Online ISSN : 1687-8329

    




Quick Search 
 
Author  
Year    
Title  
Vol:  

 
 
July2014 Vol.51 Issue:      3 (Supp.) Table of Contents
Full Text
PDF


Early Surgery for Anterior Communicating Artery Aneurysms: Clinical Outcome in Consecutive 20 Cases

Ahmed Elsayed

Department of Neurosurgery, Cairo University, Egypt



ABSTRACT

Background: Anterior communicating artery aneurysms are the most common aneurysms involving the anterior circulation. They account for approximately 20% of all intracranial aneurysms. The risk of rupture of an unruptured cerebral aneurysm range from 0.1 to 8%annually. Objective: The aim of this study is to investigate the outcome of early anterior communicating artery aneurysms surgery and to review its morbidity and mortality. Methods: In this series, surgery was performed on 20 patients with ruptured anterior communicating artery aneurysm. Thirteen were males and seven were females with a mean age of 56.3 years. The majority of patients presented with symptoms of subarachnoid hemorrhage (SAH) at the time of admission. Each patient was evaluated radiologically by Computed tomography (CT) scan and Four-vessel angiography of brain. Results: All Patients on admission were in grade I, II or III (Hunt and Hess scale). They all underwent surgical clipping of anterior communicating artery (ACoA) aneurysms within 48 hours after presentation. Postoperative functional outcomes at discharge using the modified Rankin Scale were good in 14 (70%) patients, fair in four (20%), and poor in two (10%). At last follow-up, clinical functional outcomes were good in 85% of patients, fair in 5%, and poor outcome remained 10% despite death of one case from the poor group. Conclusions: Early surgical interference for anterior communicating artery aneurysm is a reliable management that provides satisfactory improvement of the functional outcome lowers morbidity rates and achieves total occlusion of the aneurysmal sac. [Egypt J Neurol Psychiat Neurosurg.  2014; 51(3) : 281-285]


Key Words: Anterior communicating artery, subarachnoid hemorrhage, aneurysms.

Correspondence to Ahmed Elsayed, Department of Neurosurgery, Cairo University, Egypt. Tel: +201223409034. Email: drahmed-73@hotmail.com




 


INTRODUCTION

 

Anterior communicating artery complex is the most common site for intracranial aneurysms. Anterior communicating artery aneurysms (ACoAAs) usually originate from the junction of the dominant A1 and the ACoA.1

ACoAAs is diagnosed by presence of subarachnoid hemorrhage (SAH). Four-vessel angiography or CT angiography of brain is used to confirm the diagnosis as early as possible.2

ACoAAs are mainly treated by either microsurgical clipping or endovascular coiling but the operative management should be the first choice in low-risk cases.3

A global debate among neurosurgeons about ideal timing of surgery either early aneurysm surgery (in first 48hours after SAH incidence) or delayed surgery (after 12 days post SAH).4

These aneurysms usually bleed into the adjacent frontal lobe or the ventricular system.5 Rupture of ACoAAs may cause several complications as infarction in  the  territories  of  the  anterior  cerebral  artery  or   the

Email: drahmed-73@hotmail.com).

ACoA perforating branches usually due to vasospasm, brain swelling, hydrocephalus or raised intracranial pressure from intracerebral bleeding.6 Surgery for ACoAAs is aiming the  total occlusion of the aneurysm while preserving the flow in the branching arteries and perforators.7 This is done by experienced microneurosurgical clipping of the aneurysm otherwise perforators arising from the ACoA complex and The recurrent artery of Heubner (RAH) can be occluded intraoperative with serious consequences.8,9 The preservation of these perforators considered a potential challenge for the surgeon especially ACoAAs surgery has high rate of morbidity and Mortality which is usually due to Initial SAH impact, vasospasm, and surgical trauma.6,7,10

This study is aimed to report the outcome of early anterior communicating artery aneurysms surgery and to review its consequences.

 

SUBJECTS AND METHODS

 

In this prospective cohort, which included 20 patients, they all admitted to Neurosurgery Department, Cairo university hospitals from 2010 to 2012. They all presented by ruptured anterior communicating artery aneurysm. Each patient was evaluated neurologically and radiologically by Computed tomography (CT) scan and Four-vessel angiography of brain (Figures 1 & 2). Patients aged between 38 and 71 years with mean age of 56.3 years.13 were males and seven were female. Patients received clipping of ACoA aneurysms within 48 hours after presentation with SAH through a pterional approach. Patients were prospectively followed for a period from 16-42 month .Postoperative CT scans performed within 48 hours of surgery. No postoperative magnetic resonance imaging (MRI) was done.

