Surgical treatment of multiple intracranial aneurysms

Martelli, Nelson; Colli, Benedicto Oscar; Assirati Jr, João Alberto; Machado, Hélio Rubens; Parente Jr, Roberto

doi:10.1590/S0004-282X1988000200001

Abstracts

A retrospective study was conducted on 42 patients with multiple aneurysms surgically treated from 1975 to 1986. Thirty one of them had 2 aneurysms 6 had 3, 3 had 4 and 2 had 5 (62 in the internal carotid, 27 in the middle cerebral artery, 11 in the anterior cerebral and 3 in the basilar artery). All patients had subarachnoid hemorrhage and were classified as follows upon admission: 11, grade I; 12, grade II; 15, grade III, and 4, grade IV, and most of them improved before surgery (29, grade I, 7, grade II, and 6, grade III). In most cases, surgery was delayed and the 42 patients needed 57 craniotomies for clipping the aneurysms. Of the 24 patients with bilateral aneurysms, 15 were operated on both sides (11 are asymptomatic, 1 has hemiparesis, and 3 died later). Of the 9 patients submitted to unilateral craniotomy, 4 died and 5 are alive and well. Of the 18 patients with unilateral aneurysms, 11 are asymptomatic, 2 have hemiparesis, 1 has diplegia and behavioral disorders, and 4 died. Overall mortality was 26.1%, intraoperative mortality was 11.9%, and no mortality occurred among the patients operated over the last 5 years. The management of the these patients is discussed.

Foram analisados retrospectivamente 42 pacientes com aneurismas múltiplos (17,8% do total de pacientes com aneurismas) atendidos no período de 1975 a março de 1986. Vinte e sete eram do sexo feminino e 15 do masculino, com idade variando da terceira à sétima décadas. Trinta e um pacientes tinham 2 aneurismas (15 uni e 16 bilaterais), 6 tinham 3 (2 uni e 4 bilaterais), 3 tinham 4 (todos bilaterais) e 2 tinham 5 (bilaterais), totalizando 102 aneurismas (61 na carótida interna, 27 na cerebral média, 9 no complexo cerebral anterior/comunicante anterior, 3 na basilar e 2 na cerebral anterior distai). Todos os casos foram internados por hemorragia subaracnóidea e 11 foram classificados em grau I, 12 em grau II, 15 em grau III e 4 em grau IV na internação. Os pacientes foram mantidos em repouso absoluto, sob sedação e a evolução pré-operatória mostrou melhora clínica da maioria dos pacientes (29 operados em grau I, 7 em grau II e 6 em grau III). A cirurgia foi realizada tardiamente na maioria dos casos (28 entre o 11º e o 30º dia) e os 42 pacientes foram submetidos a 57 craniotomias para clipagem dos aneurismas. Dos 24 pacientes com aneurismas bilaterais, 15 foram operados dos dois lados (11 estão assintomáticos e 1 com hemiparesia e 3 faleceram tardiamente por outras causas que não hemorragia subaracnóidea). Dos 9 pacientes submetidos a craniotomia unilateral, 4 faleceram e 5 estão bem. Dos 18 pacientes com aneurismas unilaterais, 11 estão assintomáticos, 2 apresentam hemiparesia, 1 apresenta diplegia e distúrbios do comportamento e 4 faleceram. A mortalidade global foi de 26,1% durante todo o seguimento, a mortalidade operatória foi 11,9% e não houve mortalidade nos casos operados nos últimos 5 anos. A conduta preconizada para o tratamento destes pacientes é discutida.

Nelson Martelli; Benedicto Oscar Colli; João Alberto Assirati Jr.; Hélio Rubens Machado; Roberto Parente Jr.

Division of Neurosurgery, Department of Surgery, Orthopedics and Traumatology; Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo

SUMMARY

A retrospective study was conducted on 42 patients with multiple aneurysms surgically treated from 1975 to 1986. Thirty one of them had 2 aneurysms 6 had 3, 3 had 4 and 2 had 5 (62 in the internal carotid, 27 in the middle cerebral artery, 11 in the anterior cerebral and 3 in the basilar artery). All patients had subarachnoid hemorrhage and were classified as follows upon admission: 11, grade I; 12, grade II; 15, grade III, and 4, grade IV, and most of them improved before surgery (29, grade I, 7, grade II, and 6, grade III). In most cases, surgery was delayed and the 42 patients needed 57 craniotomies for clipping the aneurysms. Of the 24 patients with bilateral aneurysms, 15 were operated on both sides (11 are asymptomatic, 1 has hemiparesis, and 3 died later). Of the 9 patients submitted to unilateral craniotomy, 4 died and 5 are alive and well. Of the 18 patients with unilateral aneurysms, 11 are asymptomatic, 2 have hemiparesis, 1 has diplegia and behavioral disorders, and 4 died. Overall mortality was 26.1%, intraoperative mortality was 11.9%, and no mortality occurred among the patients operated over the last 5 years. The management of the these patients is discussed.

