Problems of surgical treatment for multiple intracranial aneurysms]

A series of 105 patients presenting with multiple aneurysms and subarachnoid hemorrhage (SAH) were operated on for ruptured and unruptured aneurysms between 1976 and 1984. Clinical factors other than the severity of SAH affecting the outcomes included: 1) Misdiagnosis of the location of a ruptured aneurysm among multiple aneurysms resulted in poor outcomes because of multiple surgical approaches or rebleeding during the acute period. 2) Combinations of aneurysmal locations requiring multiple surgical approaches, such as interhemispheric and transsylvian, during the acute stage caused worse outcomes than with multi-stage surgeries. If an unruptured aneurysm could not be reached during the initial exposure, multi-stage surgery was safe if the ruptured aneurysm had been clipped during the acute period. 3) Complications occurring during unruptured aneurysm surgery. The patient's age, the location and size of the unruptured aneurysms were significant factors in the clinical prognosis. Surgery for unruptured aneurysm caused 1.8% morbidity in patients between 28 and 55 years, but 18.0% morbidity in patients over 56 years of age. Surgery for internal carotid artery aneurysms resulted in 14.8% overall morbidity. Surgery for middle cerebral and anterior cerebral artery aneurysms caused below 5% morbidity. Postoperative morbidity in patients with aneurysms less than 5 mm in diameter was 1.3%, and with aneurysms measuring 10 mm or more, 20%. The optimum treatment for multiple aneurysms with SAH should be based on all factors of the patient's condition, including the unruptured aneurysms.     

The role of ventricular and cisternal drainage in the early operation for ruptured intracranial aneurysms

Summary In a series of 177 patients with ruptured supratentorial aneurysms we studied retrospectively the results of early and delayed operation without aggressive removal of subarachnoid blood clots but ventricular and cisternal drainage. The early and delayed groups were comparable demographically and neurologically. The overall results for the early group were a good outcome in 65%, poor outcome in 10% and death in 24%, compared to 53, 20 and 27% respectively in the delayed group. Thus, patients with an early operation and CSF drainage had better results. Permanent ischaemic neurological deficits due to cerebral vasospasm accounted for the poor outcome in 10 and 21% of the patients in the early and delayed groups, respectively and rebleeding accounted for the poor outcome in 5 and 10% in the early and delayed groups respectively.The mean amount of haemoglobin in the cerebrospinal fluid from cisternal drainage was 6.4 g, corresponding to about 40 ml of whole blood, during the 12-day period after SAH. The level was higher in patients with larger subarachnoid clots or with symptomatic vasospasm than in those with smaller clots or without such vasospasm.Early operation combined with ventricular and cisternal drainage is considered to be a useful surgical method for patient with a ruptured aneurysm.     

Treatment of intradural paraclinoidal aneurysms

Intradural paraclinoidal aneurysm still presents conceptual confusion and technical surgical problems. The clinical features of 68 consecutive patients with paraclinoidal aneurysms were analyzed. The pterional approach was used in all patients. Subarachnoid hemorrhage (SAH) occurred in 37 patients from the paraclinoidal aneurysm and in 10 patients from another associated aneurysm. Thirty-four of the 37 ruptured paraclinoidal aneurysms were clipped, two blister-like aneurysms required trapping, and one blister-like aneurysm was coated. Thirteen of the 31 unruptured paraclinoidal aneurysms, consisting of 10 with ruptured associated aneurysm, four symptomatic, and 17 incidental, were clipped and 18 were coated. Favorable outcomes were obtained in 38 of 47 patients with SAH and 17 of 21 patients without SAH. Nine unfavorable outcomes in SAH patients were caused by primary brain damage (5), vasospasm (2), cerebral infarction after trapping (1), and pneumonia (1). All four unfavorable outcomes in non-SAH patients were due to surgical procedures for giant aneurysms or associated basilar artery aneurysm. Removal of the anterior clinoid process was performed to secure the proximal neck in 15 patients with large or giant aneurysms. Multiple clips with or without fenestrated clips were required in all giant aneurysms, and exposure of the cervical internal carotid artery (ICA) in 17 giant or large aneurysms. Fenestrated clips were also useful for one small aneurysm projecting posteriorly. A favorable outcome was achieved in 17 of 19 patients undergoing coating. Coating without clipping might be better for some blister-like ICA aneurysms, even if ruptured. Paraclinoidal aneurysms can be clipped with favorable results using these techniques except for giant aneurysms and associated basilar artery aneurysm.     

