The results of a prospective cooperative study on aneurysmal subarachnoid hemorrhage (SAH) in Japan, 1994 (PCS-Japan 94) are reported. Eleven neurosurgical centers participated in this study over Japan and a total of 525 patients were entried and followed up for 3 months. The results were compared with those of International Cooperative Study on Timing of Aneurysm Surgery (ICSTAS) reported in J Neurosurg by Kassell, et al. in 1990. In PCS-Japan 94, more aged patients and cases in serious condition (WFNS Grade, IV, V) were enrolled. The overall outcome of these 525 cases were as follows by Glasgow Outcome Scale (GOS): GR, 56.7%; MD, 9.9%; SD, 8.6%; PVS, 4.6%; D, 20.2%. These results are almost the same as those of ICSTAS. This is possibly due to the fact that the management results of aged and serious grade patients in PCS-Japan 94 were better than in ICSTAS. As for the causes of unfavorable results, the direct effect of SAH increased (21%)) and vasospasm showed a tendency to decrease (12.4%) compared with ICSTAS.
We have categorized the pitfalls Of aneurysm surgery into 4 groups base on our experience with 1,433 cases. These 4 groups consists of: 1. Inappropriate preoperative organization of surgical strategies. 2. Inappropriate attitude with repeat to unexpected premature rupture. 3. Inadequate clipping techniques and selection of clips. 4. Unintentional occlusion or injury of perforating branches. This report provides a presentation of key techniques that we employ for successful acute stage surgery. Our newly designed jet irrigation bipolar system and suction method are used for easy removal of thick subarachnoid clot and obtaining clear access to anatomical structures. Performing a ventricular tap for hydrocephalus and removal of hematoma for hemorrhage cases are necessary for making the brain soft before approaching the aneurysm. A venous pathway should be also maintained for blood circulation. Clipping on wrapping technique or our newly designed encircling clip is very useful for special occasions, such as blister-like aneurysm and laceration of the neck area or arterial wall. Small arteries and perforating branches from the aneurysm neck or dome can be spared by the use of fenestrated clips. Tentative clipping and the dome coagulation method with or without short-term temporary clipping allow reliable and secure clipping in case of intraoperative rupture. Since most of the ruptures occur during dissection of the aneurysm neck or neck clipping, these techniques are helpful for certain types of clipping and to lessen ischemic damage. All of the above strategies for aneurysm surgery yield satisfactory results. This report provides a discussion of the technical management of these pitfalls.
This paper describes 12 patients with aneurysmal subarachnoid hemorrhage treated with cellulose acetate polymer (CAP) delivered intra-aneurysmally, to prevent early rebleeding, and then with tissue plasminogen activator (tPA) delivered via spinal catheter to lyse and draw off the subarachnoid clot. All the patients were Grade 3 to 5. Seven incomplete thrombotic aneurysms underwent direct clipping 2 to 7 weeks after CAP thrombosis, when intracranial pressure was normal, subarachnoid blood had cleared and the patients was presumably a more favorable clinical grade. There was no rebleeding and no severe symptomatic vasospasm in this treatment. The overall outcomes were satisfactory (including good in 8, disabled in 2, dead in 2).
We report management results of 100 consecutive patients with cerebral aneurysms admitted to our clinic during 1994. Among 100 patients, 67 were patients with ruptured cerebral aneurysms and 33 were unruptured aneurysms. Thirty-one of the 33 patients with unruptured aneurysms underwent surgery with favorable results. There was no surgical mortality or morbidity in this series. It is our policy that acute stage aneurysm surgery is indicated when the patients were in Grades I to IV and Grade V patients were contraindicated for surgery. Among the 67 consecutive cases of ruptured cerebral aneurysm, direct surgery was performed in 48 patients (72%). At the 3-month evaluation, 85% of surgically treated patients exhibited good recovery and 6% had died. All of the 11 conservatively managed patients but one had died from the primary brain damage or aneurysmal rerupture during the short period of admission. Overall, 69% of 67 patients had recovered to their premorbid state. Six percent of the patients were moderately disabled, 4% were severely disabled, and 21% had died. In this series, as the prevention of vasospasm, 28 patients with diffuse thick subarachnoid blood clots were treated by the intrathecal fibrinolytic therapy. We have administered tissue-type plasminogen activator (tPA) in multiple injections to the basal cisterns and ventricles intra- and postoperatively. Twenty-five of 28 patients did not present with delayed ischemic neurological deficits (DIND) in their postoperative course, but 3 patients showed DIND. Those three patients had several postoperative complications including catheter obstruction and intracranial bleeding presumably related to the intrathecal tPA injections. Consequently, the tPA administration was discontinued before all of the cisterns became low density in CT scans. In such patients with postoperative complications, there are still problems in applying this therapy. The surgical indication for aged patients was decided carefully considering several factors, including the patient's age, preoperative grades, surgical difficulty, and medical condition. There were 11 patients over 70 years of age. Five of these 11 patients who had Grades II or III preoperatively were treated surgically and made a good recovery. Four patients with surgically difficult aneurysms or severe medical complications were treated by the endovascular approach with relatively satisfactory results. Although the number of patients was small, recent development of the intravascular neurosurgical techniques is promising for the treatment of aged patients with surgically high risks.