RESUMO

Foram analisados retrospectivamente 42 pacientes com aneurismas múltiplos (17,8% do total de pacientes com aneurismas) atendidos no período de 1975 a março de 1986. Vinte e sete eram do sexo feminino e 15 do masculino, com idade variando da terceira à sétima décadas. Trinta e um pacientes tinham 2 aneurismas (15 uni e 16 bilaterais), 6 tinham 3 (2 uni e 4 bilaterais), 3 tinham 4 (todos bilaterais) e 2 tinham 5 (bilaterais), totalizando 102 aneurismas (61 na carótida interna, 27 na cerebral média, 9 no complexo cerebral anterior/comunicante anterior, 3 na basilar e 2 na cerebral anterior distai). Todos os casos foram internados por hemorragia subaracnóidea e 11 foram classificados em grau I, 12 em grau II, 15 em grau III e 4 em grau IV na internação. Os pacientes foram mantidos em repouso absoluto, sob sedação e a evolução pré-operatória mostrou melhora clínica da maioria dos pacientes (29 operados em grau I, 7 em grau II e 6 em grau III). A cirurgia foi realizada tardiamente na maioria dos casos (28 entre o 11º e o 30º dia) e os 42 pacientes foram submetidos a 57 craniotomias para clipagem dos aneurismas. Dos 24 pacientes com aneurismas bilaterais, 15 foram operados dos dois lados (11 estão assintomáticos e 1 com hemiparesia e 3 faleceram tardiamente por outras causas que não hemorragia subaracnóidea). Dos 9 pacientes submetidos a craniotomia unilateral, 4 faleceram e 5 estão bem. Dos 18 pacientes com aneurismas unilaterais, 11 estão assintomáticos, 2 apresentam hemiparesia, 1 apresenta diplegia e distúrbios do comportamento e 4 faleceram. A mortalidade global foi de 26,1% durante todo o seguimento, a mortalidade operatória foi 11,9% e não houve mortalidade nos casos operados nos últimos 5 anos. A conduta preconizada para o tratamento destes pacientes é discutida.

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Departamento de Cirurgia, Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - I4048 Ribeirão Preto SP - Brasil.

