New Trends in Cerebral Aneurysm Management

119 Pages·2002·10.07 MB·English

by  Tetsuya Tsukahara M.D.

Acta N eurochirurgica
Supplements
Editor: H.-J. Reulen
Assistant Editor: H.-J. Steiger
New Trends in Cerebral Aneurysm Management
Edited by
Y. Yonekawa, Y. Sakurai, E. Keller,
and T. Tsukahara
Acta Ne urochirurgica
Supplement 82
SpringerW ienN ewYork
Prof. Dr. Y. Y onekawa
Dr. E. Keller
University Hospital, Zurich, Switzerland
Dr. Y. Sakurai
National Hospital, Sendai, Japan
Dr. T. Tsukahara
National Hospital, Kyoto, Japan
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SPIN: 10857051
With 63 partly coloured Figures
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ISSN 0065-1419
ISBN-13: 978-3-7091-7396-1 e-ISBN-13: 978-3-7091-6736-6
DOl: 10.1007/978-3-7091-6736-6
Preface
The management of cerebral aneurysms is still sub are being carried out on unruptured cerebral aneu
ject of controversy in spite of recent dramatic advances rysms and presentation of such new clinical experi
in surgical techniques and neuro-intensive care. Cur ences allowed intensive discussions in order to find out
rently there are three main topics in this field with to updated and proper ways to focus the treatment. The
tally different aspects: second day provided updated information on neuro
critical care aspects as well as endovascular and surgi
1) management of unruptured cerebral aneurysms as
cal treatment modalities as performed in daily practice
a preventive medicine and
in Zurich and Japan. Round table discussions encour
2) neurocritical management of severe subarachnoid
aged an interactive communication between the par
hemorrhage (SAH) after rupture and
ticipants and faculty.
3) advances in the microsurgical and endovascular
techniques regarding the management of cerebral In this volume we publish the proceedings of this
aneurysms. Swiss-Japanese Joint Conference on Cerebral Aneur
ysm. Our gratitude is extended to the many contrib
In order to create an opportunity to discuss these top
utors and to all those who participated in the confer
ics, the Swiss-Japanese Joint Conference on Cerebral
ence. Publication of the proceedings is supported by
Aneurysm Management was held in Zurich, Switzer
Health Sciences Research Grants for Medical Frontier
land, from May 5 to 7, 2001; Prof. Dr. Y. Yonekawa,
Strategy Research regarding multi-center studies on
Zurich and Prof. Dr. Y. Sakurai, Sendai were the
the treatment of unr uptured cerebral aneurysms by the
presidents of the conference. The first day offered a
Japanese Ministry of Health, Labor and Welfare.
unique forum for European and Japanese neuro
surgeons to discuss the treatment of unruptured cere
bral aneurysms. In Japan cooperative clinical studies The Editors
Contents
Part I: Management of Unruptured Aneurysms
Tsukahara, T, Murakami, N, Sakurai. Y, Yonekura, M., Takahashi, T, Inoue, T:
Treatment of Unruptured Cerebral Aneurysms - A Multi-Center Study of Japanese National Hospitals.. 3
Inoue, T:
Treatment ofIncidental Unruptured Aneurysms. . . .. . ... . .. .. .. . . . .. . . . .. . .. .. .. . .. . . .. . . . . .. . .. .. .. . .. . . .. 11
Takahashi, T:
The Treatment of Symptomatic Unruptured Aneurysms... . . . . .. . . . . . . . . .. . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . .. 17
Yonekura, M.:
Importance of Prospective Studies for Deciding on a Therapeutic Guideline for Unruptured Cerebral
Aneurysm.................................................................................................... 21
Juvela, s:
Natural History of Unr uptured Intracranial Aneurysms: Risks for Aneurysm Formation, Growth, and
Rupture...................................................................................................... 27
San Millim Ruiz, D., Tokunaga, K., Dehdashti, A. R., Sugiu, K., Delavelle, J., Rufenacht, D. A.:
Is the Rupture of Cerebral Berry Aneurysms Influenced by the Peri aneurysmal Environment? ............ 31
Ishihara, H., Yoshimura, S, Honu, L., Khan, N, Yonekawa, Y:
Surgical Prognosis of Unr uptured Cerebral Aneurysms. Report of 40 Cases in University Hospital
Zurich....................................................................................................... 35
Regli, L., Dehdashti, A. R., Uske, A., de Tribolet, N:
Endovascular Coiling Compared with Surgical Clipping for the Treatment of Unr uptured Middle
Cerebral Artery Aneurysms: An Update.................................................................... 41
