Tohoku
J. exp.
Med.,
Intracranial
1978 , 126, 117-124
Saccular
-Surgical
Results
Aneurysms of 1
,000 Consecutive
Cases
TAKAMASA KAYAMA, TAKASHI YOSHIMOTO, KEITA UCHIDA, AKIRA TAKAKU and JIRO SUZUKI
Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, Sendai 982
KAYAMA, T., YOSHIMOTO,T., UCHIDA, K., TAKAKU, A. and SUZUKI, J. Intracranial Saccular Aneurysms -Surgical Results of 1,000 Consecutive Cases. Tohoku J. exp. Med., 1978, 126 (2), 117-124-The results of our surgical treatment of 1,000 patients with intracranial saccular aneurysm were analyzed with special consideration for age, site of aneurysm, preoperative condition and operative timing. The results on discharge were as follows: 543 cases, excellent; 186, good; 117, fair; 93, poor; and 61, dead. About three-fourths of the cases except for 23 cases of vertebrobasilar aneurysm showed either excellent or good result. The mortality rate became worse with aging. The results fairly correlated with the preoperative grades by Hunt and Hess (1968), but the cases of Grade la were unexpectedly worse. The timing of operation influenced the mortality rate; especially, the cases operated within 3 to 7 days following the last subarach noid hemorrhage bore poor results. Follow-up studies revealed that excellent and good cases increased and poor cases decreased. The mortality rate for each year decreased annually to 2% in 1975. This improvement may be attributed to the advancement in the operative management with supplementary procedures and in the treatment for cerebral angiospasms and general condition. intracranial saccular aneurysm ; surgical result
Intracranial surgery has generally been accepted as the only treatment for ruptured intracranial aneurysm. In Japan, neurosurgical treatments were not so advanced up to 1960 as in Europe or U.S.A. However, during the last fifteen years remarkable advances have been made in the surgical treatment of intracranial aneurysms in our country (Suzuki et al. 1971). In
our
aneurysm
Institute, in
consecutive consideration
surgery
September cases
was
1975.
of intracranial
for some
preoperative
performed This
in the
paper
saccular
deals
aneurysms
1,000th with
case the
operated
of intracranial
results on,
with
of
1,000 special
conditions.
PATIENTS AND METHOD During the period from saccular aneurysms including seen at in our Institute. surgery in 96 per cent of the Received
for publication,
June 1961 to September 1975, 1,080 cases of intracranial 1,000 cases treated by direct intracranial surgery were Prof. J. Suzuki, one of the present authors, performed cases with naked eyes (Table 1). This investigation is based January
7, 1978. 117
118
T. Kayama
on follow-up In
studies
our
artery
(AcomA)
(MCA)
in
multiple 7th tion years the (Table surgery within
of 1,000 cases with
series,
the in
174,
346
anterior
aneurysms
decade. of
six
artery
As
within week.
to two
the
and
of
49,
vertebrobasilar
age
distribution
female
with
Grade ‡V
the
cases
(ICA)
(Fig.
last
were
1). or
more
IV
the in
to
one-third
the of
hr
of
the
TABLE 2.
1.
Age
distribution.
Grade of preoperative condition
the junc
life
at
92
cases, by
Hunt
underwent 14
last
and
the
total
cases
including from
TABLE1. Intracranial aneurysms (Tohoku University, June 1961 through September 1975)
Fig.
her
classification the
23
above at
the
artery in
cases
enjoying
one-third
according
48
163 aneurysm
is
about
within
cerebral (V-BA)
revealed
hemorrhage, on
communicating
middle artery
arteries, In
than
anterior
246,
a ruptured
subarachnoid operated
lives of the patients.
were
communicating
timing,
after
cases
artery in
The
operation
were
weeks
(ACA)
posterior
the
on the daily
1,000
carotid
86-year-old
operative
Fifty-four
in
1).
a
after
conditions
2).
(Table
case,
carotid years
preoperative
one
cerebral 162
emphasis
aneurysms internal
oldest
internal
age
of
cases,
in
The
the of
sites
et al.
per
hemorrhage.
cent
Intracranial
Saccular
Aneurysms
119
Surgery was performed within 3 to 7 days in 89 cases, within 8-14 days in 177, and after 15 or more days in 660 (Table 3).
The results of surgery were evaluated on discharge and more than six months later. Follow-up studies were made in 876 (93%) out of 939 cases which were discharged from the hospital. The interval between discharge and follow-up ranged from 6 months to 14 years and 5 months, averaging 3 years and 7 months (Table 4). TABLE 3.
Interval between the last hemorrhage and surgery
TABLE 4. Results of operation at the follow-up study
* 63 untraceable cases were excluded. Duration of follow-up: from 6 months to 14 years and 5 months, averaging 3 years and 7 months after operation. Follow-up rate: 93.3%.