Evaluation of ruptured cerebral aneurysms under 5 mm in size on 3D-rotation angiography

According to the recent guideline of the Japanese Society for Detection of Asymptomatic Brain Diseases, it should be considered that the operative indication for unruptured cerebral aneurysms is larger than 5 mm, but we have often encountered patients with subarachnoid hemorrhage (SAH) caused by small ruptured cerebral aneurysms. The aim of our study was to evaluate retrospectively the characteristics of ruptured cerebral aneurysms under 5 mm in size on 3-dimensional digital rotation angiography (3D-RA). Eighty patients who presented with acute SAH caused by ruptured aneurysms were admitted in our hospital between January 2003 and September 2007. All patients were examined with 3D-RA and divided into two groups by aneurysmal size; group A was under 5 mm (N = 18), group B was larger than 5 mm (N = 62). Of aneurysms under 5 mm, 45% were located in the anterior communicating artery or anterior cerebral artery, 78% were female and 78% were treated with clipping. Clips of mini and/or the slim type were often applied for aneurysmal clipping. 3D-RA images were useful not only in identification of smaller aneurysms, but also in assessing aneurysmal morphology and relationships to neighboring vessels. However, in the cases of small aneurysms, it is necessary to remember that aneurysms become blood blister-shaped or thrombosed. The clipping for the aneurysm should be performed with consideration of choice for clips consisting of various types according to aneurysmal morphology.     

Hydrocephalus: comparison of clipping and embolization in aneurysm treatment

OBJECT: In this retrospective study conducted at Atkinson Morley's Hospital and Middlesbrough General Hospital, the authors analyzed 100 matched patients who had suffered subarachnoid hemorrhage (SAH) to determine whether the technical procedure by which aneurysms are treated affects the development of chronic hydrocephalus. METHODS: Four hundred seventy-five patients presented with SAH between 1995 and 1998. Exclusion criteria included posterior circulation aneurysms, multiple aneurysms, electively clipped or embolized aneurysms, angiographically undetected SAH, patients who died within 1 month of neurosurgical intervention, and patients with the same aneurysm location but a different Fisher grade. The authors matched 50 patients who underwent embolization of their aneurysms with another 50 who had similar Fisher grades and aneurysm types and underwent clipping of their aneurysms. The maximum incidence of ruptured aneurysms occurred in patients who were between 41 and 60 years of age, with women preponderant in both study groups. In each group, 27 patients had anterior communicating artery aneurysm, 13 had posterior communicating artery aneurysm, seven had middle cerebral artery aneurysm, and three had internal carotid artery aneurysm. The lesions in three patients in each group were Fisher Grade I, in 23 patients they were Fisher Grade II, in 14 they were Fisher Grade III, and 10 patients had Fisher Grade IV SAH. Nine patients among those with clipped aneurysms and eight of the patients who underwent embolization had hydrocephalus for which they needed intervention. These interventions included lumbar puncture, ventricular drainage, and ventriculoperitoneal (VP) shunt placement; three patients in each group needed VP shunt placement. CONCLUSIONS: The technical procedure used to treat aneurysms, whether clipping or embolization, does not significantly affect the development of chronic hydrocephalus. However, a larger sample of patients is needed for accurate comparisons and stronger conclusions.     

Does a safe size-limit exist for unruptured intracranial aneurysms?

Summary Of 1076 patients with intracranial ruptured aneurysms (RA) included in the Danish Aneurysm Study, 948 had the RA verified by angiography. Of these cases 908 RA had a maximum diameter less than 25 mm. 162 RA were <5 mm, 474 and 272 were between 5–10 mm and 11–24 mm, respectively. The average diameter of the RA according to the day of angiography after the aneurysm rupture did not differ significantly within the first 10 days. In these circumstances, using this indirect method for estimation of aneurysm rupture according to the size, we also recommend that unruptured aneurysms with a size 10 mm or less should be seriously considerated for operation.     

