Management and Outcome of Ruptured Anterior Circulation Cerebral Aneurysms – An Experience of Neurosurgery Department of Nawabshah

Authors

  • Fahmida Arab Mallah Peoples University of Medical and Health Sciences for Women (PUMHSW), Nawabshah – Shaheed Benazir Abad.
  • Abdul Razaque Mari Peoples University of Medical and Health Sciences for Women (PUMHSW), Nawabshah – Shaheed Benazir Abad
  • Muzammil Dilbar Peoples University of Medical and Health Sciences for Women (PUMHSW), Nawabshah – Shaheed Benazir Abad.
  • Shams Raza Brohi Suleman Roshan Medical College, Tando Adam
  • Hamid Akbar Sheikh Peoples University of Medical and Health Sciences for Women (PUMHSW), Nawabshah – Shaheed Benazir Abad
  • Syed Aamir Shah Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), PIMS, Islamabad – Pakistan
  • Imran Mirbaher Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), PIMS, Islamabad – Pakistan

DOI:

https://doi.org/10.36552/pjns.v25i3.596

Keywords:

Aneurysms, subarachnoid hemorrhage

Abstract

Objectives:  To analyze the management and outcome of ruptured anterior cerebral circulation aneurysm by a variety of procedures including microsurgical clipping.

Material and Methods:  A quasi-experimental study, carried out in The Department of Neurosurgery, Peoples’ Medical University Hospital Nawabshah from November 2010 to December 2020.We enrolled 38 patients and 40 aneurysms who presented with ruptured aneurysms. Hunt and Hess grading was used to evaluate the neurological status and ruptured aneurysms were managed by microsurgical clipping, excision, and suture ligation.

Results:  Out of 38 patients Male were (23) 61% and females were (15) 39%, with a mean age of 50±25 years with aneurysmal subarachnoid hemorrhage and graded according to Hunt and Hess grade and fissure grading. Middle cerebral artery aneurysm was 45%, Anterior communicating artery 30%, Anterior Cerebral Artery 10%, carotid bifurcation 2.5%. Multiple aneurysms at internal carotid plus anterior communicating artery (n = 2) and internal carotid plus middle cerebral artery aneurysms n = 2. Distal anterior cerebral (n = 1). In 33 patients, the aneurysm was clipped, in 3 patients with fissure grading 4 and huge intracerebral bleed with signs of brain herniation, decompression plus aneurysm clipping was done, suture ligation (n = 1) and excision of a giant aneurysm (n = 3).

Conclusions:  Microsurgical clipping is considered an ideal modality to secure a ruptured intracerebral aneurysm. Rarely it can be amendable by suture ligation, or excision. Presenting Hunt and Hess, fissure grading, age, and volume of intracerebral bleed have a direct impact on prognosis.

