Clinical Features and Management in Severe Cases of Ruptured Intracranial Aneurysms

• Published in: Nōshotchū no geka Vol. 17; no. 3; pp. 230 - 235
• Main Authors: ONO, Junichi, YAMAKAMI, Iwao, TANNO, Hirokazu, OKIMURA, Yoshitaka, KARASUDANI, Hirohide, SUDA, Sumio, ISOBE, Katsumi
• Format: Journal Article
• Language: Japanese; English
• Published: The Japanese Society on Surgery for Cerebral Stroke 20.09.1989
• Subjects: cerebral blood flow; ruptured aneurysm; severe cases; symptomatic vasospasm; systemic complication
• ISSN: 0914-5508; 1880-4683
• DOI: 10.2335/scs1987.17.3_230

In a consecutive series of 163 patients, who were operated on for ruptured anterior circulation aneurysm within three days after a subarachnoid hemorrhage, 93 patients (57%) were classified as Hunt and Kosnik Grade III and IV (defined as severe cases), and 70 as Grade I and II (mild cases). Mean age, site of ruptured aneurysm and serial changes in mean blood pressure showed no significant difference between the two groups. Postoperative electrolytes balance was examined on the 7th day after surgery. Both hyponatremia and hypernatremia were significantly frequent (p<0.025, p<0.001, respectively) in severe cases. Septicemia, with or without disseminated intravascular coagulopathy, was the main postoperative complication in both groups. Over all, 26% of severe cases had systemic complications, whereas only 13% of mild cases had. This difference was statistically significant (p<0.05). The outcome was considerably unfavorable in the patients with systemic complications. Delayed ischemic neurological deterioration with irreversible deficits occurred in 30% of severe cases, but in only nine percent of mild cases (p<0.005). In CT findings, the amount of subarachnoid clot was classified into four groups, described by Fisher, et al. Group 3 (clot or thick layer), which was considered to be most responsible for symptomatic vasospasm, was frequently visualized with significant difference in severe cases (p<0.05; preoperatively, p<0.005; postoperatively). Hydrocephalus with shunt dependency occurred in 44% of severe cases but in only 13% of mild cases (p<0.005). In the serial measurement of mean hemispheric blood flow, reduced flow was continuously revealed in severe cases, as compared with mild cases. The difference was statistically significant on both the 14th day after surgery, and in the long-term follow-up (p<0.05). The ultimate outcome at six months was quite poor in severe cases. Only 56% had good outcome (good recovery and moderate disability) and 24% died, whereas 90% had good outcome and nine percent died in mild cases. These results suggest that postoperative systemic complications are of some prognostic value in predicting outcome, and it is stressed that systemic intensive care is also indispensable in the management of ruptured intracranial aneurysms.