Surgical Management of Ruptured Posterior Circulation Aneurysms – A Single Center Experience

Abstract

Objective The treatment of ruptured aneurysms of the posterior circulation is a controversy in neurosurgery. The aim of this work is to describe the experience and results of the early surgical treatment of this pathology at Centro Hospitalar do Porto.

Method We retrospectively analyzed the medical records of all patients aged over 18 who, in the period between 1999–2013, were admitted to our center with the diagnosis of ruptured saccular posterior circulation aneurysm. The patients were clinically staged at admission using the Hunt & Hess (H&H) scale. The modified Glasgow Outcome Scale (mGOS) was used to assess the outcome at discharge and after 6 months.

Results Between 1999–2013, 59 patients underwent surgery for ruptured posterior circulation aneurysms. Eighty percent of the patients were female, and their average age was 58.7 years. Posterior-inferior cerebellar artery aneurysms accounted for 49.2% of surgeries, while basilar aneurysms accounted for 28.8%. Upon admission, 86.4% of patients were classified as H&H1–3, and 13.6% as H&H4–5. The outcomes at discharge and at 6 months were as follows: at discharge, mGOS1 in 5.1%, mGOS2–3 in 18.6%, and mGOS4–5 in 76.3%; at 6 months, mGOS1 in 10.2%, mGOS2–3 in 10.2%, and mGOS4–5 in 79.6%. There was a statistically significant correlation between basilar aneurysms and worse outcomes (p = 0.011). No correlation was found between the values of the H&H scale upon admission and outcome.

Conclusions The functional outcome of our group of patients is mainly in line with what is described in other series from the literature. However, there is a trend toward lower mortality but higher morbidity rates.

Resumo

Objetivo O tratamento dos aneurismas rotos da circulação posterior é uma controvérsia neurocirúrgica. Pretende-se com este trabalho relatar a experiência e os resultados do tratamento cirúrgico precoce desta patologia no Centro Hospitalar do Porto.

Métodos Foram analisados retrospectivamente os processos clínicos dos pacientes com idade > 18 anos que, no período entre 1999–2013, foram admitidos no nosso centro com o diagnóstico de aneurisma sacular roto da circulação posterior. Utilizou-se a escala de Hunt & Hess (H&H) para aferir a gravidade clínica dos pacientes, e a Escala de Outcome de Glagow modificada (mGOS) para aferir o outcome dos pacientes à data da alta e aos 6 meses.

Resultados Entre 1999–2013, foram operados 59 pacientes com aneurismas rotos da circulação posterior. Oitenta por centro dos pacientes eram do sexo feminino, com uma média de idade média de 58.7 anos. Aneurismas da artéria cerebelosa posteroinferior foram responsáveis por 49,2% das cirurgias, ao passo que os da artéria basilar, por 28,8%. À admissão, 86,4% dos pacientes eram H&H1–3, e 13,6%, H&H4–5. O outcome à data da alta e aos 6 meses foi o seguinte: à data de alta, mGOS1 em 5,1%, mGOS2–3 em 18,6%, e mGOS4–5 em 76,3%; aos 6 meses, mGOS1 em 10,2%, mGOS2–3 em 10,2%, e mGOS4–5 em 79,6%. Verificou-se uma correlação estatisticamente significativa entre aneurismas da basilar e um pior outcome (p = 0,011). Não se verificou qualquer correlação entre os valores da escala de H&H à admissão e o outcome.

Conclusões O outcome funcional do nosso grupo de pacientes está em linha com o descrito noutras séries da literatura. Contudo, destaca-se uma tendência para uma mortalidade mais baixa, mas uma morbilidade mais alta no nosso grupo de pacientes.