References

1. Wecht DA, Awwad IA. Subarachnoid Haemorrhage: Principle of neurosurgery. 2nd ed. Grossman RG, Loftus CM (ed). Philadelphia: Lippincott-Raven Publishers, 1999: 297-308.
2. Wadd IH, Haroon A, Habibullah. Aneurysmal Subarachnoid Hemorrhage: Outcome of Aneurysm Clipping Versus Coiling in Anterior Circulation Aneurysm. Journal of the College of Physicians and Surgeons Pakistan, 2015; 25 (11): 798-801.
3. International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. New England Journal of Medicine, 1998 Dec. 10; 339 (24): 1725-33.
4. Linn FH, Rinkel GJ, Algra A, et al. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke, 1996; 276: 25–9.
5. Fukuda S, Koga Y. Hyperexemia during the hyperacute phase of aneurysmal subarachnoid hemorrhage is associated with delayed cerebral ischemia and poor outcome: A retrospective observational study. J Neurosurg. 2021; 134 (15): 1-8.
6. Fayyaz M, Hassan MA, Attique MH. Risk factors and early prognosis in stroke. Ann KE Med Col. 1999; 5: 12-5.
7. Rhoney DH, McAllen K, DeRyke XL. Current and future treatment considerations in the management of aneurysmal subarachnoid haemorrhage. J Pharm Pract. 2010; 23: 408-24.
8. Samaha E, Rizk T, Nohra G, Mohasseb G, Okais N. Intracranial arterial aneurysm: from diagnosis to treatment. A retrospective study of 46 surgically treated cases. J Med Liban. 1998; 46: 1225.
9. De Oliveira JG, Beck J, Seifert V, Teixeira MJ, Raabe A. Assessment of flow in perforating arteries during intracranial aneurysm surgery using intraoperative near-infrared indocyanine green video angiography. Operative Neurosurg. 2007; 61-72.
10. Nieuwkamp DJ, Rinkel GJ, Silva R, Greebe P, Schokking DA, Ferro JM. Subarachnoid haemorrhage in patients > or = 75years: clinical course, treatment and outcome. J Neurol Neurosurg Psy. 2006; 77: 933-7.
11. Bohm E, Hugosson R. Experiences of surgical treatment of 400 consecutive ruptured cerebral arterial aneurysms. Acta Neurochir (Wein). 1978: 40–43.
12. Khan MJ, M. Nasir H, Ali S. Outcome of Microsurgical Clipping of Ruptured Anterior Circulation Aneurysms. Pak. J. of Neurol. Surg. 2019: 277-281.
13. Rinne J, Keisuke I, HU Shen et al. Surgical management of aneurysms of middle cerebral artery, Henry H. Schemidek, Operative neurosurgical techniques. 5th ed. Saunders: Elsevier Publishing, 2006: 1144-1166.
14. Raza BS, Muzammil D. Silk ligation and Excision of Giant MCA aneurysm as Alternative Method of Treatment. Pak J Neurol Surg. 2018; 22 (4): 196-8.
15. Lafuente J, Maurice-Williams RS. Ruptured intracranial aneurysms: The outcome of surgical treatment of experienced hands in the period prior to the advent of endovascular coiling. J Neurol Neurosurg Psy. 2003; 74 (12): 1680-4.
16. Lehecka M, Lehto H, Niemelä M, Juvela S, Dashti R, Koivisto T, Ronkainen A, Rinne J, Jääskeläinen JE, Hernesniemi JA. Distal anterior cerebral artery aneurysms: treatment and outcome analysis of 501 patients. Neurosurgery, 2008; 62 (3): 590-601.
17. Taha MM, Alawamry A, Abdelbary TH. Outcome of microsurgical clipping of anterior circulation aneurysms during the period of vasospasm: single center experience in Egypt. Egyptian Journal of Neurosurgery, 2019; 34 (1): 1-6.
18. Kassell NF, Drake C. Timing of aneurysm surgery. Neurosurgery, 1982; 10 (4): 514-9.
19. Dorhout Mees SM, Molyneux AJ, Kerr RS, Algra A, Rinkel GJ. Timing of aneurysm treatment after subarachnoid hemorrhage: relationship with delayed cerebral ischemia and poor outcome. Stroke, 2012; 43 (8): 2126-9.
20. Orakdogen M, Emon ST, Somay H, Engin T, Ates O, Berkman MZ. Prognostic factors in patients who underwent aneurysmal clipping due to spontaneous subarachnoid hemorrhage. Turk Neurosurg. 2016; 26 (6): 840–8.
21. Bohnstedt BN, Nguyen HS, Kulwin CG, Shoja MM, Helbig GM, Leipzig TJ, Payner TD, Cohen-Gadol AA. Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms. World Neurosurg. 2013; 80: 335–41.
22. Koivisto T, Vanninen R, Hurskainen H. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms: a prospective randomized study. Stroke, 2000; 31: 2369-77.
23. David G. Piepgras, Vini G. Khurana and Jack P. Whishant. Ruptured giant intracranial aneurysms part II. A retrospective analysis of timing and outcome of surgical treatment. J Neurosurg. 1998; 88: 430–435.

Downloads

Published

2021-10-17

Issue

Vol. 25 No. 3 (2021): July-September

Section

Original Articles

License

The work published by PJNS is licensed under a Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Copyrights on any open access article published by Pakistan Journal of Neurological Surgery are retained by the author(s).