By analyzing consecutive 100 cases with aneurysmal SAH, problems involved in the treatment of poor-grade patients are discussed. Among 100 cases, 55 cases were in Grade IV or V by Hunt system. We operated on all the cases in an acute stage except cases that had lost brain stem functions. Good outcome was obtained in 40 of 43 operated on of the good-grade patients (Grade I-III), in half of the operated Grade IV patients but exceptionally in Grade V patients. Although “primary damage” might be the major cause of poor results in poor-grade patients, it was not possible to differentiate primary and secondary damage. To improve surgical results, further investigation on brain protection after initial damage is mandatory.
Application of early surgery for ruptured infratentorial aneurysms is investigated in 86 consecutive cases with subarachnoid hemorrhage of 1994, and results of early surgery for ruptured infratentorial aneurysms were analyzed in 40 cases over the past 5 years. Seven of 86 cases with subarachnoid hemorrhage in 1994 had ruptured infratentorial aneurysms, 6 of whom underwent early surgery, while the other one was treated conservatively because of poor grade (Hunt and Kosnik Grade V). In 40 cases over the past 5 years who underwent early surgery, variable surgical approaches were selected in consideration of the location and size of each aneurysm. The three-month outcome of those were good recovery (G) in 24, moderate disability (MD) in 5, severe disability (SD) in 8, vegetative (V) in 1 and death (D) in 2 by Glasgow Outcome Scale. Twenty-nine of these 40 patients (72.5%) showed favorable outcome better than MD, and mortality of this series was 5.1%. These results were comparable to those of recent reports for total ruptured cerebral aneurysms. Technical improvement and adequate application of several surgical approaches for infratentorial aneurysms contributed to the results, although, perforator infarctions as surgical complications were encountered especially in cases with large basilar bifurcation aneurysms. On the other hand, cerebral vasospasm was also a significant complication even in cases with ruptured infratentorial aneurysms. Further technical advances to preserve perforating arteries around the aneurysms are expected.
A retrospective and prospective analysis of clinical outcome has been conducted in cases of ruptured cerebral aneurysm during the years 1987 to 1994. Our treatment strategy for ruptured cerebral aneurysm is acute surgery except in the cases of moribund condition with brain stem damage, severe vasospasm at the time of admission or severe general complication. A total of 394 cases were admitted; 51 cases were treated conservatively and 343 cases were operated on. The outcomes of conservatively treated cases were poor; two cases had severe disability, one was in a vegetative state and the others died. Of 343 operations 318 (92.7%) were performed within 24 hours after admission. Operations were delayed in 12 cases because of vasospasm at the time of admission. The patients who were operated on within 3 days after the attack were divided into two groups according to their hospital admission: 245 patients who were operated on during the years 1987 through 1993 were assigned to one group, and 35 patients operated on in 1994 were assigned to the other. Outcomes were about the same between both treatment period and aneurysm site. Most of the cases with poor outcome were due to the severity of the hemorrhage, vasospasm, and general and operative complications. Incidence of good outcome was about the same for Grade I to III and incidence of vegetative state and death was about the same for Grade V on admission between the two treatment periods in overall patients. Overall outcome is determined by severity of the grade on admission, and is about the same between the two treatment periods for cases treated with acute surgery. Causes of poor clinical outcome in Grade I to III were vasospasm, rebleeding and general and operative complications. Overall outcome would be improved somewhat by further progress of the treatment for vasospasm and management of the patients in the acute stage.
