Summary
In patients suffering from subarachnoid haemorrhage (SAH) and presenting with multiple intracranial aneurysms (MIA) two questions have to be decided on: 1st when is the ideal moment to eliminate the ruptured aneurysm and 2nd when to treat the coexisting aneurysms.
In our series we retrospectively analysed 124 SAH-patients presenting with a total of 323 aneurysms.
In 57 patients the ruptured aneurysm and all coexisting aneurysms were clipped during the first operation, whereas in 9 patients only some of the coexisting aneurysms (group-A; age in median 55 years) were clipped besides the ruptured one. In 55 patients (group-B; age in median 55 years) the first operation was restricted to clipping the ruptured aneurysm, dealing with the coexisting aneurysm subsequently. Immediately after admission 3 patients passed away. One of the 64 patients waiting (average 60 days, median 14 days) for the subsequent clipping of the not yet secured aneurysms suffered a SAH. Six to 12 months after the initial SAH, 78% of the cases in both groups reached a Glasgow Outcome Score of 4 or 5.
Even if in patients with coexisting unruptured intracranial aneurysms the elimination of each and every aneurysm is recommended, the advantages of an unstaged procedure versus the additional strain caused by the prolongation of the procedure, e.g. approach over the midline, 2 or more craniotomies, and the risk of additional ischemic damage to the brain, caused by increased manipulation of cerebral arteries and brain tissue, have to be carefully considered. This is of special importance in dealing with patients in higher Hunt and Hess grades.
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Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, Brott T, Hademenos G, Chyatte D, Rosenwasser R, Caroselli C (2000) Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 31: 2742–2750
Chyatte D, Fode NC, Sundt TM Jr (1988) Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg 69: 326–331
de Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A (2002) Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature. Neurosurgery 50: 336–342
Elliott JP, Le Roux PD (1998) Subarachnoid hemorrhage and cerebral aneurysms in the elderly. Review. Neurosurg Clin N Am 9: 587–594
Findlay JM (1997) Current management of aneurysmal subarachnoid hemorrhage guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci 24: 161–170
Grigorian AA, Marcovici A, Flamm ES (2003) Intraoperative factors associated with surgical outcome in patients with unruptured cerebral aneurysms: the experience of a single surgeon. J Neurosurg 99: 452–457
Heiskanen O (1981) Risk of bleeding from unruptured aneurysm in cases with multiple intracranial aneurysms. J Neurosurg 55: 524–526
Hernesniemi J, Rinne J (2003) Multiple aneurysms. Surg Neurol 60: 136–137
Hino A, Fujimoto M, Iwamoto Y, Yamaki T, Katsumori T (2000) False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage. Neurosurgery 46: 825–830
Inagawa T (1991) Surgical treatment of multiple intracranial aneurysms. Acta Neurochir (Wien) 108: 22–29
International Study of Unruptured Intracranial Aneurysms Investigators (1998) Unruptured intracranial aneurysms — risk of rupture and risks of surgical intervention. N Engl J Med 339: 1725–1733
Kaminogo M, Yonekura M, Shibata S (2003) Incidence and outcome of multiple intracranial aneurysms in a defined population. Stroke 34: 16–21
Kassell NF, Torner JC, Jane JA, Haley EC Jr, Adams HP (1990) The international cooperative study on the timing of aneurysm surgery. Part 2: surgical results. J Neurosurg 73: 37–47
Laidlaw JD, Siu KH (2002) Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg 97: 250–259
Mizoi K, Suzuki J, Yoshimoto T (1989) Surgical treatment of multiple aneurysms: Review of experience with 372 cases. Acta Neurochir (Wien) 96: 8–14
Nehls DG, Flom RA, Carter LP, Spetzler RF (1985) Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg 63: 342–348
Ohman J, Heiskanen O (1989) Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg 70: 55–60
Orz Y, Osawa M, Tanaka Y, Kyoshima K, Kobayashi S (1996) Surgical outcome for multiple intracranial aneurysms. Acta Neurochir (Wien) 138: 411–417
Rinne J, Hernesniemi J, Niskanen M (1995) Management outcome for multiple intracranial aneurysms. Neurosurgery 36: 31–38
Rinne J, Hernesniemi J, Puranen M, Saari T (1994) Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study. Neurosurgery 35: 803–808
Solomon RA, Onesti ST, Klebanoff L (1991) Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia. J Neurosurg 75: 56–61
Swift DM, Solomon RA (1992) Unruptured aneurysms and postoperative volume expansion. J Neurosurg 77: 908–910
Ujiie H, Sato K, Onda H, Oikawa A, Kagawa M, Takakura K, Kobayashi N (1993) Clinical analysis of incidentally discovered unruptured aneurysms. Stroke 24: 1850–1856
Ulrich P, Perneczky A, Muacevic A (1997) Surgical strategy in cases of multiple aneurysms. Zentralbl Neurochir 58: 163–170
Vajda J, Juhasz J, Pasztor E, Nyary I (1988) Contralateral approach to bilateral and ophthalmic aneurysms. Neurosurgery 22: 662–668
Vajda J (1992) Multiple intracranial aneurysms: a high risk condition. Acta Neurochir (Wien) 118: 59–75
Whitfield PC, Kirkpatrick PJ (2001) Timing of surgery for aneurysmal subarachnoid haemorrhage. (Review). Cochrane Database Syst Rev: CD001697
Wiebers DO, Whisnant JP, Hoston J, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O'Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman Gl, Torner JC, International Study of Unruptured Intracranial Aneurysms Investigators (2003) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362: 103–110
Winn HR, Almaani WS, Berga SL, Jane JA, Richardson AE (1983) The long-term outcome in patients with multiple aneurysms. Incidence of late hemorrhage and implications for treatment of incidental aneurysms. J Neurosurg 59: 642–651
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Imhof, HG., Yonekawa, Y. (2005). Management of ruptured aneurysms combined with coexisting aneurysms. In: Yonekawa, Y., Keller, E., Sakurai, Y., Tsukahara, T. (eds) New Trends of Surgery for Stroke and its Perioperative Management. Acta Neurochirurgica Supplements, vol 94. Springer, Vienna. https://doi.org/10.1007/3-211-27911-3_14
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DOI: https://doi.org/10.1007/3-211-27911-3_14
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