TABLE5. Classification of operative results
Our evaluation of surgical results, similar to that of the U.S.A. Cooperative Study, is based on six factors, i.e., consciousness, psychic symptoms, cranial nerve deficits, motor disturbances especially walking ability, incontinentia urinae and aphasia. These six factors are extremely valuable for normal life, and therefore reflect the influence of surgery. So, the postoperative conditions of the cases were classified according to capabilities for daily life into the following 5 groups (Table 5); "Excellent", the patient is
120
T. Kayama
et al.
fully capable for employment; "Good", the patient is capable of working, although some neurological deficits remain; "Fair", the patient has one or more of three handicaps incapability of walking alone, psychic disturbances, and aphasia; and "Poor", the patient is completely incapable of walking even with assistance.
RESULTS Results
on discharge
The results of 1,000 cases on discharge were evaluated as follows; 543 excellent cases, 186 good, 117 fair, 93 poor, and 61 fatal, that is, there were 729 excellent and good cases (72.9%), and 154 poor and fatal cases (15.4%) (Table 6). In relation to the site of aneurysm, about three-fourths were either excellent or good in cases of aneurysms associated with the anterior communicating, internal carotid, middle cerebral, and anterior cerebral arteries. On the other hand, in 23 cases of vertebrobasilar aneurysms the results were excellent or good in 13 cases (57%) and poor or fatal in 8 (34%). In 161 cases of multiple aneurysms, 108 cases (67%) were excellent or good (Table 7). TABLE 6.
TABLE 7.
Results of operation on discharge
Site and
operative
results
on discharge
The age of patients seemed to affect the results, that is, the mortality rate during hospitalizationwas 4% in patients in the 4th decade and 9% in the 7th decade (Table 8). The
surgical
preoperative contrary,
results
grading the
results
of by
of
cases
Hunt
Grade
classified and
la
were
Hess worse
as
poor
(1968) than
risk
patients
were that
not of
according favorable.
Grade ‡U
(Table
to On 9) .
the the
Intracranial TABLE 8.
TABLE 9.
Grades
depend
Age and operative
Preoperative
on the
TABLE 10.
Saccular
condition
results
by Hunt
timing
121
on discharge
and operative
classification Operative
Aneurysms
results
on discharge
and Hess.
and results
on discharge
The timing of operation also seemed to influencethe mortality rate, although not significant statistically. On the whole, the mortality rate in cases within 3-7 days followingthe last hemorrhage was 20%, and that in caseswithin 48 hr was 17 % (Table 10). And the mortality rate of 18% was highest in cases within 3-7 days followingthe last hemorrhage and that in cases within 48 hr was 7% in 1971 through 1975(Table 11). Results at follow-up Follow-up
studies
of 939 cases revealed
621 excellent,
112 good, 48 fair, 31 poor
122
T. Kayama
et al.
and 64 fatal cases. The remaining 63 cases could not be traced for this study. That is, the follow-up studies revealed an increase in the number of excellent and good cases including some cases which improved from poor to excellent (Table 12).
The mortality rate in each year decreased annually from 8.0% until 1970 to 2.4% in 1975 (Fig. 2). TABLE 11.
Operative timing and results in 1971 through 1975
TABLE 12.
Fig. 2.
Yearly
on discharge
in cases
operated
Comparison of operative results on discharge and at follow-up
mortality
rate
in operated
cases
of intracranial
aneurysms
.
DISCUSSION
There have been numerous reports on the surgical results of intracranial aneurysms (Norlen and Olivercrona 1953; Botterell et al. 1958; Mckissock et al. 1960; Poppen and Fager 1960; Pool 1962; Sahs et al . 1969; Hunt and Hess 1968; Hunt 1974; Paul and Arnold 1970; Drake 1971; Krayenbuhl et al . 1972). The majority of investigations were based on a relatively limited number of cases and/or cases collected from various institutions for a cooperative study , although there
Intracranial
Saccular
Aneurysms
123
were a few studies based on a large number of cases from a singleinstitution (Sahs et al. 1966; Drake 1971; Krayenbuhl et al. 1972). In our Institute, 96% of 1,000 patients with intracranial aneurysm were operated on by the same surgeon. Accordingly,the present study is thought to show the most uniform data of intracranial aneurysm surgery. The strict and uniform criteria are essential for evaluation of surgical results (Pool 1962; Sahs et al. 1969; Drake 1971; Krayenbuhl et al. 1972). In most reports only the mortality rate has been discussed (Botterell et al. 1958; Mckissock et al. 1960; Hunt and Hess 1968; Hunt 1974), and others include the morbidity classification of two groups, ability and disability in daily life (Poppen and Fager 1960; Pool 1962). The two-group classification does not correctly reflect the consequences of aneurysm surgery. Therefore, it is difficult to employ the twogroup classification as a standard for comparison. In this report, a five-group classification based on activities in daily life after a sufficient postoperative elapse of time is employed. The mortality rate of 6.1% in our series is comparable to the lowest mortality rate of 5.0% in other reports (Krayenbuhl et al. 1972), which was calculated from cases of supratentorial aneurysm only. The total of excellent, good and fair cases on discharge was 84.5% in our series and 83.0% in Krayenbuhl's series (1972). In regard tions,
to the
it is natural
older the patients,
that
correlation the severer
the poorer
between
surgical
results
and
the cases are, the poorer
the results.
