Recently less invasive diagnostic tools for the brain have been developed rapidly at a time when the population of the elderly has become enormous. Likewise, the number of patients having uAN-associated ischemic complications has grown sharply. For this special category of uAN, risk-benefit analysis is extremely difficult. Higher morbidity/mortality is common but rupture rates are considered more frequent than incidental uAN.
To prevent bleeding from uAN and to reduce complications triggered by precedent ischemic insult, we have performed radical surgery for such special uAN according to the following guidelines: 1) 70 years old and younger, without serious neurological deficits or general complications, capable of independent life, 2) significant interval (3-6 months) required between precedent ischemic insult and radical surgery, 3) meticulous examination for the etiology of ischemic condition and adequate treatment for the causes, 4) acceptance of prophylactic surgery such as CEA/stent (2 stage), and STA-MCA (concurrent with uAN surgery), 5) prevention of dehydration/hypotension and minimal washout of anti-platelet/thrombotic drug through perioperative period, 6) avoiding too much aspiration of CSF, long-time compression of the brain, temporarily occlusion of arteries, and sacrifice veins. We analyze the results of this series and evaluate the strategy in relation to the cause of complications.
Surgical mortality was 0 and morbidity was observed in 3 patients (permanent: 1; 6.25%, transient: 1; 6.25%). Good results were obtained by our strategy. Precedent ischemic insult may not deeply influence the result. Concurrent bypass did not increase risk of ischemic complication during radical surgery for uAN. However, much attention must be paid to sclerotic perforating artery, brain atrophy, and craniocerebral disproportion in patient with uAN and precedent ischemic accident.