Outcome after subarachnoid hemorrhage from a very small aneurysm: a case-control series

OBJECT: A case-control analysis of patients with SAH was performed to compare risk factors and outcomes at 6 months posthemorrhage in patients with a very small aneurysm compared with those with a larger aneurysm. METHODS: All patients with SAH who were treated between January 1998 and December 1999 were studied. A very small aneurysm was defined as "equal to or less than 5 mm in diameter." Clinical data and treatment summaries were maintained in an electronic database. The Glasgow Outcome Scale (GOS) score was determined by an independent registrar. One hundred twenty-seven patients were treated. A very small aneurysm was the cause of SAH in 42 patients (33%), whereas 85 (67%) had aneurysms larger than 5 mm (mean diameter 11 mm). There were no differences in demographic variables or medical comorbidities between the two groups. Thick SAH (Fisher Grade 3 or 4) was more common in patients with a very small aneurysm than in those with a larger aneurysm (p = 0.028). One hundred eight patients underwent microsurgery (85%), 15 underwent coil embolization (12%), and four (3%) required both procedures. Vasospasm occurred in nine patients (21%) with very small aneurysms compared with 14 (16%) with larger aneurysms (p = 0.62). Shunt-dependent hydrocephalus occurred in nine patients (21%) with very small aneurysms and in 19 (22%) with larger aneurysms (p = 1). The mean GOS score for both groups was 4 (moderately disabled) at 6 months. CONCLUSIONS: Small aneurysms produce thick SAH more often than larger aneurysms. There is no difference in outcome after SAH between patients with a very small aneurysm and those with a larger aneurysm.     

Results of microsurgical treatment of paraclinoid carotid aneurysms

The term “paraclinoid aneurysms”, has been used for aneurysms of the internal carotid artery (ICA) between the cavernous sinus and the posterior communicating artery. Due to their complex anatomical relationship at the skull base and because they are frequently large/giant, their surgical treatment remains a challenge. Ninety-five patients harboring 106 paraclinoid aneurysms underwent surgery (1990–2010). Age, 11–72 years old. Sex, 74:21 female/male. Follow-up; 1–192 months (mean?=?51.7 months). Eighty-six patients had single and 9 had multiple paraclinoid aneurysms. Sixty-six were ophthalmic, 14 were in the ICA superior wall, 13 in the inferior, 10 in the medial, and 3 in the ICA lateral wall. Eleven were giant, 29 were large, and 66 were small. Sixty-three patients had ruptured and 32 had unruptured aneurysms. Two patients with bilateral aneurysms had bilateral approaches, totaling 97 procedures. A total of 98.2 % of aneurysms were clipped (complete exclusion in 93.8 %). ICA occlusion occurred in 10 (5.6 %). There was no patient rebleeding during the follow-up period. A good outcome was achieved in 76.8 %, with better results for unruptured aneurysms, worse results for patients with vasospasm, and with no difference according to size. Thirty-six (37.9 %) patients had transient/permanent postoperative neurological deficits (25.4 % ruptured vs. 62.5 % unruptured aneurysms). The most frequent deficits were visual impairment and third cranial nerve palsies. Operative mortality was 11.6 %, all in patients presenting with ruptured aneurysms. Despite relatively high morbidity/mortality, especially for patients with ruptured aneurysms, microsurgical treatment of paraclinoid aneurysm has high efficacy, with better outcome for unruptured aneurysms and worse outcome for patients with vasospasm.     

Saccular cerebral aneurysms in young adults

BACKGROUND: The formation and rupture of cerebral aneurysms has been controversial. In order to clarify their nature, this study investigates the size and location of ruptured and unruptured aneurysms in young adults and the results of surgery. METHODS: The subjects of this study are 35 patients with ruptured and two with unruptured aneurysms. They range in age from 20 to 39 years. The size and location of their aneurysms were determined by angiographic measure of their maximal inner diameters. Direct surgery was performed on 34 patients with ruptured aneurysms and on one with an unruptured aneurysm. RESULTS: Ruptured aneurysms in young adults increase in number and size as they grow older. In young adults showing no atherosclerosis or hypertension, ruptured aneurysms occurred in locations and with a frequency found in patients with hypertension. In young adults, aneurysms in the internal carotid artery larger than 3.5 mm (Fisher's exact test; p < 0.05) and the anterior communicating artery showed a tendency to rupture. The surgery produced excellent results in young adults with grade I to III by Hunt and Kosnik classification, but extremely poor results for those with grade IV resulting from vasospasm (Fisher's exact test; p < 0.05). CONCLUSION: It is possible that aneurysms found in young adults might in fact have been present from childhood and adolescence, increasing sufficiently in size to rupture in the forties and fifties. Accordingly, while aneurysm formation may be related to fragile arterial walls, aneurysm rupture may be the result of aging factors such as hypertension and atherosclerosis. Even in young adults, vasospasm had an impact on the outcome of surgery.     

