 13 a n e u r y s m s were discovered while r e m o v i n g clots d u r i n g o p e r a t i o n s d o n e by d a y 3 after S A H . In one case, after clipping a r u p t u r e d right i n t e r n a l car o t i d - p o s t e r i o r c o m m u n i c a t i n g a r t e r y a n e u r y s m , a left u n r u p t u r e d i n t e r n a l c a r o t i d - o p h t h a l m i c a r t e r y aneur y s m was discovered d u r i n g the clot r e m o v a l and then clipped; i.e., the u n r u p t u r e d a n e u r y s m was clipped b y a c o n t r a l a t e r a l p t e r i o n a l a p p r o a c h 28. In g r o u p l-B, 19 o f 28 cases were o p e r a t e d on b y d a y 4 after S A H . I n this group, there was a case in which a r u p t u r e d a n t e r i o r c o m m u n i c a t i n g a r t e r y a n e u r y s m a n d an u n r u p t u r e d basilar a r t e r y a n e u r y s m were c l i p p e d by the same pterional a p p r o a c h . I n g r o u p l - C , 6 o f the 9 cases were
T. Inagawa: Surgical Treatment of Multiple Intracranial Aneurysms
24 Table 1. Age Distribution in Surgical Patients With multiple or single aneurysms
Group
Age (years) ~70
Group 1
29 (21) 60% (62%)
16 (12) 33% (35%)
3 (I) 6% (3%)
48 (34)
Group 2
12 (8) 57% (57%)
6 (4) 29% (29%)
3 (2) 14% (14%)
21 (14)
Group 3*
12 (5) 43% (28%)
5 (3) 18% (17%)
11 (10) 39% (55%)
28 (18)
Single
133 (89) 58% (60%)
63 (39) 28% (26%)
32 (20) 14% (14%)
228 (148)
Total
186 (123) 57% (57%)
90 (58) 28% (27%)
49 (33) 15% (15%)
325 (214)
Group 1: ruptured and unruptured aneurysms were treated by one-stage operations. Group 2: multiple aneurysms were treated by two-stage operations. Group 3: only the ruptured aneurysms were operated on. Numbers in parentheses indicate patients who were operated on by day 4 after subarachnoid haemorrhage. * The number of elderly patients aged 70 years or older is significantly higher in group 3 than in groups 1 and 2 and in patients with single aneurysms (Z2= 12,894 and 11,377, both p
Acta Neurochir (Wien) (1991) 108:22-29
9 Springer-Verlag 1991 Printed in Austria
Surgical Treatment of Multiple Intracranial Aneurysms T. Inagawa Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
Summary A retrospective review of 126 patients with multiple aneurysms seen over a 10 year period was undertaken. They had a total of 302 aneurysms. Thirty-seven percent of the patients were males, and 63% were females. Direct operations were performed on 97 cases. Both the ruptured and unruptured aneurysms were treated in 71% (69 of the 97 cases), and only the ruptured aneurysms were treated in 29% (28). In 69 cases in whom both ruptured and unruptured aneurysms were treated, one-stage operations were used for 48 cases, and twostage operations were used for 21 cases. Thirty-four of the 48 cases, who were treated in one-stage operations, were operated on by day 4 after subarachnoid haemorrhage. In 12 eases, a total of 13 small unruptured aneurysms, which had not been found by preoperative angiograms, were discovered during surgery, and 9 of the 13 were discovered while removing blood clots to reduce cerebral vasospasm. Regardless of the operative method selected and the timing of operations, the surgical outcome of patients with multiple aneurysms was comparable to that of the 228 cases with single aneurysms treated during the same period at the same hospital. The analysis of this study suggests that surgical results for multiple aneurysms are satisfactory, even for early operations. Further, the actual incidence of multiple aneurysms may be higher than has been reported to date because small unruptured aneurysms which have been discovered during clot removal may not have been reported. Keywords: Multiple intracranial aneurysms; early operation; unruptured aneurysm; surgical outcome.
