Tratamento cirúrgico dos aneurismas intracranianos: comparação entre cirurgias precoce e tardia

Colli, Benedicto O.; Martelli, Nelson; Assirati Júnior, João A.; Machado, Hélio R.; Sassoli, Valéria P.

doi:10.1590/S0004-282X1993000100014

Resumos

Neste estudo são analisadas as evoluções clínicas de 225 pacientes que apresentaram hemorragia subaracnóidea (HSA) por ruptura de aneurismas, atendidos no período de 1985 a 1990. A idade dos pacientes variou de 7 a 84 anos, com predomínio na faixa de 30 a 50 anos (60%). Quanto ao sexo, houve predomínio do feminino (62,2%). Quanto à localização dos aneurismas rotos, os pacientes distribuiram-se em: 75 na artéria carótida interna, 66 na comunicante anterior, 61 na cerebral média, 14 na circulação posterior, 1 na cerebral anterior distal; e 8 em localização não identificada. Quarenta e cinco pacientes (20%) apresentaram mais de um aneurisma. Quarenta e quatro pacientes foram submetidos a tratamento cirúrgico nas primeiras 72 horas após a HSA, 40 no período de 4 a 7 dias, 16 no período de 8 a 10 dias e 57 após o 10º dia. As evoluções clínicas dos pacientes estudados são analisadas, baseadas na época da cirurgia em relação à HSA.

Aneurismas intracranianos; hemorragia subaracnóidea; cirurgia precoce; cirurgia tardia

The clinical course of patients with subarachnoid hemorrhage (SAH) due to rupture of cerebral aneurysm admitted during the last five years is analysed: 157 patients were treated by direct surgical approach of the aneurysm, 58 localized in the anterior communicating artery (ACoA), 48 in the internal ctarotid artery (ICA), 43 in the middle cerebral artery (MCA), and 8 in the posterior circulation. Fourty-four patients were operated on during the first 72 hours (early surgery), 40 during the 4th and 7th days, 16 during the 8th and the 10th, and 57 after the 10th (late surgery), According to main localizations, the outcome of patients with aneurysms in the ACoA was good in 79.1%, in the ICA in 69.7%, and in the MCA in 69.7%. Patients treated in Hunt & Hess grade I and II had both good results in 77.5%, grade HI patients had good results in 71.3%, and grade IV in 56.2%. According to timing of surgery good results were observed in 61.4% for patients submitted to early surgery, in 80% for patients treated during the 4th and 7th days, in 81.2% for patients treated during the 8th and the 10th days, and in 70.2% for that submitted to late surgery. The overall mortality was 14.6%. For grade I patients mortality was 6.4%, for grade, II was 12.2%, for grade III was 15.2%, for grade" IV was 25%, and all patients operated on in grade V died. Mortality for patients operated on during the first 72 hours was 29.5%, during the 4th and the 7th days was 15.0%, during the 8th and the 10th days was 6.2%, and after the 10th day was 8.7%. The mortality of non operated patients was 88.2%. The overall outcome for patients with aneurysm rupture was 52% and the overall mortality was 36.8%. Based on the results regarding the final clinical outcome early surgery for treatment of intracranial aneurysms was effective as late surgery, although

intracranial aneurysms; subarachnoid hemorrhage; early surgery; late surgery

Tratamento cirúrgico dos aneurismas intracranianos: comparação entre cirurgias precoce e tardia

Timing and results in intracranial aneurysm surgery

Benedicto O. Colli^I; Nelson Martelli^II; João A. Assirati Júnior^III; Hélio R. Machado^II; Valéria P. Sassoli^IV

^IDisciplina de Neurocirurgia, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP): Professor Associado, Neurocirurgia

^IIDisciplina de Neurocirurgia, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP): Professor Assistente Doutor, Neurocirurgia

^IIIDisciplina de Neurocirurgia, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP): Médico Assistente, Neurocirurgia

^IVDisciplina de Neurocirurgia, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP): Médica Residente, Neurocirurgia