脑动脉瘤破裂出血手术的麻醉处理

目的：探讨脑动脉瘤破裂出血围手术期的麻醉处理。方法：采用静脉快速诱导气管内插管、普鲁卡因静脉复合全麻、控制性降压等方法处理。结果：２６例患者术后无１例并发再出血，２例死于脑血管痉挛，２例偏瘫，２例巨大复杂后交通动脉瘤的患者在深低温体外循环下手术获得成功，余２２例痊愈出院。结论：围手术期麻醉处理关键是：采取有效措施防止再出血和脑血管痉挛，深低温体外循环、控制性降压、降低颅内压、脑室穿刺引流术等均有利于提高治愈率。     

Leukocytosis as an independent risk factor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage

OBJECT: The identification of patients at an increased risk for cerebral vasospasm after subarachnoid hemorrhage (SAH) may allow for more aggressive treatment and improved patient outcomes. Note, however, that blood clot size on admission remains the only factor consistently demonstrated to increase the risk of cerebral vasospasm after SAH. The goal of this study was to assess whether clinical, radiographic, or serological variables could be used to identify patients at an increased risk for cerebral vasospasm. METHODS: A retrospective review was conducted in all patients with aneurysmal or spontaneous nonaneurysmal SAH who were admitted to the authors' institution between 1995 and 2001. Underlying vascular diseases (hypertension or chronic diabetes mellitus), Hunt and Hess and Fisher grades, patient age, aneurysm location, craniotomy compared with endovascular aneurysm stabilization, medications on admission, postoperative steroid agent use, and the occurrence of fever, hydrocephalus, or leukocytosis were assessed as predictors of vasospasm. Two hundred twenty-four patients were treated for SAH during the review period. One hundred one patients (45%) developed symptomatic vasospasm. Peak vasospasm occurred 5.8 +/- 3 days after SAH. There were four independent predictors of vasospasm: Fisher Grade 3 SAH (odds ratio [OR] 7.5, 95% confidence interval [CI] 3.5-15.8), peak serum leukocyte count (OR 1.09, 95% CI 1.02-1.16), rupture of a posterior cerebral artery (PCA) aneurysm (OR 0.05, 95% CI 0.01-0.41), and spontaneous nonaneurysmal SAH (OR 0.14, 95% CI 0.04-0.45). A serum leukocyte count greater than 15 x 10(9)/L was independently associated with a 3.3-fold increase in the likelihood of developing vasospasm (OR 3.33, 95% CI 1.74-6.38). CONCLUSIONS: During this 7-year period, spontaneous nonaneurysmal SAH and ruptured PCA aneurysms decreased the odds of developing vasospasm sevenfold and 20-fold, respectively. The presence of Fisher Grade 3 SAH on admission or a peak leukocyte count greater than 15 x 10(9)/L increased the odds of vasospasm sevenfold and threefold, respectively. Monitoring of the serum leukocyte count may allow for early diagnosis and treatment of vasospasm.     

Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle

The purpose of this study is to describe our series of nine unclippable and uncoilable ruptured aneurysms in eight patients treated by microsurgical wrapping with autologous muscle. Records were retrospectively reviewed for rebleeding rate, morbidity and mortality, changes in size or the aneurysm’s configurations, and inflammatory reaction. We conducted a Medline search in the post-microsurgical era, excluding patients in whom wrapping was part of the aneurysm treatment in combination with clipping or coiling. The surgically related morbidity was 12.5 %. Global mortality rate was 25 % due to vasospasm (one case) and rebleeding (one case). Six patients are still alive. Rebleeding rate was 14.3 % within 6 months; then, it was zero. Glasgow outcome scale (GOS) score at discharge was 1 and 4 in one patient, respectively, and 5 in the remaining six. Mean clinical follow-up was 126 months. GOS at last follow-up was 4 and 5 in 50 % of patients, respectively. Mean mRS score was 0.8 at 2 months, and 2.4 at 12 months. Follow-up MR demonstrated persistence of the aneurysm’s sac, without changes in size and configuration. Patients did not describe or exhibit symptoms attributable to complications inherent to the use of muscle. Microsurgical muscle-wrapping of ruptured intracranial aneurysm is safe, is associated with a low rate of acute and delayed postoperative complications and rebleeding, and could be a valid alternative for unclippable and non-amenable to endovascular procedure ruptured aneurysms.     

Comparison of ruptured vs unruptured aneurysms in recanalization after coil embolization

BACKGROUND: Aneurysm recanalization is a significant problem in coil-treated intracranial aneurysms. We hypothesize ruptured aneurysms are more likely to demonstrate this phenomenon than unruptured aneurysms. METHODS: This was a retrospective study over 4 years. Initial and follow-up angiography results were reviewed and aneurysm obliteration was classified: I, complete; II, residual neck; III, residual aneurysm; and IV, partial treatment. Recanalization was classified as significant, mild, and none. RESULTS: Two hundred twelve aneurysms were coiled in 199 patients, of which 180 patients survived to 6 months after treatment. Follow-up angiography (>6 months) was available for 116 (64.4%) aneurysms (44 ruptured, 72 unruptured). Mean angiographic follow-up was 20 months. Recanalization was significant in 16 (13.8%) aneurysms, mild in 23 (19.8%), and absent in 87 (75%). Sixteen aneurysms underwent recoiling. Factors significant for recanalization by univariate analysis were ruptured vs unruptured (53.5% vs 22.5%; P = .001), larger aneurysm size (t test, P < .0001; median, 8-mm cut point, P < .01), aneurysm location (basilar tip and ICA terminus, P < .05), posterior circulation (P < .05), and younger age (t test, P < .05), whereas aneurysm neck size (4 mm) demonstrated a trend (P = .09). Incomplete initial aneurysm obliteration (II-IV, 20.6% vs I, 4.3%; P < .05) was associated with significant recanalization. In multivariate analysis, younger age (age <52 years; OR, 2.4; 95% CI, 0.194-2.08), ruptured aneurysm (OR, 3.2; 95% CI, 1.25-8.13), and larger aneurysm size (OR, 1.14; 95% CI, 1.04-1.24 linearly; OR, 3.5; 95% CI, 1.38-8.72) significantly predicted aneurysm recanalization. Performance of recoiling was significant with larger aneurysm size (OR, 2.0; 95% CI, 0.02-3.25) and younger age (age <52, OR, 2.4; 95% CI, 0.34-3.31) by multivariate analysis, whereas ruptured aneurysm demonstrated a trend. CONCLUSIONS: In multivariate analyses, ruptured aneurysms, larger aneurysms, and younger patient age were significantly associated with recanalization. Larger aneurysms and younger age were significantly associated with recoiling.     

Early surgical repair of large intracranial saccular aneurysms

Summary Among 302 patients with cerebral aneurysms admitted between 1981 and 1986, 63 had a large (45) or giant (18) aneurysm with a diameter of more than 12 mm and 24 mm, respectively. 24 of these 63 patients were admitted early after a subarachnoid haemorrhage (SAH) so as to allow surgical repair within 72 hours. Eight of them were inoperable for various reasons and could not undergo definitive surgical repair and died. 16 patients underwent craniotomy and clipping of the aneurysm. 77% of the patients in preoperative grades I-IV made a good recovery with no or minimal neurologic deficit. During the same period 84% of patients with small aneurysms made a good recovery.The present data indicate, that large aneurysms rupture with a similar incidence compared to small aneurysms; saccular large ruptured aneurysms can be operated upon early with similar results as small aneurysms. However, devastating initial bleeds and poor outcome occur more frequently in patients with ruptured giant than in patients with small aneurysms. Most of the patients with ruptured giant aneurysms are comatose on early admission and cannot be considered for early surgery. Their poor prognosis is further reduced by a high rebleeding rate.     