O p i n i o n s r e g a r d i n g surgical i n d i c a t i o n for m u l t i p l e a n e u r y s m s have changed. M c K i o s s o c k e t al. a~ in 1964, a n d P a t e r s o n a n d B o n d 3~ in 1973 t h o u g h t t h a t opera t i o n s for u n r u p t u r e d a n e u r y s m s were n o t indicated. H e i s k a n e n a n d M a r t t i l a 9 in 1970 a d v o c a t e d t h a t only those u n r u p t u r e d a n e u r y s m s which c o u l d be reached t h r o u g h the s a m e a p p r o a c h as the r u p t u r e d a n e u r y s m s s h o u l d be o p e r a t e d on, a n d t h a t a second o p e r a t i o n w o u l d n o t be indicated. H a m b y 6 in 1959, P o p p e n a n d F a g e r 32 in 1959, M o y e s 27 in 1971, M o u n t a n d Brisman24, 26 in 1971 a n d in 1977, a n d S a m s o n e t a l . 36 in 1977 r e c o m m e n d e d t h a t if c o n d i t i o n s were satisfactory, all surgically accessible u n r u p t u r e d a n e u r y s m s s h o u l d be o p e r a t e d on. Suzuki a n d S a k u r a i 37 in 1979, a n d S a l a z a r 34' 35 in 1980 a n d in 1983 insisted t h a t all o f the m u l t i p l e a n e u r y s m s s h o u l d be c o n s i d e r e d for o p e r a t i o n , even if a second o p e r a t i o n were necessary to clip the u n r u p t u r e d aneurysms. T h e m a i n objectives o f this study were to assess the surgical results for patients with m u l t i p l e i n t r a c r a n i a l a n e u r y s m s , especially those w h o were o p e r a t e d on in the early stages after s u b a r a c h n o i d h a e m o r r h a g e (SAH).
Material and Methods Introduction W h i l e there are different o p i n i o n s r e g a r d i n g the app r o p r i a t e n e s s o f direct surgery on incidental u n r u p t u r e d a n e u r y s m s in p a t i e n t s w i t h m u l t i p l e a n e u r y s m s , surgery for such a n e u r y s m s is g r a d u a l l y b e c o m i n g the a c c e p t e d practice as the result o f i m p r o v e d operative, anaesthetic, a n d m a n a g e m e n t techniques. R e c e n t p a pers on surgical t r e a t m e n t o f u n r u p t u r e d a s y m p t o m a t i c a n e u r y s m s have d e m o n s t r a t e d excellent surgical results; i.e., several series have r e p o r t e d o p e r a t i v e m o r talities o f zero o r o n l y a few p e r c e n t 8' 24, 2s, 34, 36, 44
During the 10 year period from 1979 to 1988, 478 patients who had suffered aneurysmal SAH were admitted to the Department of Neurosurgery of Shimane Prefectural Central Hospital. The subjects of the present study are 435 consecutive patients in whom the exact location of the ruptured aneurysm could be confirmed. With the calendar day of initial SAH considered as day 0, 59% (258) of the patients were admitted on day 0 and 88% (381) were admitted by day 7 (Fig. 1). Of the total 435 patients, 29% (126) had multiple aneurysms, and 71% (309) had single aneurysms. Of the 126 patients with multiple aneurysms, 37% (46) were males, and 63% (80) were females. The mean age was 60 years for the 126 patients, 53 years for males, and 64 years for females. The 126 patients with multiple aneurysms had 302 aneurysms. Ninety-one patients had 2 aneurysms,
T. Inagawa: Surgical Treatment of Multiple Intracranial Aneurysms 300 with multiple aneurysms with single aneurysms re
200
Q
*8 ..Q
E 100 z
1
2 3 4
5
6 7
8-14 15~ Day
Fig. 1. Day of admission in relation to the initial subarachnoid haemorrhage, with the day of haemorrhage considered as day 0 150 ~ll
with single aneurysms
I
O9
o~100 ..~ O_
with multiple aneurysms
~s ..Q
50
z
0
2
3
4 5
6 7
"/---8-I-4
15~Day
Fig. 2. Timing of first operation in relation to the initial subarachnoid haemorrhage, with the day of haemorrhage considered as day 0
24 had 3 aneurysms, 8 had 4 aneurysms, 2 had 5 aneurysms and I had 6 aneurysms. The percentage of the patients with 3 or more aneurysms were 28% for both males and females (13 of 46 patients and 22 of 80 patients). Of the 309 patients with single aneurysms, 45% (139) were males and 55% (170) were females. The mean age was 59 years for the 309 patients, 55 years for males, and 6l years for females. In accordance with a policy of early operation for ruptured intracranial aneurysms of the anterior circle I~' ~2, ~s, ~6, direct operations were performed on 75% of the 435 patients (325). This included 77% of 126 cases with multiple aneurysms (97) and 74% of 309 cases with single aneurysms (228). Figure 2 shows the interval between the initial SAH and the first surgery. Of the 325 surgical patients, 66% (214) were operated on by day 4 after the initial SAH. Each patient's preoperative clinical condition was graded according to Hunt and Hess 1~ without modification. The 97 patients with multiple aneurysms, who were operated upon, were classified into three groups. Group 1 comprised 48 patients whose ruptured and unruptured aneurysms were treated by one-stage operations. Group 2 included 21 patients whose multiple aneurysms were treated by two-stage operations, i.e., initially, the ruptured aneurysms were
23 operated upon, and then the unruptured aneurysms were treated by a second operation. Group 3 included 28 patients in whom only the ruptured aneurysms were operated upon. Group 1 patients were subdivided into three subgroups: (group l-A) had unruptured aneurysms which were discovered fortuitously during surgery and treated; (group l-B) had unruptured aneurysms which were discovered by preoperative angiograms, and were treated by the same approach as used for the ruptured aneurysms; and (group l-C) had unruptured aneurysms which were discovered by preoperative an~ograms, and treated by a different approach to that used for the ruptured aneurysms. A study was made of the following two points: (1) relationships of the site of ruptured aneurysms to the site ofunruptured aneurysms in groups 1 to 3, and (2) outcome at 1 year after the initial SAH. The outcome was classified according to the Glasgow Outcome ScaleTM. Statistical analyses were done using the chi-square test.