RESUMO

Neste estudo são analisadas as evoluções clínicas de 225 pacientes que apresentaram hemorragia subaracnóidea (HSA) por ruptura de aneurismas, atendidos no período de 1985 a 1990. A idade dos pacientes variou de 7 a 84 anos, com predomínio na faixa de 30 a 50 anos (60%). Quanto ao sexo, houve predomínio do feminino (62,2%). Quanto à localização dos aneurismas rotos, os pacientes distribuiram-se em: 75 na artéria carótida interna, 66 na comunicante anterior, 61 na cerebral média, 14 na circulação posterior, 1 na cerebral anterior distal; e 8 em localização não identificada. Quarenta e cinco pacientes (20%) apresentaram mais de um aneurisma. Quarenta e quatro pacientes foram submetidos a tratamento cirúrgico nas primeiras 72 horas após a HSA, 40 no período de 4 a 7 dias, 16 no período de 8 a 10 dias e 57 após o 10º dia. As evoluções clínicas dos pacientes estudados são analisadas, baseadas na época da cirurgia em relação à HSA.

Palavras-chave: Aneurismas intracranianos, hemorragia subaracnóidea, cirurgia precoce, cirurgia tardia.

SUMMARY

The clinical course of patients with subarachnoid hemorrhage (SAH) due to rupture of cerebral aneurysm admitted during the last five years is analysed: 157 patients were treated by direct surgical approach of the aneurysm, 58 localized in the anterior communicating artery (ACoA), 48 in the internal ctarotid artery (ICA), 43 in the middle cerebral artery (MCA), and 8 in the posterior circulation. Fourty-four patients were operated on during the first 72 hours (early surgery), 40 during the 4th and 7th days, 16 during the 8th and the 10th, and 57 after the 10th (late surgery), According to main localizations, the outcome of patients with aneurysms in the ACoA was good in 79.1%, in the ICA in 69.7%, and in the MCA in 69.7%. Patients treated in Hunt & Hess grade I and II had both good results in 77.5%, grade HI patients had good results in 71.3%, and grade IV in 56.2%. According to timing of surgery good results were observed in 61.4% for patients submitted to early surgery, in 80% for patients treated during the 4th and 7th days, in 81.2% for patients treated during the 8th and the 10th days, and in 70.2% for that submitted to late surgery. The overall mortality was 14.6%. For grade I patients mortality was 6.4%, for grade, II was 12.2%, for grade III was 15.2%, for grade" IV was 25%, and all patients operated on in grade V died. Mortality for patients operated on during the first 72 hours was 29.5%, during the 4th and the 7th days was 15.0%, during the 8th and the 10th days was 6.2%, and after the 10th day was 8.7%. The mortality of non operated patients was 88.2%. The overall outcome for patients with aneurysm rupture was 52% and the overall mortality was 36.8%. Based on the results regarding the final clinical outcome early surgery for treatment of intracranial aneurysms was effective as late surgery, although

Key words: intracranial aneurysms, subarachnoid hemorrhage, early surgery, late surgery.

Full text available only in PDF format.

Texto completo disponível apenas em PDF.

Aceite: 26-junho 1992

Dr. Benedicto Oscar Colli Departamento de Cirurgia, Hospital das Clinicas, FMRP Campus Universitário, SP 14048-900 Ribeirão Preto SP Brasil.