1. Almaani WS, Richardson AE - Multiple aneurysms: identifying the ruptured lesion. Surg Neurol 9 :303, 1978.
2. Adams HP Jr, Kassel NF, Tomer JC - CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study. Neurology 33: 981, 1983.
3. Andrews RJ, Spiegel PK - Intracranial aneurysms: a sex, blood pressure, and multiplicity in an unselected series of patients. J Neurosurg 51: 27, 1979.
4. Beatty RA, Richardson AE - The value of eletroencephalography in management of multiple intracranial aneurysms. J Neurosurg 30:150, 1969.
5. Bigelow NH - Multiple intracranial arterial aneurysms: an analysis of their significance. Arch Neurol Psychiat 73: 76, 1955.
6. Bjorkensten GA, Troupp H - Multiple intracranial aneurysms. Acta Chir Scand 118: 387, 1959/1960.
7. Bjorkensten GA, Halonen V - Incidence of intracranial vascular lesions in patients with subarachnoid hemorrhage investigated by four vessel angiography. J Neurosurg 23: 29, 1965.
8. Drake CG, Vanderlinden RG - The late consequence of incomplete surgical treatment of cerebral aneurysms. J Neurosurg 27: 226, 1967.
9. Graf CJ - Prognosis for patients with non-surgically treated aneurysms: analysis of the Cooperative Study of Intracranial Aneurysms and Subarachnoid hemorrhage. J Neurosurg 35: 438, 1971.
10. Hamby WB - Multiple intracranial aneurysms: report of treatment. J Neurosurg 16: 558, 1959.
11. Heiskenen O - Multiple intracranial aneurysms. Acta Neurol Scand 41: 356, 1965.
12. Heiskenen O, Martilla I - Risk of rupture of a second aneurysm in patients with multiple aneurysms. J Neurosurg 32: 295, 1970.
13. Hunt WE, Hess RM - Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28: 14, 1968.
14. Jackson FE, Pratt RB, Back JB, Fleming PM, Juteau L, - Multiple intracranial arterial aneurysms: current thougths about diagnosis and treatment. Military Med 139: 37, 1947.
15. Jane JA, Kassel NF, Torner JC, Winn HR - The natural history of aneurysms and arteriovenous malformations. J Neurosurg 62: 321, 1985.
16. Locksley HB - Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section V, Part I. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the Cooperative Study. J Neurosurg 25: 219, 1966.
17. McKissock W, Paine KWE, Walsh L - An analysis of the results of treatment of ruptured intracranial aneurysms: report of 772 consecutive cases. J Neurosurg 17: 762, 1960.
18. McKissock W, Richardson A, Walsh L, Owen E - Multiple intracranial aneurysms. Lancet 1: 623, 1964.
19. Mount LA, Brisman R - Treatment of multiple intracranial aneurysms. J Neurosurg 35: 728, 1971.
20. Moyes PD - Surgical treatment of multiple aneurysms and of incidentally discovered unruptured aneurysms. J Neurosurg 35: 291, 1971.
21. Nehls DG, Flom RA, Carter LP, Spetzler RF - Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg 63: 342, 1985.
22. Ostergaard JR, Hog E - Incidence of multiple intracranial aneurysms: influence of arterial hypertension and gender. J Neurosurg 63: 49, 1985.
23. Overggard J, Rushed J - Multiple cerebral saccular aneurysms. Acta Neurol Scand 41: 363, 1965.
24. Paillas JE, Bonnal J, Pellegrin J, Sedan R - Les anevrysmes intracraniens multiples. Neuro-Chirurgie 2: 271, 1956.
25. Paterson A, Bond MR - Treatment of multiple intracranial arterial aneurysms. Lancet 1: 1302, 1973.
26. Perret G, Nishioka H - Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section IV. Cerebral angiography. An analysis of the diagnostic value and complications of carotid and vertebral angiography in 5484 patients. J Neurosurg 25: 98, 1966.
27. Perria L, Davini V, Grudeli R - Indications opératoires dans les anevrysmes multiples intra-craniens. Neuro-Chirurgie 3: 311, 1957.
28. Poppen JL, Fager CA - Multiple intracranial aneurysms. J Neurosurg 16: 581, 1959.
29. Pouyanne H, Banayan A, Got M, Guèrin J, Riemens V - Les anevrysmes sacculaires multiples du système carotidien supra-clinoidien: étude anatomo-clinique et therapeutique. Neuro-Chirurgie 19 (Suppl 1): 1, 1973.
30. Samson DS, Hodosh RM, Clarck WK - Surgical management of unruptured asymptomatic aneurysms. J Neurosurg 46: 731, 1977.
31. Stroobandt G, Cornelis G, Thauvoy C - Les anevrysmes intracraniens multiples: I. Evolution et orientation actuelle du traitment chirurgicale. Acta Neurol Belg 73: 298, 1973.
32. Wood E - Angiographic identification of the ruptured lesoin in patients with multiple cerebral aneurysms. J Neurosurg 21: 182, 1964.
33. Weisbcrg LA - Computed tomography in aneurysmal subarachnoid hemorrhage. Neurology 29:802, 1979.
34. Yasargil MG, Fox JL - The microsurgical approach to intracranial aneurysms. Surg Neurol 3:7, 1975.
35. Yoshimoto T, Kayama T, Kodama N, Suzuki J - Distribution of intracranial aneurysms. Tohoku J Exp Med 126:125, 1978.
36. Yoshimoto T, Uchida K, Kaneko U, Kayama T, Suzuki J - An analysis of follow-up results of 1000 intracranial saccular aneurysms with definitive surgical treatment. J Neurosurg 50: 152, 1975.

Surgical treatment of multiple intracranial aneurysms

Tratamento cirúrgico de aneurismas intracranianos múltiplos

Publication Dates

Publication in this collection
21 June 2011
Date of issue
June 1988

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Almaani WS, Richardson AE - Multiple aneurysms: identifying the ruptured lesion. Surg Neurol 9 :303, 1978.

[2] 2. Adams HP Jr, Kassel NF, Tomer JC - CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study. Neurology 33: 981, 1983.

[3] 3. Andrews RJ, Spiegel PK - Intracranial aneurysms: a sex, blood pressure, and multiplicity in an unselected series of patients. J Neurosurg 51: 27, 1979.

[4] 4. Beatty RA, Richardson AE - The value of eletroencephalography in management of multiple intracranial aneurysms. J Neurosurg 30:150, 1969.

[5] 5. Bigelow NH - Multiple intracranial arterial aneurysms: an analysis of their significance. Arch Neurol Psychiat 73: 76, 1955.

[6] 6. Bjorkensten GA, Troupp H - Multiple intracranial aneurysms. Acta Chir Scand 118: 387, 1959/1960.

[7] 7. Bjorkensten GA, Halonen V - Incidence of intracranial vascular lesions in patients with subarachnoid hemorrhage investigated by four vessel angiography. J Neurosurg 23: 29, 1965.

[8] 8. Drake CG, Vanderlinden RG - The late consequence of incomplete surgical treatment of cerebral aneurysms. J Neurosurg 27: 226, 1967.