Treatment selection for ruptured aneurysm and outcomes: clipping or coil embolization

The International Subarachnoid Aneurysm Trial has shown that coil embolization achieves a better outcome for aneurysms treatable by either clipping or coil embolization. However, many ruptured aneurysms are hardly treatable by either clipping or coil embolization. Selection of either clipping or coil embolization will affect the treatment outcome for ruptured aneurysms. The relationship between patient selection and treatment outcome in a so-called "regional center hospital" in Japan must be clarified. This study included 113 patients with ruptured intracranial saccular aneurysms measuring less than 10 mm. Selection criteria for coil embolization were principally paraclinoid or posterior circulation aneurysm, Hunt and Hess grade IV or over, and patient age 75 years or older. Other aneurysms were principally treated by clipping. Aneurysms with a dome/neck ratio of less than 1.5, distorted aneurysms, Hunt and Hess grades I-III, patient age 74 years or younger, and middle cerebral artery aneurysm were actively treated by clipping. A few exceptional indications were considered in detail. Low invasiveness coil embolization is better than clipping to obtain good neurological outcome for patients with perforators difficult to dissect, aneurysms difficult to dissect due to previous open surgery, and aneurysms requiring bilateral open surgery, despite the slightly higher rebleeding rate in coil embolization. Overall outcomes were modified Rankin Scale (mRS) 0-2 in 82 of 113 patients (73%) and mRS 3-6 in 31 (27%). Appropriate selection of clipping or coil embolization can achieve acceptable treatment outcomes for ruptured aneurysm.     

Saccular aneurysms of the distal anterior cerebral artery

We report a series of 42 consecutive patients with aneurysms of the distal anterior cerebral artery (ACA). Of these, 36 patients had one aneurysm, 5 had two aneurysms, and one had three aneurysms. Thirty patients had a ruptured distal ACA aneurysm; among these patients, the size of the aneurysm was less than 5 mm in diameter in 20, 6 to 10 mm in 7, and larger than 11 mm in 3. Eighteen patients (42.9%) had multiple aneurysms, and distal ACA aneurysms were responsible for a subarachnoid hemorrhage in 10. Thirty-four patients underwent direct surgery, and 30 of these had excellent outcomes 3 months after surgery. The treatment of patients with distal ACA aneurysms is often technically difficult, because of their broad neck configuration and the coexistence of other aneurysms. Nevertheless, the present study emphasizes that distal ACA aneurysms tend to bleed, irrespective of their size, and that excellent outcomes are obtainable by direct surgery.     

The significance of early operation in the management of ruptured intracranial aneurysms—An analysis of 251 cases hospitalized within 24 hours after subarachnoid haemorrhage

Summary An analysis of 251 patients who were hospitalized within 24 hours after rupture of supratentorial aneurysms and were not comatose during the very early stage was carried out. The patients were divided into three groups in relation to timing and methods of surgery. In 61 patients of Group A, the operation was planned to be delayed more than 10 days from subarachnoid haemorrhage (SAH). In 91 patients of Group B, clipping of aneurysms was performed within 48 hours of SAH and subarachnoid blood clots were simultaneously removed while approaching the aneurysms. In 99 patients of Group C, clipping of aneurysms was performed within 48 hours of SAH and radical and extensive removal of any subarachnoid blood clot identified on the computerized tomographic scan was tried at the same time. The outcome at 3 months after SAH was the most favourable in Group C patients and the least favourable in Group A patients.Early operation combined with radical removal of subarachnoid clots minimizes the overall mortality and morbidity in patients with ruptured intracranial aneurysms by preventing rebleeding and probably by avoiding vasospasm.     