Fifty-five patients with ruptured cerebral aneurysm were surgically treated in our department in 1994. In overall postoperative results of these 55 patients, Glasgow Outcome Scales were Grade 1 in 35 cases (63.6%), Grade 2 in 5 cases (9.1%), Grade 3 in 5 cases (9.1%), Grade 4 in 2 cases (3.6%) and Grade 5 in 8 cases (14.5%). To prevent cerebral vasospasm for these patients, we performed a prospective trial: (1) cisternal drainage (2) IIIrd ventriculostomy, (3) intracisternal injection of steroid (7 days) and (4) intravenous injection of Sodium Ozagrel and Nizofenone (14 days). DIND was observed in 14 cases (25.5%) out of 55 patients, in which 8 cases were transient and had a good recovery to GOS Grade 1, 3 cases were left with neurological deficits and 1 case died. These results were better in 1994 than in 1992. Two cases out of 5 that were left with neurological deficits were unusual and had delayed onset.Onset of these two cases was 15 days after subarachnoid hemorrhage and one or two days after the end of postoperative therapy for vasospasm. We called this unusual and posttherapeutic onset of DIND “vasospasm lag.”
A series of 269 patients with ruptured cerebral aneurysm over the last five years were analyzed. This series consists of 227 patients whose operations were delayed for about 2 weeks, 17 patients with intracerebral hematoma in acute operation and 25 patients without treatment because of severe grade clinically (Hunt & Kosnik Grade V ). In the group whose operations were delayed 2 weeks, the rate of ADL 1 and 2 is 93.3% in Hunt & Kosnik Grade I, 77.7% in Grade II, 67.2% in Grade III and 52.6% in Grade IV. And also the rate of ADL 1 and 2 is 94.4% in Fisher Group 1 on CT scan, 84.2% in Group 2, 68.5% in Group 3 and 72% in Group 4. The factors of poor prognosis in ADL 3, 4 and 5 are 8.8% in the rerupture, 8.4% in the vasospasm, 6.2% in the complication and 1.8% in the operation technique. In all patients with ruptured cerebral aneurysm, the rate of 1 and 2 is 65.4% of 269 patients. The factors of poor prognosis in ADL 3, 4 and 5 and 12% in the initial attack, 7% in the rebleeding, 6% in the vasospasm, 6% in the complication and 2% in the operation technique.
In the present study, we report on the hemodynamic mechanism of appearance of hemiparesis after aneurysmal subarachnoid hemorrhage (SAH), usefulness of intracisternally located echography to detect narrowing of the first segment (M1 segment) of the middle cerebral artery, clinical introduction of dynamic digital subtraction angiography (dynamic DSA) to measure local transit time in the territory of spastic intracranial vessels, and finally the clinical results of endovascular treatment using percutaneous transluminal angioplasty and/or papaverine hydrochloride. Appearance of hemiparesis due to delayed vasospasm was thought to be caused by decrease in blood flow in the corona radiata fed by lenticulostriate arteries and medullary arteries of the middle cerebral artery. Intracisternally located echography detected a decrease in inner diameter of M1 segment. When the mean transit time lasted over 5.52 sec just after endovascular treatment for delayed vasospasm, cerebral infarction occurred, resulting in motor and/or cortical deficits. Thirteen (56.5%) of 23 patients endovascularlly treated for delayed vasospasm, resulted in good recovery more than three months after onset of SAH.
It is well known that rebleeding of ruptured intracranial aneurysm is associated with higher morbidity and mortality rate. And this second bleeding from ruptured aneurysm has been shown to occur frequently within 6 hours. A study of the preoperative intensive control of blood pressure was performed to determine whether this protocol provided benefits in patients undergoing microsurgical clipping of aneurysms. We conducted a retrospective chart review of 81 patients with ruptured cerebral aneurysm who underwent acute stage clipping in 1992 and 1993, of whom 19 (24%) had second bleeding before surgery. All rebleedings occurred during transfer to our clinic. Review of the detailed medical records indicates substantial increase of blood pressure on admission. After that, the intensive control of blood pressure (<100-120mmHg) using nicardipine, diltiazem, or trimetaphan was recommended to the primary clinics. During 1994 and 1995, 41 patients with ruptured aneurysm were transferred to our clinic with this protocol. Blood pressure on admission significantly decreased, and this was associated with remarkable reduction of rebleeding rate (5%). Using this protocol, critical blood pressure control during transfer appears to be a fundamental strategy for the prevention of second bleeding of ruptured aneurysm.
