Treatment of Ruptured Intracranial Aneurysms: Our Approach

Abstract

Objective: Subarachnoid hemorrhage (SAH) often results in devastating neurological deficits requiring hospitalization and loss of independence. This is often a difficult time for patients and their families who are struggling to cope with this sudden illness. Current treatment options include surgical clipping of the aneurysm or endovascular obliteration using Guglielmi detachable coils. Our purpose in writing this paper was to review the factors that determine the choice of treatment. In addition to this we wanted to study the benefits of surgical clipping for ruptured aneurysms over endovascular coiling. Material and Methods: We studied - retrospectively - 450 cases of ruptured cerebral aneurysms admitted to our institution from 1997 to 2003. Out of these, 324 were subjected to surgical clipping and 126 to endovascular techniques. The outcome was studied using the Glasgow Outcome Score (GOS). Results: Of the 324 cases of surgical clipping 222 had a good recovery, 38 had moderate disability, 15 had severe disability, 13 became vegetative and 36 patients died. In the endovascular group 34 had a good recovery, 22 had moderate disability, 18 had severe disability, 15 became vegetative and 37 patients died. Grade to Outcome was compared for both forms of treatment. In our series clipping for ruptured aneurysm was preferred to coiling in fusiform-shaped aneurysms, large or giant aneurysms, MCA aneurysms, blister aneurysms, complex configurations, partially thrombosed aneurysms and aneurysms associated with cerebral hemorrhage. Coiling was performed for basilar tip and trunk aneurysms, high anterior communicating artery aneurysms, patients in subacute stages of subarachnoid hemorrhage, and those with associated medical complications. Conclusion: Based on this study we were able to formulate a few definite indications for clipping, even in the times of advanced endovascular techniques. In addition we could also prove the benefits of surgical clipping over the endovascular technique in severe subarachnoid hemorrhage.

Key words

Subarachnoid hemorrhage - aneurysms - treatment

References

• 1 Vinuela F, Duckwiler G, Mawad M. Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients.  J Neurosurg. 1997;  86 475-482
• 2 Byrne J V, Sohn M J, Molyneux A J, Chir B. Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding.  J Neurosurg. 1999;  90 656-663
• 3 Raymond J, Roy D. Safety and efficacy of endovascular treatment of acutely ruptured aneurysms.  Neurosurgery. 1997;  41 1235-1245
• 4 International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group . International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial.  Lancet. 2002;  360 1267-1274
• 5 Raymond J, Guilbert F, Weill A, Georganos S A, Juravsky L, Lambert A, Lamoureux J, Chagnon M, Roy D. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils.  Stroke. 2003;  34 1398-1403
• 6 David C A, Vishteh A G, Spetzler R F, Lemole M, Lawton M T, Partovi S. Late angiographic follow-up review of surgically treated aneurysms.  J Neurosurg. 1999;  91 396-401
• 7 Ogilvy C S, Hoh B L. Clinical and radiographic outcome in the management of posterior circulation aneurysms by use of direct surgical or endovascular techniques.  Neurosurgery. 2002;  51 14-21; discussion: 21 - 22
• 8 Gruber D P, Zimmerman G A, Tomsick T A, Loveren H R van, Link M J, Tew Jr  JM. A comparison between endovascular and surgical management of basilar artery apex aneurysms.  J Neurosurg. 1999;  90 868-874
• 9 Tateshima S, Murayama Y, Gobin Y P, Duckwiler G R, Guglielmi G, Vinuela F. Endovascular treatment of basilar tip aneurysms using Guglielmi detachable coils: anatomic and clinical outcomes in 73 patients from a single institution.  Neurosurgery. 2000;  47 1332-1339
• 10 Raftopoulos C. Is surgical clipping becoming underused?.  Acta Neurochir (Wien). 2005;  147 117-123; discussion 123 - 124
• 11 Murayama Y, Nien Y L, Duckwiler G, Gobin Y P, Jahan R, Frazee J, Martin N, Vinuela F. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years experience.  J Neurosurg. 2003;  98 959-966
• 12 Debono B, Proust F, Langlois O. Ruptured anterior communicating artery aneurysm. Therapeutic options in 119 consecutive cases.  Neurochirurgie. 2004;  50 21-32
• 13 Groden C, Kremer C, Regelsberger J, Hansen H C, Zeumer H. Comparison of operative and endovascular treatment of anterior circulation aneurysms in patients in poor grades.  Neuroradiology. 2001;  43 778-783
• 14 Orz Y I, Hongo K, Tanaka Y, Nagashima H, Osawa M, Kyoshima K, Kobayashi S. Risks of surgery for patients with unnruptured intracranial aneurysms.  Surg Neurol. 2000;  53 21-27
• 15 Drake C G, Peerless J. Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992.  J Neurosurg. 1997;  87 141-162
• 16 Sano H, Kat Q Y, Shankar K. et al . Treatment and results of partially thrombosed giant aneurysms.  Neurol Ned Chir Suppl (Tokyo). 1998;  38 58-61
• 17 Lawton T, Spetzler R F. Surgical management of giant intracranial aneurysm: Experience with 171 patients.  Clinical Neurosurg. 1995;  42 245-266
• 18 Laidlaw J D, Siu K H. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age.  J Neurosurg. 2002;  97 250-258; discussion 247 - 249
• 19 Varma A, Mehta V S, Singh V P, Patir R. Role of emergency surgery to reduce mortality from rebleed in patients with aneurysmal SAH.  Neurol India. 2000;  48 56-62
• 20 Seifert V, Stolke D, Trost H A. Timing of aneurysm surgery. Comparison of results of early and delayed surgical intervention.  Eur Arch Psychiatry Neurol Sci. 1988;  237 291-297
• 21 Lot G, Houdart E, Cophignon J, Casasco A, George B. Combined management of intracranial aneurysms by surgical and endovascular treatment. Modalities and results from a series of 395 cases.  Acta Neurochir (Wien). 1999;  141 557-562
• 22 Christopher S, Ogilvy M D. Neurosurgical clipping versus endovascular coiling of patients with ruptured intracranial aneurysms.  Stroke. 2003;  34 2540
• 23 Pelz D M, Lownie S P, Fox A J. Thromboembolic events associated with the treatment of cerebral aneurysms with Guglielmi detachable coils.  AJNR Am J Neuroradiol. 1998;  19 1541-1547
• 24 Kivisaari R P, Salonen O, Servo A, Autti T, Hernesniemi J, Ohman J. MR imaging after aneurysmal subarachnoid hemorrhage and surgery: a long-term follow-up study.  AJNR Am J Neuroradiol. 2001;  22 1143-1148
• 25 Soeda A, Sakai N, Sakai H, Iihara K, Yamada N, lmakita S, Nagata I. Thromboembolic events associated with Guglielmi detachable coil embolization of asymptomatic cerebral aneurysms: evaluation of 66 consecutive cases with use of diffusion-weighted MR imaging.  AJNR Am J Neuroradiol. 2003;  24 127-132
• 26 Johnston S C, Zhao S, Dudley R A, Berman M F, Gress D R. Treatment of unruptured cerebral aneurysms in California.  Stroke. 2001;  32 597-605
• 27 Kato Y, Sano M, Katada K. et al . Clinical usefulness of 3D CT endoscopic imaging of cerebral aneurysms.  Neurol Res. 1996;  18 98-102
• 28 Getch C H, Batjer H, Bendok B R. Rupture intracranial aneurysms: The case for clipping.  Clin Neurosurg. 2004;  51 290-295