Subarachnoid hemorrhage after aneurysm surgery

Carlotti Junior, Carlos Gilberto; Martelli, Nelson; Assirati Junior, João Alberto; Machado, Hélio Rubens; Santos, Antonio Carlos dos; Colli, Benedicto Oscar

doi:10.1590/S0004-282X1996000200001

Abstracts

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.

recurrent subarachnoid hemorrhage; ruptured cerebral aneurysms; surgical treatment

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.

hemorragia subaracnóide recorrente; aneurisma cerebral roto; tratamento cirúrgico

Subarachnoid hemorrhage after aneurysm surgery

Carlos Gilberto Carlotti Junior^I; Nelson Martelli^II; João Alberto Assirati Junior^I; Hélio Rubens Machado^III; Antonio Carlos dos Santos^IV; Benedicto Oscar Colli^III

^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.

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.

1. Drake CG, Vanderlinger RG. The late consequences of incomplete surgical treatment of cerebral aneurysms. J Neurosurg 1967;27:226-238.
2. Drake CG, Friedman AH, Peerless SJ. Failed aneurysm surgery: reoperation in 115 cases. J Neurosurg 1984;61:848-856.
3. Ebina K, Suzuki M, Andoh A, Saitoh K, Iwabuchi T. Recurrence of cerebral aneurysm after initial neck clipping. Neurosurgery 1982;11:764-768.
4. Feuerberg I, Lindquist C, Lindqvist M, Steiner L. Natural history of postoperative aneurysm rests. J Neurosurg 1987;66:30-34.
5. Hassler O, Saltzman GF. Histologic changes in infundibular widening of the posterior communicating artery: a preliminary report. Acta Pathol Microbiol Scand 1959;46:305-312.
6. Kamitani H, Masuzawa H, Kanazawa I, Kubo T, Tokuyama Y. A long term follow-up study in direct cerebral aneurysm surgery. ActaNeurochir(Wien) 1995;133:134-140.
7. Koike G, Seguchi K, Kyoshima K, Kobayashi S. Subarachnoid hemorrhage due to rupture of infundibular dilatation of a circumflex branch of the posterior cerebral artery: case report. Neurosurgery 1994;34:1075-1077.
8. Lin T, Fox A, Drake CG. Regrowth of aneurysm sacs from residual neck following aneurysm clipping. J Neurosug 1989;70:556-560.
9. Little JR, Awad IA. Intracranial aneurysm. In Little JR, Awad IA (eds.)I: Reoperative neurosurgery. Williams & Wilkins, 1992:209-218.
10. Macdonald RL, Mallace C, Kestle JRW. Role of angigraphy following aneurysm surgery. J Neurosug 1993;79:826-832.
11. Martelli N, Colli BO, Assirati JA Jr., Machado HR, Moriol AR. Aumento de tamanho de pequeno aneurisma documentado por angiografia e autópsia. Arq Bras Neurocirurg 1983;2:133-138.
12. Moyes PD. Surgical treatment of multiple aneurysms and of incidentally discovery unruptured aneurysms. J Neurosurg 1971;35:291-295.
13. Rhine J, Hemesniemi. De novo aneurysms: special multiple intracranial aneurysms. Neurosurgery 1993;33:981-985.
14. Sakaki T, Takeshima T, Tominaga M, Hashimoto H, Kawaguchi S. Recurrence of ICA-PCoA aneurysms after neck clipping. J Neurosurg 1994;80:58-63.
15. Stehbens W. Etiology of intracranial aneurysms. J Neurosurg 1989;70:823-831.
16. Stroobandt G, Comelis G, Thauvoy CH. Les anévrysmes sacculaires multiples du système carotidien supraclinoidien. etude anatomo-clinique et thérapeutique. Neuro Chirurgie 1973;19(SuppI 1): 1-96.
17. Stuntz JT, Ojemann GA, Alvord CC Jr. Radiographic and histologic demonstration of an aneurysm developing on the infundibulum of the posterior communicating artery: case report. J Neurosurg 1979;35:591 -595.
18. Waga S, Morikawa A. Aneurysms developing in the infundibular widening of the posterior communicating artery. Surg Neurol 1979;11:125-127
19. Yasargil MG. Microneurosurgery: clinical considerations, surgery of the intracranial aneurysms and results. Stuttgart:: Georg ThiemeVeriag, 1984, Vol 2.
20. Yoshida M, Anegawa S, Moritaka A. Significance of infundibular dilatation in unexplained subarachnoid hemorrhage. Neurosurgery 1981 ;9:718-721.
21. Yoshimoto T, Suzuki J. Eight year demonstrated study of an aneurysm growth at the origin of the posterior communicating artery. Neurol Med Chir (Tokyo) 1974;5:571-573.