 

 

 

 

Figure 1. CT brain showing subarachnoid hemorrhage.

 

 

Figure 2. Four vessels angiography shows the anterior communicating aneurysm.

At the time of admission, the majority of patients presented with symptoms of subarachnoid hemorrhage (SAH) and they were assessed according to Hunt and Hess scale (Table 1).

We recorded patient demographics, postoperative complications and approach related complications were reported in this study.

 

Table 1. Patients Distribution according to Hunt-Hess Score.

 

Hunt-Hess Score

Number of Patients

I

6

II

10

III

4

IV

-

V

-

 

The American Heart Association (AHA) Guidelines for the treatment of Subarachnoid Hemorrhage was applied to all patients once diagnosis obtained. Patients were subjected to early surgery within 48 hours from admission.

The pterional technique was used in all cases. In craniotomy, the lateral sphenoid was removed ridge until reached the cisterns of base with no significant retraction of brain. Proximal sylvian fissure dissection was carried out in all cases and optic carotid cisternae were opened. In some cases rectus gyrus corticectomy was done. The dissection was continued to achieve access for the aneurysm. Brain protection was granted during the temporary clipping, which was applied in some cases, and finally permanent clipping of the neck of aneurysm was done.

Postoperative clinical assessment of the patients was done by using Modified-Rankin Scores (mRS) (Table 2). Scale outcome is presented as (good: 0 to 2, fair: 3, poor: 4 to 6)

 

Table 2. Patient assessment on Modified-Rankin scale.

 

Score

Clinical status

0

No symptoms

1

No significant disability. Able to carry out all usual activities, despite some symptoms

2

Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities

3

Moderate disability. Requires some help, but able to walk unassisted

4

Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

5

Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

6

Dead

Scale (good: 0 to 2, fair: 3, poor: 4 to 6)

RESULTS

 

On admission, all patients were in grade I, II or III assessed by Hunt and Hess scale. All patients underwent proximal sylvian fissure dissection, temporary clipping in 13 cases only in association with brain protection procedures. Gyrus rectus corticectomy was done in eight cases. After surgery, all patients were admitted in intensive care unit (ICU), elevation of blood pressure to160-180 mmHg in to treat the vasospasm. Patients received three lit serum and s

 

At discharge, Postoperative functional outcomes using the modified Rankin Scale were good in 14(70%) patients, fair in four (20%), and poor in two (10%). At last follow-up, clinical functional outcomes were good in 17 (85%) patients, fair in 1(5%), and poor in 2(10%) (One of the two cases died). Outcomes is shown in Table (3).

Complications in this study included Vasospasm in six cases (30%), postoperative brain edema from the retraction in four cases (20%), Hydrocephalus in 2 cases (10%) and mental changes in 3cases (15%).All complications were managed before last follow up.


Table 3. Patient outcomes on Modified-Rankin scale.

 

Modified Rankin Scale

At discharge (%)

At last follow up (%)

Good

14 (70%)

17 (85%)

Fair

4 (20%)

1(5%)

Poor

2 (10%).

2(10%)

 

 


DISCUSSION

 

Surgery for anterior communicating artery aneurysms is considered a great challenge for neurosurgeons. Surgery can be done early or delayed. Vasospasm peaks 4 to 12 days after the bleeding date, consequence of vasospasm includes delayed ischemic neurologic deficit and diffuse edema pattern.11

Outcomes of anterior communicating artery aneurysm surgery is affected by several factors as timing of surgery, effect of SAH, patients score on Hunt and Hess scale, preoperative and intraoperative planning, Appropriate surgical technique and avoidance of surgical trauma, improved visualization and good neurocritical care.12

In this series, we tried to offer surgery to patients as soon as possible once diagnosis confirmed. Early surgery helps in removal of subarachnoid clots (especially within 48 hours of SAH) and rinsing the basal cisterns which contributes to reduce delayed ischemic deficit, avoid risk of aneurysmal rebleeding, to reduce the frequency of hydrocephalus and achieve good prognosis.13,14,15

Approach used in this study was the pterional approach; it is more familiar and allows easy proximal control. In addition, most of surgeons are more experienced in this method and prefer it rather than other techniques10. Temporary clipping was used in 13 cases; the duration of temporary clipping was 5-8 minutes in this survey and no cognitive deficits has been reported. Many series reported that prolonged temporary clipping (more than 9 minutes) could cause cognitive changes early before ischemic injuries. 2

