Abstract
It is important to prevent intraoperative aneurysm rupture in patients with ruptured cerebral aneurysms, because intraoperative bleeding can have catastrophic consequences. It is very useful for aneurysm surgeons trying to prevent this complication to know the incidence of intraoperative ruptures, the clinical grades and the location of aneurysms in which they occur and, when during operations intraoperative ruptures occur most frequently. We evaluated 905 of our patients with ruptured cerebral aneurysms and discussed the prevention of intraoperative rupture.
Intraoperative aneurysm rupture was noted in 117 cases (13%). That rate was significantly higher in cases with middel cerebral artery aneurysms, anterior communicating artery aneurysms and anterior cerebral artery aneurysms than in those with internal cerebral artery aneurysms and vertebrobasilar artery aneurysms. The incidence was significantly higher in cases undergoing surgery on Day 0 to 3 and 8 to 14 than on Day 4 to 7 and after Day 15. The intraoperative bleeding rate was also significantly higher in cases with Hunt and Kosnik Grade III to V than in those with I to II. The rate of intraoperative hemorrhage was significantly lower in cases enduring temporary occlusion to prevent intraoperative bleeding than in those without temporary clipping. Over 90%of the intraoperative rupture occurred at the timing of aneurysm dissection and application of clips.
Temporary clipping effectively prevents intraoperative bleeding. That should be followed by aneurysmal dissection with sharp microsurgical technique, when the intraoperative rupture may most likely occur due to the aneurysm tightly adhering to the surrounding tissues and its thinned and reddened wall. Especially, temporary clips should be used in clinical grade III to V patients with aneurysms in the anterior communicating artery, the distal anterior cerebral artery or the middle cerebral artery, who undergo surgery on Day 0 to 3 or Day 8 to 14.
To avoid aneurysm rupture when retracting the frontal lobe, methods to decrease the retractor pressure should be devised. And the brain spatula should be pulled in the proper direction according to the position of aneurysms, involving the direction of aneurysmal domes, the location of blebs, and these possible adherence to the surrounding tissue. As insufficient dissection of the neck causes bleeding in clip application, it should be remembered that the aneurysmal neck must be sufficiently dissected from the surrounding tissue with temporary clipping. A wrapping aneurysm clip should be applied for a blister-like aneurysm in the anterior wall of the internal cerebral artery.