[9] 9. Graf CJ - Prognosis for patients with non-surgically treated aneurysms: analysis of the Cooperative Study of Intracranial Aneurysms and Subarachnoid hemorrhage. J Neurosurg 35: 438, 1971.

[10] 10. Hamby WB - Multiple intracranial aneurysms: report of treatment. J Neurosurg 16: 558, 1959.

[11] 11. Heiskenen O - Multiple intracranial aneurysms. Acta Neurol Scand 41: 356, 1965.

[12] 12. Heiskenen O, Martilla I - Risk of rupture of a second aneurysm in patients with multiple aneurysms. J Neurosurg 32: 295, 1970.

[13] 13. Hunt WE, Hess RM - Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28: 14, 1968.

[14] 14. Jackson FE, Pratt RB, Back JB, Fleming PM, Juteau L, - Multiple intracranial arterial aneurysms: current thougths about diagnosis and treatment. Military Med 139: 37, 1947.

[15] 15. Jane JA, Kassel NF, Torner JC, Winn HR - The natural history of aneurysms and arteriovenous malformations. J Neurosurg 62: 321, 1985.

[16] 16. Locksley HB - Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section V, Part I. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the Cooperative Study. J Neurosurg 25: 219, 1966.

[17] 17. McKissock W, Paine KWE, Walsh L - An analysis of the results of treatment of ruptured intracranial aneurysms: report of 772 consecutive cases. J Neurosurg 17: 762, 1960.

[18] 18. McKissock W, Richardson A, Walsh L, Owen E - Multiple intracranial aneurysms. Lancet 1: 623, 1964.

[19] 19. Mount LA, Brisman R - Treatment of multiple intracranial aneurysms. J Neurosurg 35: 728, 1971.

[20] 20. Moyes PD - Surgical treatment of multiple aneurysms and of incidentally discovered unruptured aneurysms. J Neurosurg 35: 291, 1971.

[21] 21. Nehls DG, Flom RA, Carter LP, Spetzler RF - Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg 63: 342, 1985.

[22] 22. Ostergaard JR, Hog E - Incidence of multiple intracranial aneurysms: influence of arterial hypertension and gender. J Neurosurg 63: 49, 1985.

[23] 23. Overggard J, Rushed J - Multiple cerebral saccular aneurysms. Acta Neurol Scand 41: 363, 1965.

[24] 24. Paillas JE, Bonnal J, Pellegrin J, Sedan R - Les anevrysmes intracraniens multiples. Neuro-Chirurgie 2: 271, 1956.

[25] 25. Paterson A, Bond MR - Treatment of multiple intracranial arterial aneurysms. Lancet 1: 1302, 1973.

[26] 26. Perret G, Nishioka H - Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section IV. Cerebral angiography. An analysis of the diagnostic value and complications of carotid and vertebral angiography in 5484 patients. J Neurosurg 25: 98, 1966.

[27] 27. Perria L, Davini V, Grudeli R - Indications opératoires dans les anevrysmes multiples intra-craniens. Neuro-Chirurgie 3: 311, 1957.

[28] 28. Poppen JL, Fager CA - Multiple intracranial aneurysms. J Neurosurg 16: 581, 1959.

[29] 29. Pouyanne H, Banayan A, Got M, Guèrin J, Riemens V - Les anevrysmes sacculaires multiples du système carotidien supra-clinoidien: étude anatomo-clinique et therapeutique. Neuro-Chirurgie 19 (Suppl 1): 1, 1973.

[30] 30. Samson DS, Hodosh RM, Clarck WK - Surgical management of unruptured asymptomatic aneurysms. J Neurosurg 46: 731, 1977.

[31] 31. Stroobandt G, Cornelis G, Thauvoy C - Les anevrysmes intracraniens multiples: I. Evolution et orientation actuelle du traitment chirurgicale. Acta Neurol Belg 73: 298, 1973.

[32] 32. Wood E - Angiographic identification of the ruptured lesoin in patients with multiple cerebral aneurysms. J Neurosurg 21: 182, 1964.

[33] 33. Weisbcrg LA - Computed tomography in aneurysmal subarachnoid hemorrhage. Neurology 29:802, 1979.

[34] 34. Yasargil MG, Fox JL - The microsurgical approach to intracranial aneurysms. Surg Neurol 3:7, 1975.

[35] 35. Yoshimoto T, Kayama T, Kodama N, Suzuki J - Distribution of intracranial aneurysms. Tohoku J Exp Med 126:125, 1978.

[36] 36. Yoshimoto T, Uchida K, Kaneko U, Kayama T, Suzuki J - An analysis of follow-up results of 1000 intracranial saccular aneurysms with definitive surgical treatment. J Neurosurg 50: 152, 1975.