Comparison of morphologic features of intact and ruptured aneurysms of infrarenal abdominal aorta

INTRODUCTION: Endovascular aneurysm repair (EVAR) has been suggested as a technique to improve outcome of ruptured abdominal aortic aneurysm (AAA). Whether this technique becomes an established treatment will depend, in part, on the anatomy of ruptured AAA. METHODS: The anatomy of intact and ruptured AAA seen in a university department of vascular surgery over 5 years was reviewed. Aneurysm anatomy was assessed with spiral computed tomographic angiography. Suitability for EVAR was assessed from the dimensions of the proximal neck and common iliac arteries. Neck length less than 15 mm, neck width greater than 30 mm, and common iliac artery diameter greater than 22 mm were declared unsuitable for EVAR. RESULTS: Three hundred sixty-three patients with intact AAA and 46 with ruptured AAA were identified. Larger intact aneurysms were significantly associated with longer renal artery-bifurcation distance and more complex proximal neck architecture. In this sample, patients with ruptured AAA were more likely to have larger aneurysms with shorter and narrower proximal necks. Significantly more intact aneurysms were morphologically suitable for endovascular repair compared with ruptured AAA (78% vs 43%; P <.001). CONCLUSIONS: Ruptured AAA are less likely to be suitable for endovascular repair than are intact AAA, most probably because of larger diameter at presentation. Open repair will likely remain the treatment of choice in most patients with ruptured AAA, because of current morphologic constraints of endovascular repair.     

Rupture of previously documented small asymptomatic saccular intracranial aneurysms. Report of three cases.

In a recent study from the Mayo Clinic on the natural history of intact saccular intracranial aneurysms, none of the aneurysms smaller than 10 mm in diameter ruptured. It was concluded that these aneurysms carry a negligible risk for future hemorrhage and that surgery for their repair could not be recommended. These findings and recommendations have been the subject of much controversy. The authors report three patients with previously documented asymptomatic intact saccular intracranial aneurysms smaller than 5 mm in diameter that subsequently ruptured. In Case 1, a 70-year-old man bled from a 4-mm middle cerebral artery aneurysm that had been discovered incidentally 2 1/2 years previously during evaluation of cerebral ischemic symptoms. A 10-mm internal carotid artery aneurysm and a contralateral 4-mm middle cerebral artery aneurysm had not ruptured. Case 2 was that of a 66-year-old woman who bled from a 4-mm pericallosal aneurysm that had been present 9 1/2 years previously when she suffered subarachnoid hemorrhage (SAH) from a 7 x 9-mm posterior inferior cerebellar artery aneurysm. Although the pericallosal aneurysm had not enlarged in the intervening years, a daughter aneurysm had developed. The third patient was a 45-year-old woman who bled from a 4- to 5-mm posterior inferior cerebellar artery aneurysm that had measured approximately 2 mm on an angiogram obtained 4 years previously; at that time she had suffered SAH due to rupture of a 5 x 12-mm posterior communicating artery aneurysm. These cases show that small asymptomatic intact saccular intracranial aneurysms are not innocuous and that careful consideration must be given to their surgical repair and long-term follow-up study.     

Endovascular treatment for basilar tip aneurysms

The aim of this study was to analyze the effect of endovascular treatment of basilar (BA) tip aneurysms. The authors performed a retrospective analysis of 79 aneurysms of the BA tip that had been treated using endovascular coil embolization for the last 11 years. Fifty-six patients were women, and 23 were men. The average age of the patients was 63.7 years (range, 35-83 year). The average maximum diameter of the aneurysms was 8.0 mm (range, 2-30 mm). Forty-seven patients (60%) presented with acute subarachnoid hemorrhage (SAH), 1 patient (1%) had an unruptured aneurysm with mass effect, and 31 patients (39%) had incidental aneurysms. Immediate anatomic outcomes demonstrated complete occlusion (CO) in 53 aneurysms (67%), residual neck (RN) in 22 aneurysms (28%), and residual aneurysm (RA) in 4 aneurysms (5%). One patient died from rebleeding 6 hours after the embolization. Another patient suffered from rebleeding 6 years after the initial embolization, and was successfully treated with re-embolization. Four patients suffered from asymptomatic P1 occlusion. No symptomatic complication was observed in the unruptured group. Retreatment was performed in 5 patients, including 4 broad-neck large ruptured aneurysms and 1 giant thrombosed aneurysm. Angiographic and clinical results have been improving in recent cases in this study. Technical advances such as highly compliant balloon remodeling microcatheter and 3D-reconstructed digital angiography contributed to this improvement. Our results indicate that endovascular treatment of BA tip aneurysm is safe and effective. The long-term stability after coil embolization is still a matter of concern. Further improvement is expected.