In the current series, modified Rankin Scale was used to assess functional outcome of the involved patients. At last follow-up, clinical functional outcomes were good in 85% of patients, fair in 5%, and poor in 10% of patients. In other series, outcomes by the end of follow up period were good in 84% of patients, fair in 8% and poor in 8% of patients. Another assessment tools for clinical outcomes includes involved Glasgow Outcome Disability Rating Scale (DRS) which are commonly used scales as well.16

Mortality in this series was reported in one case only (5%) in the follow-up period, it had a poor outcome after surgery. This was similar to other studies as Frenchet al.17, who reported a series of 25 patients with 4% mortality. Yashargil and colleagues 18 also mentioned in their series with microsurgical pterional approach that the rate of mortality was 5.9% .19

Neal and colleagues20 mentioned that patients received early surgery for aneurismal obliteration had a mortality rate of 10% to 12% compared with 3% to 5% when surgery was performed after Day ten. He assumed that early surgery was neither more hazardous nor beneficial than delayed surgery as the postoperative risk following early surgery is equivalent to the risk of vasospasm and rebleeding in patients waiting for delayed surgery .This was agreed by Samson and colleagues21 his review of 106 patients who underwent same surgery. There was no significant difference in the operative mortality in each group (early surgery, 5%; late surgery, 4%), intraoperative complications or postoperative morbidity.

Several procedures was followed in this series to decrease surgery-induced cerebral damage like removal of the sphenoid ridge ,sylvian fissure dissection, avoidance of manipulation of other areas beyond the frontal lobe fenestration of the lamina terminal is that improve brain relaxation during surgery and reduce incidence of cerebral vasospasm and postoperative  hydrocephalus.22Another studies mentioned that even minimal manipulation of brain tissue during aneurysm surgery may cause damage and also gentle dissection of the sylvian fissure arachnidan planes can affect cerebral microvasculature.23

Taneda15 in his study reported that delayed ischemic deficit causing permanent disability or death occurred in 25% of patients in whom surgery was delayed for 10 days or more while in 10.9% of patients in whom the aneurysms were obliterated within 48 hours of SAH. Solomon and colleagues four mentioned in their experience that prophylactic hypervolemic hypertensive therapy might help in reducing delayed ischemia (through volume expansion therapy) after early aneurysm surgery.

Complication occurred in this study, included vasospasm, postoperative brain edema from the retraction, Hydrocephalus and mental change. All complications were managed before last follow up.  Hashemiet and colleagues10 reported in their survey, which included 30 patients operated for ruptured anterior communicating artery aneurysm in the first 72 hours from SAH that complications include aspiration, congestive heart failure, seizure, DVT, electrolyte disturbances, mental change, and meningitis.24

 

Conclusions

Surgery is considered as a definitive treatment for anterior communicating artery aneurysm. Early interference achieves better patient outcomes and functionality and contributes to lower morbidity rates.

 

[Disclosure: Author reports no conflict of interest]

 

REFERENCES

 

1.      Dashti R, Rinne J, Hernesniemi J. Microneurosurgical management of proximal middle cerebral artery aneurysms. Surg Neurol .2007;67:6-14.

2.      Hino A, Fuse I, Echigo T, Oka H, Iwamoto Y, Fujamoto M. Clipping of upward projecting anterior communicating aneurysms via pterional craniotomy: approach from the side of A2 of anterior displacement. No Shinkei Geka. 2006; 34(2):149-58.

3.      Akyuz M, Tuncer R, Yilmaz S, Sindel T. Angiographic follow-up after surgical treatment of intracranial aneurysms. Acta Neurochir (Wien). 2004; 146:245-50.

4.      Solomon R, Fink M, Lennihan L. Early Aneurysm Surgery and Prophylactic Hypervolemic Hypertensive Therapy for the Treatment of Aneurysmal Subarachnoid Hemorrhage. Neurosurgery. 1988; 23: 699-704.

5.      Sasaki T, Kodama N, Matsumoto M. Blood flow disturbance in perforating arteries attributable to aneurysm surgery. J Neurosurg .2007; 107:60-7.

6.      Stenhouse LM, Knight RG, Longmore BE, Bishara SN. Long-term cognitive deficits in patients after surgery on aneurysms of the anterior communicating artery. J Neurol Neurosurg Psychiatry. 1991;54: 909-14.

7.      Rosen D, Amidei C, Tolentino J. Subarachnoid clot volume correlates with age, neurological grade, and blood pressure. Neurosurgery. 2007; 60: 259-66.

8.      Hernesniemi J1, Dashti R, Lehecka M, Niemelä M, Rinne J, Lehto H, et al. Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol. 2008;70: 8–29.