Results T a b l e 1 shows the age d i s t r i b u t i o n o f patients with m u l t i p l e or single a n e u r y s m s w h o were o p e r a t e d upon. T h e m e a n age was higher in g r o u p 3 t h a n in the o t h e r groups; that is, 56 years for g r o u p 1, 59 years for g r o u p 2, 64 years for g r o u p 3, a n d 57 years for the p a t i e n t s with single aneurysms. F u r t h e r , the rate o f elderly p a tients aged 70 years or older was higher in g r o u p 3 t h a n in the o t h e r groups. There were no significant differences between these g r o u p s in the p r e o p e r a t i v e clinical grades (Table 2).
1. Relationships of Site of Ruptured Aneurysms to Site of Unruptured Aneurysms in Groups 1 to 3 T a b l e s 3 a n d 4 shows the r e l a t i o n s h i p s o f the site o f r u p t u r e d a n e u r y s m s to the site o f u n r u p t u r e d aneurysms in g r o u p s 1 to 3. In the 12 cases in g r o u p l - A , 13 u n r u p t u r e d aneurysms were discovered d u r i n g surgery. M o s t o f these were tiny a n e u r y s m s a few m m in d i a m e t e r on m a i n t r u n k s o f the cerebral arteries. Therefore, while it was possible to clip 5 o f the aneurysms, 8 o f t h e m were t o o small to clip a n d were w r a p p e d or c o a t e d instead. N i n e o f the 13 a n e u r y s m s were discovered while r e m o v i n g clots d u r i n g o p e r a t i o n s d o n e by d a y 3 after S A H . In one case, after clipping a r u p t u r e d right i n t e r n a l car o t i d - p o s t e r i o r c o m m u n i c a t i n g a r t e r y a n e u r y s m , a left u n r u p t u r e d i n t e r n a l c a r o t i d - o p h t h a l m i c a r t e r y aneur y s m was discovered d u r i n g the clot r e m o v a l and then clipped; i.e., the u n r u p t u r e d a n e u r y s m was clipped b y a c o n t r a l a t e r a l p t e r i o n a l a p p r o a c h 28. In g r o u p l-B, 19 o f 28 cases were o p e r a t e d on b y d a y 4 after S A H . I n this group, there was a case in which a r u p t u r e d a n t e r i o r c o m m u n i c a t i n g a r t e r y a n e u r y s m a n d an u n r u p t u r e d basilar a r t e r y a n e u r y s m were c l i p p e d by the same pterional a p p r o a c h . I n g r o u p l - C , 6 o f the 9 cases were
T. Inagawa: Surgical Treatment of Multiple Intracranial Aneurysms
24 Table 1. Age Distribution in Surgical Patients With multiple or single aneurysms
Group
Age (years) ~70
Group 1
29 (21) 60% (62%)
16 (12) 33% (35%)
3 (I) 6% (3%)
48 (34)
Group 2
12 (8) 57% (57%)
6 (4) 29% (29%)
3 (2) 14% (14%)
21 (14)
Group 3*
12 (5) 43% (28%)
5 (3) 18% (17%)
11 (10) 39% (55%)
28 (18)
Single
133 (89) 58% (60%)
63 (39) 28% (26%)
32 (20) 14% (14%)
228 (148)
Total
186 (123) 57% (57%)
90 (58) 28% (27%)
49 (33) 15% (15%)
325 (214)
Group 1: ruptured and unruptured aneurysms were treated by one-stage operations. Group 2: multiple aneurysms were treated by two-stage operations. Group 3: only the ruptured aneurysms were operated on. Numbers in parentheses indicate patients who were operated on by day 4 after subarachnoid haemorrhage. * The number of elderly patients aged 70 years or older is significantly higher in group 3 than in groups 1 and 2 and in patients with single aneurysms (Z2= 12,894 and 11,377, both p