1. Adams HP, Kassel NF, Torner JC, Nibbelink DK, Sans AL. Early management of aneurysmal subarachnoid hemorrhage: a report of the cooperative aneurysm study. J Neurosurg 1981, 54:141-145.
2. Asano T. Delayed ischemic neurological deficits (DINDS). In Sano K, Asano T, Tanura A. Acute aneurysm surgery. New York: Springer, 1987, p 27-51.
3. Asano T, Sasaki T, Sano K. Lipid peroxidation and cerebral vasospasm. Brain and Nerve 1981, 33:33-46.
4. Dolenc V. A combined epi and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg 1985, 62:667-672.
5. Costa V, Lobo H, Souza BP. Experiência com 46 casos de aneurismas intracranianos operados na fase precoce (Abstr). XVII Congresso Brasileiro de Neurocirurgia. Brasília, 1988.
6. Faleiros LCM. Estudo cooperativo brasileiro de aneurismas (Abstr). XVII Congresso Brasileiro de Neurocirurgia. Brasília, 1988.
7. Jane JA, Winn HR, Richardson AE. The natural history of intracranial aneurysm: rebleeding rates during the acute and long term period implication for surgical management. Clin Neurosurg 1977, 24:176-184.
8. Kassel NF, Drake CG. Timing of aneurysm surgery. Neurosurgery 1982, 10:514-519.
9. Kassel NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the cooperative study. Neurosurgery 1983, 13:476-481.
10. Kassel NF, Torner JC, Haley EC, Jane JA, Adiams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery: Part 1. Overall managements results. J Neurosurg 1990, 73:18-36.
11. Kassel NF, Torner JC, aley EC, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery: Part 2: Surgical results. J Neurosurg 1990, 73:37-47.
12. Ljundggren B, Brant L, Kagstron E, Sundbarg G. Results of early operations for ruptured aneurysm. J Neurosurg 1981, 54:473-479.
13. Locksley HB. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage: Section V, Part II. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations based on 6368 cases in the cooperative study. J Neurosurg 1966, 25:321-368.
14. Nishimoto A, Ueta K, Onbe H, Kitamura K, Omae T, Goto F, Ohneda G, Chigasaki H, Tsuru M, Suzuki J, Wada T, Sano K, Mannen T, Yoshioka M, Nakai O, Kageyama N, Nomura T, Handa H, Tanaka K. Nationwide cooperative study of intracranial aneurysm surgery in Japan. Stroke 1958, 16:48-52.
15. Odon GL. Cerebral vasospasm. Clin Neurosurg 1975, 22:29-58.
16. Ohman J, Heiskenen O. Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg 1989, 70:55-60.
17. Pia HW. Grading of cerebral (aneurysms and the timing of operation. Neurosurg Rev 1979, 4:143-150.
18. Ropper AH, Zervas NT. Outcome 1 year SHA from cerebral aneurysms. J Neurosurg 1984, 60:909-915.
19. Saito I, Ueda Y, Sano K. Significance of vasospasm in the treatment of ruptured intracranial aneurysms. J Neurosurg 1977, 47:412-429.
20. Sano K. Timing of surgery: the Japanese experience (Abstr). Proceedings of the Workshop «Calcium antagonists: possible therapeutic use in neurosurgery». Puerto Rico, 1983.
21. Sano K. Surgical indications and decision making. In Acute aneurysms surgery. New York: Springer, 1987, p 170-180.
22. Sano K, Asano T. Introduction. In Sano K, Asano T, Tamura A: Acute aneurysm surgery. New York: Springer, 1987, p 1-3.
23. Sano K, Asano T, Tanishima T, Sasaki T. Lipid peroxidation as a cause of cerebral vasospasm. Neurol Rev 1980, 2:253-272.
24. Sundt M, Whisnant JP. Subarachnoid hemorrhage from intracranial aneurysms: surgical management and natural history of disease. N Engl J Med 1978, 299:116-122.
25. Tamura A, Asano T, Sano K, Tsumagari T, Nakajima A. Protection from cerebral ischemia by a new imidazole derivate (y-9179) and pentobarbital: a comparative study in chronic middle cerebral artery occlusion in cats. Stroke 1979, 10:126-134.
26. Yasargyl MG. Microsurgery: Clinical considerations, surgery of the intracranial aneurysms and results. New York: G Thieme, 1984, Vol 2, p 340.
27. Yasargyl MG, Fox JL. The microsurgical approach to intracranial anuerysms. Surg Neurol 1975, 3:7-14.

Datas de Publicação

Publicação nesta coleção
19 Jan 2011
Data do Fascículo
Mar 1993

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

[1] 1. Adams HP, Kassel NF, Torner JC, Nibbelink DK, Sans AL. Early management of aneurysmal subarachnoid hemorrhage: a report of the cooperative aneurysm study. J Neurosurg 1981, 54:141-145.

[2] 2. Asano T. Delayed ischemic neurological deficits (DINDS). In Sano K, Asano T, Tanura A. Acute aneurysm surgery. New York: Springer, 1987, p 27-51.

[3] 3. Asano T, Sasaki T, Sano K. Lipid peroxidation and cerebral vasospasm. Brain and Nerve 1981, 33:33-46.

