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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.54 no.2 São Paulo June 1996

https://doi.org/10.1590/S0004-282X1996000200001 

Subarachnoid hemorrhage after aneurysm surgery

 

 

Carlos Gilberto Carlotti JuniorI; Nelson MartelliII; João Alberto Assirati JuniorI; Hélio Rubens MachadoIII; Antonio Carlos dos SantosIV; Benedicto Oscar ColliIII

IM.D., Assistant Physician (Neurosurgery)
IIM.D., Assistant Professor (Neurosurgery)
IIIM.D., Associated Professor (Neurosurgery)
IVM.D., Assistant Professor (Neuroradiology). Paper presented in the 10th European Congress of Neurosurgery (Berlin, May 1995)

 

 


ABSTRACT

The surgical treatment of intracranial aneurysms by clipping is recognized as effective and definitive. However some cases that suffered a new subarachnoid hemorrhage (SAH) some time after they were submitted to aneurysm clipping have raised doubts about the concept of "cure"after this treatment. Eleven patients previously submitted to aneurysm clipping who presented a new SAH were analyzed. The time elapsed from surgery to SAH varied from 3 to 10 years. After SAH four patients had a poor outcome. The new episode of SAH occurred due to intrinsic factors of the cerebral vasculature: 1. a weak point of the vessel wall near the previous aneurysm, 2. a weak point of another vessel far from the previous aneurysm, 3. a previous infundibular dilation of the posterior communicating artery; and due to technical problems: 1. aneurysm not identified during the previous treatment, 2. aneurysm deliberately left untreated, 3. persistence of the aneurysm due to inappropriate surgery, 4. persistency of part of the aneurysm neck after clipping and 5. slipping of the clip from the neck of the aneurysm. The measures to prevent new SAH after surgery start with adequate preoperative angiographic studies, a careful inspection of the position of the clip and emptying of the aneurysm. Early angiography studies may reveal a persistent neck and later ones may reveal newly developed aneurysms. In conclusion, SAH after aneurysm clipping is a late and severe phenomenon and the concept of "cure" after this surgery should be interpreted with caution.

Key-words: recurrent subarachnoid hemorrhage, ruptured cerebral aneurysms, surgical treatment.


RESUMO

O tratamento cirúrgico dos aneurismas cerebrais através de sua clipagem é reconhecido como eficaz e definitivo. Entretanto alguns casos sofrem nova hemorragia algum tempo após a cirurgia, deixando dúvidas sobre a "cura" pelo tratamento. Onze pacientes submetidos anteriormente a clipagem do aneurisma e que apresentaram nova hemorragia foram analisados. O intervalo de tempo da cirurgia para a nova hemorragia foi de 3 a 10 anos. Após a nova hemorragia, 4 pacientes tiveram evolução desfavorável. O novo episódio de hemorragia subaracnóide ocorreu devido a fatores intrínsicos dos vasos cerebrais ou a problemas técnicos. Dentre os fatores intrínsicos temos: l.um ponto fraco da parede do vaso próximo ao aneurisma, 2. um ponto fraco em outro vaso longe do aneurisma, 3. dilataçâo infundibular já existente próximo a artéria comunicante posterior. Devido a problemas técnicos encontramos: 1. aneurismas não identificados no tratamento anterior, 2. aneurisma deliberadamente não tratado, 3. persistência do aneurisma por cirurgia inapropriada, 4. persistência de parte do colo do aneurisma após a cirurgia, S. escorregamento do clip. As medidas para prevenir a nova hemorragia subaracnóide iniciam-se no estudo angiográfico pré-operatório, inspeção cuidadosa da posição do clip e no esvaziamento do aneurisma. A angiografia precoce pode revelar a persistência do colo e a tardia pode revelar o desenvolvimento de novos aneurismas. A hemorragia subaracnóide após a clipagem de aneurisma é um evento tardio e severo, e o conceito de "cura" após a cirurgia deve ser visto com reservas.

Palavras-chave: hemorragia subaracnóide recorrente, aneurisma cerebral roto, tratamento cirúrgico.


 

 

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

 

 

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Aceite: 15-janeiro-1995.

 

 

Division of Neurosurgery, Department of Surgery and Division of Radiology, Department of Internal Medicine, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
Dr. Carlos Gilberto Carlotti Junior - Departamento de Cirurgia HCFMRP - Campus Universitário USP -14048-900 Ribeirão Preto SP - Brasil. Fax: 016 633-0836.

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