Elsevier

Neurologia i Neurochirurgia Polska

Volume 52, Issue 1, January–February 2018, Pages 15-24
Neurologia i Neurochirurgia Polska

Original research article
Clinical outcomes of multiple aneurysms microsurgical clipping: Evaluation of 90 patients

https://doi.org/10.1016/j.pjnns.2017.09.005Get rights and content

Abstract

Background

The incidence of multiple intracranial aneurysms (MIAs) among patients who are diagnosed with aneurysm is 15–45% in the literature. Treatment options depend on the patient's status, age, aneurysm location and neurosurgeon's experience. In this study outcomes of micro-surgically clipped 90 patients have been evaluated.

Materials and methods

Medical records of 90 (49 women and 41 men) patients of MIAs who underwent surgery by the authors, during a 3-year period from 2011 to 2013 were retrospectively reviewed of prospectively collected patients’ data. Surgically treated patients underwent a lateral supraorbital craniotomy followed by microsurgical clipping of all reachable aneurysms.

Results

The mean age of the sample is 50.8 ± 11.9 (25–82) years. There were 67 patients presented with SAH. The most common complaint was severe headache of sudden onset (94%) in SAH group and migraine type headache (60.8%) in incidentally diagnosed group. According to location of the arteries; ACoA (50), MCA (R:49,L:45), ICA (R:34,L:15), PCoA (R:9,L:4), ACA (R:6,L:4), basilar artery (3) and SCA (2). Mortality rate was 13.3% (n = 12), morbidity rate (new deficit was developed) was 18.8% (n = 17) [7 out of them were partially/completely dependent on others for daily living activities before surgery (i.e. GOS < 3)] and 67.8% (n = 61) of the patients returned to their normal jobs and daily activities.

Conclusions

Multiple cerebral aneurysms are not associated with a less favorable outcome than are single aneurysm cases. Authors prefer microsurgical clipping of all the aneurysms, be it on the reverse side, if the aneurysm location is reachable and that includes bilaterally presenting MIAs.

Introduction

Cerebral aneurysms occur in 1–2% of the population and account for about 80–85% of non-traumatic subarachnoid hemorrhages (SAH). Autopsy studies indicate prevalence in the adult population between 1% and 5%; however, 50–80% of all aneurysms do not rupture during the course of a person's lifetime. Unruptured intracranial aneurysms are more common in women as much as three times [1], [2]. Some rare familial forms of aneurysms have been associated with conditions such as autosomal dominant polycystic kidney disease, Marfan's syndrome, Ehlers–Danlos syndrome type IV, fibromuscular dysplasia, Moyamoya disease, sickle cell disease, and arteriovenous malformations of the brain [1]. An important risk factor for aneurysm is the family history. Patients with one affected family member have approximately a 4% risk of having an aneurysm, whereas patients with 2 or more affected first-degree family members have an 8–10% risk of developing an aneurysm [1].

Despite the fact that no accurate number, we estimate that the incidence of SAH that related to ruptured cerebral aneurysms in Turkey is approximately 8/100,000 person-years (our hospital is one of main four reference centers in Istanbul, in which yearly operated on approximately 150 patients). SAH is more common in women than in men (2:1) with the peak incidence occurring in age group 50–60 years old [2], [4]. The mortality rate for SAH is 8.3–66.7%, and as high as 3 in 5 of those who survive SAH may be functionally dependent [3].

It is still being debated when neurosurgeons have to treat unruptured aneurysms especially in multiple intracranial aneurysm (MIA) cases. It is well-known that aneurysms over years will grow and may get ruptured. The rupture risk assessments for MIAs are mainly based on morphology [1], [3], [4], [5], [6], [7], [8]. Hemodynamics play a fundamental role in aneurismal rupture [3], [6], [7], [8]. It is largely unknown whether hemodynamic factors are also involved in modulating the risk of rupture in MIAs. Several studies showed that MIAs are associated with a less favorable outcome than are single aneurysm cases after SAH [2], [8]. Herein, the authors reviewed their own microsurgical clipping experience for treatment of MIAs.

Section snippets

Materials and methods

This present retrospective study was approved by the medical ethics committee of our hospital. Written informed consent was obtained from all patients or from their first-degree relatives (if they are not neurologically intact) for publication of their cases and accompanying images.

Medical records were prospectively collected (all entrance data were collected at the time of hospitalization) from consecutive 409 cases of cerebral aneurysms which were treated surgically at Department of

Results

221 aneurysms were detected in 90 (49 female, 41 male) patients. The mean age was 50.8 ± 11.9 (25–82) years. There were 67 patients presented with SAH, while 23 patients were diagnosed incidentally as unruptured aneurysms. Sixty-five patients (72.2%) were presented with 2 aneurysms (2 out of them presented after 9 and 10 years as single aneurysm), seventeen patients (18.9%) were presented with three aneurysms, whereas eight patients (8.9%) were presented with four or more aneurysms (Table 1). The

Discussion

The incidence of multiple cerebral aneurysms (MIAs) among patients who are diagnosed with aneurysm is 15–45% in the literature [2], [9]. MIAs are observed in a fifth to a third of all cases of intracranially located aneurysms [7], [10]. The prognosis of aneurysmal SAH has remained a serious medical challenge largely unaffected by the improvement in medical and micro-neurosurgical treatment modalities. The female preponderance in patients with MIAs is well-established observation in most

Conclusion

MIAs are not associated with a less favorable outcome than are single aneurysm cases when operated in single séance. We prefer microsurgical clipping of all the aneurysms in one stage if the aneurysm location is reachable. Combination of treatment options may be the choice of the treatment. Contralateral micro-surgical clipping does not increase the mortality or morbidity rates. Thus, a single intervention definitely benefits the patient by halving the surgical risk and psychological trauma of

Conflict of interest

None declared.

Acknowledgement and financial support

None declared.

References (19)

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This study was approved under decision number: (573) by the medical ethics committee of Bakırköy Research and Training Hospital for Neurology Neurosurgery, and Psychiatry (BRSHH) in Istanbul-Turkey.

1

Drs. Asiltürk and Abdallah contributed equally to this work.

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