9.      Rosengart AJ, Schulteiss KE, Tolentino J. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007; 38:23, 15-21.

10.    Hashemi SM, Raie M. Surgical outcomes in patients with anterior communicating artery aneurysm. Acta Medica Iranica. 2007; 45(4): 316-320.

11.    Yavagal DR, Perera GR, Lignelli A. Detection of microvascular vasospasm after aneurysmal subarachnoid hemorrhage with MR diffusion perfusion imaging. Neurology. 2002; 58(suppl 3): A94.

12.    Andaluz N, Zuccarello M. Fenestration of the lamina terminalis as a valuable adjunct in aneurysm surgery.Neurosurgery.2004;55:1050–9.

13.    Horiuchi T, Tanaka Y, Hongo K, Kobayashi S. Aneurysmal subarachnoid hemorrhage in young adults: a comparison between patients in the third and fourth decades of life. J Neurosurg. 2003; 99(2):276-279.

14.    Sung H, Pil W, Yu S, Young J, Hyun C, Chun S. Effect of Cisternal Drainage on the Shunt Dependency Following Aneurysmal Subarachnoid Hemorrhage. J Kor Neurosurg Soc. 2012; 52:5, 441-6.

15.    Taneda M. Effect of early operation for ruptured aneurysms on prevention of delayed ischemic symptoms. J Neurosurg. 1982 Nov; 57(5):622-8.

16.    Kamitani H, Masuzawa H, Kanazawa I, Kubo T. Saccular cerebral aneurysms in young adults. Surg Neurol. 2000; 54: 59–66.

17.    French LA, Zarling ME, Schultz EA. Management of aneurysms of the anterior communicating artery. J Neurosurg. 1962; 19:870-6.

18.    Yasargil MG. Microneurosurgery: II. Clinical considerations, surgery of the intracranial aneurysms and results. New York. Georg: Thieme Verlag/Thieme Statton; 1984.

 

19.    Zabramski JM, Kiriş T, Sankhla SK, Cabiol J, Spetzler RF. Orbitozygomatic craniotomy. Technical note. J Neurosurg.1998; 89(2):336-41.

20.    Neal F, James C, John A, Clarke E. The International Cooperative Study on the Timing of Aneurysm Surgery Part 2: Surgical results. J  Neurosurg. 1990; 73(1):37-47.

21.    Samson DS, Hodosh RM, Reid WR, Beyer CW, Clark WK. Risk of intracranial aneurysm surgery in the good grade patient: early versus late operation. Neurosurgery. 1979; 5(4):422-6.

 

 

 

22.    Figueiredo EG, Deshmukh P, Zabramski JM. Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex. Neurosurgery. 2005; 56: 397–405.

23.    Norberto A, Mario Z. Anterior Communicating Artery Aneurysm Surgery through the Orbitopterional Approach: Long-Term Follow-Up in a Series of 75 Consecutive Patients. Skull Base. 2008; 18:265-74.

24.    Khandelwal P, Kato Y, Sano H, Yoneda M, Kanno T. Treatment of ruptured intracranial aneurysms: our approach. Minim Invasive Neurosurg. 2005; 48 (6):325-9.


الملخص العربي

الجراحة المبكرة لعلاج تمدد الشريان الموصل الأمامي: المخرج الإكلينيكي لعشرين حاله متتالية

 

يعتبر تمدد الشريان الامامى الواصل هو الأكثر شيوعا بين تمددات الأوعية الدموية بالمخ.فى هذه الدراسة التي شملت20 مريضا مصابين بتمدد شرياني منفجر بالشريان الأمامي الواصل، عند دخولهم المستشفى كانوا يعانون من نزيف تحت الأم العنكبوتية وتم تقييمهم إكلينيكيا بواسطة مقياس هانت وهيس. تم إجراء جراحة ربط عنق التمدد الشريانى لهم فى خلال 48 ساعة من حدوث النزيف.نتائج الجراحة تم تقييمها باستخدام مقياس رانكن المعدل الذي اظهر نتائج جيدة في 70% من المرضى، مقبولة في 20% وضعيفة في 10% من المرضى. وخلصت الدراسة إلى أن التدخل الجراحى المبكر لعلاج التمدد الشريانى المنفجر بالشريان الامامى الواصل يساهم فى تحسن الحالة الإكلينيكية للمريض وتقليل المضاعفات والتعقيدات.



2008 � Copyright The Egyptian Journal of Neurology,
Psychiatry and Neurosurgery. All rights reserved.

Powered By DOT IT