The mortality
preoperative
the results
rate
in cases
condi
are, and the operated
on
within seven days after rupture of aneurysm was highest in all post-attack periods. However, it is interesting to notice that the mortality rate in cases of surgery within 48
hr
was
considerably
In our series,
good
low. and fair cases
on discharge
were found
by follow-up
studies
to have improved to excellent ones in 55 and 35 per cent, respectively. Moreover, snore of nor eases on discharge were excellent or good at follow-up studies.
The number of postoperative deaths during hospitalization was 61, and the mortality rate was 8% prior to 1970, when our effortsand technique of aneurysm surgery were still unsatisfactory. In this period, treatment in the early stage of aneurysm rupture and treatment of severe cases were not satisfactory. Since 1971,the mortality rate decreased annually to 2.4% in 1975,despite the fact that cases of surgery within 48 hr and cases in severe condition increased yearly. During the last five years the mortality and morbidity rates have remarkably decreased even in cases of early surgery. When the cases are divided into two series, before and after the end of 1970, there is a significant difference between them, especiallyin acute cases. The mortality rate in cases of surgery within 48 hr decreasedremarkably from 50% in 1961-1970to 7% in 1971-1975(Tables10 and 11). This improvement may be attributed to supplementaryprocedures,e.g., con tinuous ventricular drainage (Suzuki et al. 1974),washing out of blood clots in the subarachnoid spaces, treatment for angiospasms,etc. The treatment for angio spasms (Suzuki et al. 1975) is considered to be the most decisive factor in the
124
T. Kayama
prognosis,
especially
in the
acute
stage,
and
et al,
will be discussed
elsewhere.
References
1)
2) 3)
4) 5) 6) 7) 8) 9) 10) 11)
12) 13) 14)
Botterell, E.H., Lougheed, W.M., Morley, T.P. & Vandewater, S.L. (1958) Hypother mia in the surgical treatment of ruptured intracranial aneurysms. J. Neurosurg., 15, 4-18. Drake, C.G. (1971) Intracranial aneurysms -Ruptured aneurysms. Proc. roy. Soc. Med., 64, 447-481. Hunt, W.E. (1974) Grading of risk in intracranial aneurysms. In: Recent Progress in Neurological Surgery, edited by K. Sano & S. Ishii, Excerpta Medica, Amsterdam, pp. 169-175. Hunt, W.E. & Hess, R.M. (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J. Neurosurg., 29, 14-20. Krayenbiihl, H.A., Yasargil, M.G., Flamm, E.S. & Tew, J.M. (1972) Microsurgical treatment of intracranial saccular aneurysms. J. Neurosurg., 37, 678-686. Mckissock, W., Paine, K.W.E. & Walsh, L.S. (1960) An analysis of the results of treatment of ruptured intracranial aneurysms. J. Neurosurg., 17, 762-776. Norlen, G. & Olivercrona, H. (1953) The treatment of aneurysms of the circle of Wills. J. Neurosurg., 10, 404-415. Paul, R.L. & Arnold, J.G. (1970) Operative factors influencing mortality in intracranial aneurysm surgery: Analysis of 186 consecutive cases. J. Neurosurg., 32, 289-294. Pool, J.L. (1962) Timing and technique in the intracranial surgery of ruptured aneurysms of the anterior communicating artery. J. Neurosurg., 19, 378-388. Poppen, J.L. & Fager, C.A. (1960) Intracranial aneurysm. J. Neurosurg., 17, 283-296. Sahs, A.L., Perret, G.E., Locksley, H.B. & Nishioka, H. (1969) Intracranial Aneurysms and Subarachnoid Hemorrhage, J.B. Lippincott Co., Philadelphia-Toronto, pp. 173-193. Suzuki, J., Hori, S. & Sakurai, Y. (1971) Intracranial aneurysm in the neurosurgical clinics in Japan. J. Neurosurg., 35, 34-39. Suzuki, J., Yoshimoto, T. & Hori, S. (1974) Continuous ventricular drainage to lessen surgical risk in ruptured intracranial aneurysm. Surg. Neurol., 2, 87-90. Suzuki, J., Iwabuchi, T. & Hori, S. (1975) Cervical sympathectomy for cerebral vasospasm after aneurysm rupture. Neurol. medicochir., 15 (1), 41-50.