To study the natural history of ruptured cerebral aneurysms, the overall management result of subarachnoid hemorrhage obtained in the Emergency Medical Center (EMC) of Kyorin University was analyzed. During the calendar year 1994, 65 cases were managed in the EMC and another 31 cases in a neurosurgical ward. Among 290 consecutive cases directly admitted to EMC since 1989, about half the patients were hospitalized within one hour from onset and 95% within 6 hours. Their neurological condition on admission was categorized according to the Hunt and Kosnik grading. Eighteen percent were in Grade IV and 63 percent were in Grade V. About 40% of the patients showed abnormal pupillary findings and also had ataxic or apneic respiratory pattern on admission. Among the studied patient-population, 23% were dead on arrival. Ruptured aneurysm was verified in 46% of all and obliteration of the aneurysm was completed in 35% of all the patients. Overall management mortality rate was 72% and favorable outcome was obtained only in 14% of cases. These figures were similar to or worse than those from reported epidemiological studies on the natural history of ruptured aneurysms. The major causes of poor outcome of the present cases were the primary brain damage due to aneurysm rupture, rebleeding of the aneurysm and acute respiratory failure. We concluded that the conventional management strategy yields a limited outcome and only the prophylactic treatment of unruptured asymptomatic aneurysm can improve the natural history of the whole spectrum of patients with cerebral aneurysms.
The usual accepted surgical treatment for hypertensive intracerebral hemorrhage has been until now craniotomy and hematoma removal. This conventional surgery, performed under general anesthesia, is, however, fairly invasive in nature, especially for elderly patients or patients who have medical risk factors. There has been a long history of debate between surgical and conservative treatment. A less invasive alternative is aspiration surgery. Aspiration surgery can be carried out under local anesthesia, is safe for high-risk patients, and can be indicated for deep-seated hematomas such as thalamic or brain stem hemorrhages. We consider aspiration surgery the choice of surgery for cases with various types of hypertensive brain hemorrhage. We treated the patients by “CT controlled stereotactic aspiration surgery” since 1983. We report the characteristics of our system and surgical procedures in detail. We use a CT controlled stereotactic operation system (Matsumoto's type) and ultrasonic hematoma aspirator for aspiration surgery. The characteristics of our operation system are as follows. First, the coordinate system of the CT scanner itself is used directly (a localizing frame is not required). Second, we carry out the operation with serial observations of repeat CT scanning to confirm the result of the operation. Third, we can check intraoperatively the trajectory of the aspiration needle, and if any problem occurs, we can easily change the direction of the aspiration needle. The ultrasonic hematoma aspirator is useful in the aspiration of the acute stage hematoma, which is always hard and impossible to sufficiently aspirate by using only negative pressure. Our surgical procedure is as follows. A burr-hole operation is performed in the operating room to prevent infection or CT scanner contamination by blood or irrigation water. Next, in the CT room, hematoma aspiration is carried out under serial CT observations, and the CT controlled operation system and ultrasonic hematoma aspirator are applied. After hematoma aspiration, a drainage tube is left in the hematoma cavity, through which urokinase is administered to achieve a complete evacuation of residual hematoma postoperatively. We believe our “CT controlled stereotactic operation” has the above-mentioned advantages over conventional surgery or other methods of aspiration surgery. We consider that this surgery facilitates the natural healing process of intracerebral hematomas and will become the standard operation for hypertensive intracerebral hemorrhage.
We describe a modified surgical technique of fronto-temporal craniotomy with interfascial dissection of temporal fascia. The purpose of this technique is to preserve the fronto-temporal branch of the facial nerve. Forty-four patients with cerebral aneurysm were operated on by this technique, and 5 (11%) of them complained of postoperative transient malfunction of the nerve. The mean duration of the malfunction was 5.4 weeks, and the decreased blood supply to the facial nerve with mechanical compression during craniotomy may contribute to the occurrence of the malfunction.