Keywords

subarachnoid hemorrhage - brain aneurysms - posterior circulation aneurysms - surgical treatment

Palavras-chave

hemorragia subaracnoideia - aneurismas cerebrais - aneurismas da circulação posterior - tratamento cirúrgico

• References

• 1 van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain 2001; 124 (Pt 2): 249-278
• 2 Ferreira M, Tedeschi H, Wen H, Oliveira E. Posterior circulation aneurysms: guideline to management. Operative Techniques in Neurosurgery Volume 3. W.B. Saunder Company; 2000: 169-178
• 3 Ferreira R, Neves R, Rodrigues V. , et al. Portugal. Doenças cérebro-cardiovasculares em números – 2014. Programa Nacional para as doenças cérebro-cardiovasculares, in Direção-Geral da Saúde. 2014 ( https://www.dgs.pt/estatisticas-de-saude/estatisticas-de-saude/publicacoes/ portugal-doencas-cerebro-cardiovasculares-em-numeros-2014.aspx) [Accessed 19 September 2015]
• 4 Vlak MH, Rinkel GJ, Greebe P, Greving JP, Algra A. Lifetime risks for aneurysmal subarachnoid haemorrhage: multivariable risk stratification. J Neurol Neurosurg Psychiatry 2013; 84 (06) 619-623
• 5 Connoly S, Rabinstein A, Carhuapoma J. , et al. Guidelines for the management of aneurismal subarachnoid hemorrhage. Stroke 2012; 43: 6-27 https://www.ncbi.nlm.nih.gov/pubmed/22556195
• 6 Tykocki T, Kostkiewicz B. Aneurysms of the anterior and posterior cerebral circulation: comparison of the morphometric features. Acta Neurochir (Wien) 2014; 156 (09) 1647-1654
• 7 Signorelli F. Explicative cases of Controversial cases in Neurosurgery, in INTECH. Chapter 11–Surgical Management of Posterior Circulation Aneurysms: Defining the role of microsurgery in the contemporary endovascular era. INTECH. 2012
• 8 Guglielmi G, Viñuela F, Sepetka I, Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis, technique, and experimental results. J Neurosurg 1991; 75 (01) 1-7
• 9 Guglielmi G, Viñuela F, Dion J, Duckwiler G. Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience. J Neurosurg 1991; 75 (01) 8-14
• 10 Molyneux A, Kerr R, Stratton I. , et al; 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 randomised trial. Lancet 2002; 360 (9342): 1267-1274
• 11 Spetzler RF, McDougall CG, Zabramski JM. , et al. The Barrow Ruptured Aneurysm Trial: 6-year results. J Neurosurg 2015; 123 (03) 609-617
• 12 Sanai N, Tarapore P, Lee AC, Lawton MT. The current role of microsurgery for posterior circulation aneurysms: a selective approach in the endovascular era. Neurosurgery 2008; 62 (06) 1236-1249 , discussion 1249–1253
• 13 Machado J. Análise da experiência do Serviço de Neurocirurgia do Centro Hospitalar do Porto no tratamento cirúrgico dos aneurismas cerebrais da circulação posterior. [tese] Porto: Instituto de Ciências Biomédicas Abel Salazar; 2015
• 14 Williamson RW, Wilson DA, Abla AA. , et al. Clinical characteristics and long-term outcomes in patients with ruptured posterior inferior cerebellar artery aneurysms: a comparative analysis. J Neurosurg 2015; 123 (02) 441-445
• 15 Peerless SJ, Hernesniemi JA, Gutman FB, Drake CG. Early surgery for ruptured vertebrobasilar aneurysms. J Neurosurg 1994; 80 (04) 643-649
• 16 Krisht AF, Krayenbühl N, Sercl D, Bikmaz K, Kadri PA. Results of microsurgical clipping of 50 high complexity basilar apex aneurysms. Neurosurgery 2007; 60 (02) 242-250 , discussion 250–252
• 17 Viñuela 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 (03) 475-482
• 18 Pandey AS, Koebbe C, Rosenwasser RH, Veznedaroglu E. Endovascular coil embolization of ruptured and unruptured posterior circulation aneurysms: review of a 10-year experience. Neurosurgery 2007; 60 (04) 626-636 , discussion 636–637
• 19 Dandy WE. Intracranial aneurysm of the internal carotid artery. Cured by operation. Ann Surg 1938; 107 (05) 654-659
• 20 Dott N. Intracranial aneurysms: cerebral arterio-radiography: surgical treatment. Edinburgh Med J 1933; 40: 219-240
• 21 Drake C, Peerless S, Hernesniemi J. Surgery of Vertebrobasilar Aneurysms: London, Ontario experience on 1767 patients. Vienna. Springer Verlag GMBH; 1996