[4] 4. Dolenc V. A combined epi and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg 1985, 62:667-672.

[5] 5. Costa V, Lobo H, Souza BP. Experiência com 46 casos de aneurismas intracranianos operados na fase precoce (Abstr). XVII Congresso Brasileiro de Neurocirurgia. Brasília, 1988.

[6] 6. Faleiros LCM. Estudo cooperativo brasileiro de aneurismas (Abstr). XVII Congresso Brasileiro de Neurocirurgia. Brasília, 1988.

[7] 7. Jane JA, Winn HR, Richardson AE. The natural history of intracranial aneurysm: rebleeding rates during the acute and long term period implication for surgical management. Clin Neurosurg 1977, 24:176-184.

[8] 8. Kassel NF, Drake CG. Timing of aneurysm surgery. Neurosurgery 1982, 10:514-519.

[9] 9. Kassel NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the cooperative study. Neurosurgery 1983, 13:476-481.

[10] 10. Kassel NF, Torner JC, Haley EC, Jane JA, Adiams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery: Part 1. Overall managements results. J Neurosurg 1990, 73:18-36.

[11] 11. Kassel NF, Torner JC, aley EC, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery: Part 2: Surgical results. J Neurosurg 1990, 73:37-47.

[12] 12. Ljundggren B, Brant L, Kagstron E, Sundbarg G. Results of early operations for ruptured aneurysm. J Neurosurg 1981, 54:473-479.

[13] 13. Locksley HB. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage: Section V, Part II. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations based on 6368 cases in the cooperative study. J Neurosurg 1966, 25:321-368.

[14] 14. Nishimoto A, Ueta K, Onbe H, Kitamura K, Omae T, Goto F, Ohneda G, Chigasaki H, Tsuru M, Suzuki J, Wada T, Sano K, Mannen T, Yoshioka M, Nakai O, Kageyama N, Nomura T, Handa H, Tanaka K. Nationwide cooperative study of intracranial aneurysm surgery in Japan. Stroke 1958, 16:48-52.

[15] 15. Odon GL. Cerebral vasospasm. Clin Neurosurg 1975, 22:29-58.

[16] 16. Ohman J, Heiskenen O. Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg 1989, 70:55-60.

[17] 17. Pia HW. Grading of cerebral (aneurysms and the timing of operation. Neurosurg Rev 1979, 4:143-150.

[18] 18. Ropper AH, Zervas NT. Outcome 1 year SHA from cerebral aneurysms. J Neurosurg 1984, 60:909-915.

[19] 19. Saito I, Ueda Y, Sano K. Significance of vasospasm in the treatment of ruptured intracranial aneurysms. J Neurosurg 1977, 47:412-429.

[20] 20. Sano K. Timing of surgery: the Japanese experience (Abstr). Proceedings of the Workshop «Calcium antagonists: possible therapeutic use in neurosurgery». Puerto Rico, 1983.

[21] 21. Sano K. Surgical indications and decision making. In Acute aneurysms surgery. New York: Springer, 1987, p 170-180.

[22] 22. Sano K, Asano T. Introduction. In Sano K, Asano T, Tamura A: Acute aneurysm surgery. New York: Springer, 1987, p 1-3.

[23] 23. Sano K, Asano T, Tanishima T, Sasaki T. Lipid peroxidation as a cause of cerebral vasospasm. Neurol Rev 1980, 2:253-272.

[24] 24. Sundt M, Whisnant JP. Subarachnoid hemorrhage from intracranial aneurysms: surgical management and natural history of disease. N Engl J Med 1978, 299:116-122.

[25] 25. Tamura A, Asano T, Sano K, Tsumagari T, Nakajima A. Protection from cerebral ischemia by a new imidazole derivate (y-9179) and pentobarbital: a comparative study in chronic middle cerebral artery occlusion in cats. Stroke 1979, 10:126-134.

[26] 26. Yasargyl MG. Microsurgery: Clinical considerations, surgery of the intracranial aneurysms and results. New York: G Thieme, 1984, Vol 2, p 340.

[27] 27. Yasargyl MG, Fox JL. The microsurgical approach to intracranial anuerysms. Surg Neurol 1975, 3:7-14.