Publication Dates

Publication in this collection
06 Dec 2010
Date of issue
June 1996

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

[1] 1. Drake CG, Vanderlinger RG. The late consequences of incomplete surgical treatment of cerebral aneurysms. J Neurosurg 1967;27:226-238.

[2] 2. Drake CG, Friedman AH, Peerless SJ. Failed aneurysm surgery: reoperation in 115 cases. J Neurosurg 1984;61:848-856.

[3] 3. Ebina K, Suzuki M, Andoh A, Saitoh K, Iwabuchi T. Recurrence of cerebral aneurysm after initial neck clipping. Neurosurgery 1982;11:764-768.

[4] 4. Feuerberg I, Lindquist C, Lindqvist M, Steiner L. Natural history of postoperative aneurysm rests. J Neurosurg 1987;66:30-34.

[5] 5. Hassler O, Saltzman GF. Histologic changes in infundibular widening of the posterior communicating artery: a preliminary report. Acta Pathol Microbiol Scand 1959;46:305-312.

[6] 6. Kamitani H, Masuzawa H, Kanazawa I, Kubo T, Tokuyama Y. A long term follow-up study in direct cerebral aneurysm surgery. ActaNeurochir(Wien) 1995;133:134-140.

[7] 7. Koike G, Seguchi K, Kyoshima K, Kobayashi S. Subarachnoid hemorrhage due to rupture of infundibular dilatation of a circumflex branch of the posterior cerebral artery: case report. Neurosurgery 1994;34:1075-1077.

[8] 8. Lin T, Fox A, Drake CG. Regrowth of aneurysm sacs from residual neck following aneurysm clipping. J Neurosug 1989;70:556-560.

[9] 9. Little JR, Awad IA. Intracranial aneurysm. In Little JR, Awad IA (eds.)I: Reoperative neurosurgery. Williams & Wilkins, 1992:209-218.

[10] 10. Macdonald RL, Mallace C, Kestle JRW. Role of angigraphy following aneurysm surgery. J Neurosug 1993;79:826-832.

[11] 11. Martelli N, Colli BO, Assirati JA Jr., Machado HR, Moriol AR. Aumento de tamanho de pequeno aneurisma documentado por angiografia e autópsia. Arq Bras Neurocirurg 1983;2:133-138.

[12] 12. Moyes PD. Surgical treatment of multiple aneurysms and of incidentally discovery unruptured aneurysms. J Neurosurg 1971;35:291-295.

[13] 13. Rhine J, Hemesniemi. De novo aneurysms: special multiple intracranial aneurysms. Neurosurgery 1993;33:981-985.

[14] 14. Sakaki T, Takeshima T, Tominaga M, Hashimoto H, Kawaguchi S. Recurrence of ICA-PCoA aneurysms after neck clipping. J Neurosurg 1994;80:58-63.

[15] 15. Stehbens W. Etiology of intracranial aneurysms. J Neurosurg 1989;70:823-831.

[16] 16. Stroobandt G, Comelis G, Thauvoy CH. Les anévrysmes sacculaires multiples du système carotidien supraclinoidien. etude anatomo-clinique et thérapeutique. Neuro Chirurgie 1973;19(SuppI 1): 1-96.

[17] 17. Stuntz JT, Ojemann GA, Alvord CC Jr. Radiographic and histologic demonstration of an aneurysm developing on the infundibulum of the posterior communicating artery: case report. J Neurosurg 1979;35:591 -595.

[18] 18. Waga S, Morikawa A. Aneurysms developing in the infundibular widening of the posterior communicating artery. Surg Neurol 1979;11:125-127

[19] 19. Yasargil MG. Microneurosurgery: clinical considerations, surgery of the intracranial aneurysms and results. Stuttgart:: Georg ThiemeVeriag, 1984, Vol 2.

[20] 20. Yoshida M, Anegawa S, Moritaka A. Significance of infundibular dilatation in unexplained subarachnoid hemorrhage. Neurosurgery 1981 ;9:718-721.

[21] 21. Yoshimoto T, Suzuki J. Eight year demonstrated study of an aneurysm growth at the origin of the posterior communicating artery. Neurol Med Chir (Tokyo) 1974;5:571-573.