Nishino, A., Sakurai, Y, Arai, H., Nishimura, S, Suzuki, S, Uenohara, H.:
Clinical Manifestations, Character of Aneurysms, and Surgical Results for Unruptured Cerebral
Aneurysms Presenting with Ophthalmic Symptoms......................................................... 47
Hempelmann, R. G., Barth, H., Buhl, R., Mehdorn, H. M.:
Clinical Outcome after Surgery of Intracranial Unruptured Aneurysms: Results of a Series Between 1991
and 2001..................................................................................................... 51
Murakami, N, Tsukahara, T, Toda, H., Kawakami, 0., Hatano, T:
Radiation-Induced Cerebral Aneurysm Successfully Treated with Endovascular Coil Embolization...... 55
VIII Contents
Part II: Treatment of Subarachnoid Haemorrhage and General Considerations
s.,
Pinsker, M. 0., Gerstner, W, Wolf, Trost, H. A., Lumenta, C B.:
Surgery and Outcome for Aneurysmal Subarachnoid Hemorrhage in Elderly Patients..................... 61
Su, C-C, Saito, K, Nakagawa, A., Endo, T, Suzuki, Y., Shirane, R.:
Clinical Outcome Following Ultra-Early Operation for Patients with Intracerebral Hematoma from
Aneurysm Rupture - Focussing on the Massive Intra-Sylvian Type of Subarachnoid Hemorrhage........ 65
Khan, N, Schuknecht, B., Yonekawa, Y.:
Presentation and Management of Patients with Initial Negative 4-Vessel Cerebral Angiography in
Subarachnoid Hemorrhage... . .. ... . .. .. . .. . .. . . . .. .. . . .. .. . . .. . . .. . .. . .. . . .. .. . . . . . . . . . . . . . .. . . . . . . . .. . . . . . 71
Bjeljac, M, Keller, E., Regard, M., Yonekawa, Y.:
Neurological and Neuropsychological Outcome after SAH ................................................ 83
Keller, E., Nadler, A., Imhof, H.-G., Niederer, P., Roth, P., Yonekawa, Y.:
New Methods for Monitoring Cerebral Oxygenation and Hemodynamics in Patients with Subarachnoid
Hemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Yasui N, Kawamura, Y. N, Suzuki, A., Hadeishi, H., Hatazawa, I.:
Role of Hypothermia in the Management of Severe Cases of Subarachnoid Hemorrhage.................. 93
Kaku, Y.:
Endovascular Aneurysm Treatment from the Neurosurgeon's Point of View. .............................. 99
Yonekawa, Y., Khan, N, Roth, P.:
Strategies for Surgical Management of Cerebral Aneurysms of Special Location, Size and Form-
Approach, Technique and Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Author Index............................ .......... ............ .............................................. 119
Index of Keywords .......................................................................................... 121
Listed in Current Contents
Part I: Management of Unruptured Aneurysms
Acta Neurochir (2002) [Suppl] 82: 3-10
© Springer-Verlag 2002
Treatment of Unruptured Cerebral Aneurysms - A Multi-Center Study of
Japanese National Hospitals
T. Tsukahara!, N. Murakami!, Y. Sakurai2, M. Yonekura\ T. Takahashi\ and T. Inoues
1 Department of Neurological Surgery and Clinical Research Unit, Kyoto National Hospital, Kyoto, Japan
2 Department of Neurological Surgery, Sendai National Hospital, Sendai, Japan
3 Department of Neurological Surgery, National Nagasaki Medical Center, Nagasaki, Japan
4 Department of Neurological Surgery, Nagoya National Hospital, Nagoya, Japan
5 Department of Neurological Surgery and Clinical Research Institute, National Kyusyu Medical Center, Fukuoka, Japan
Summary asymptomatic unruptured cerebral aneurysms. Gen
eral consensus for the management of unruptured
The treatment and natural course of unruptured cerebral aneur
aneurysms, however, has not yet been established,
ysms were analyzed in 427 cases of unruptured cerebral aneurysm
registered at five Japanese national hospitals. Of these cerebral since there are no prospective randomized trials of
aneurysms 295 were treated by craniotomy, and 22 with endovas treatment intervention versus conservative manage
cular coil embolization. Neurological deterioration after treatment
ment. Regarding the natural course of unruptured ce
occurred in 31 (9.8%) of the 295 craniotomies and 3 (13.6%) of the 22
endovascular treatments. There was no subarachnoid hemorrhage rebral aneurysm [3] it is reported that the rupture rate
(SAH) reported after the craniotomies whereas one case of SAH was was 10% 10 years after the diagnosis, 26% after 20
reported after endovascular treatment. For 145 aneurysms in 110
years, and 32% after 30 years. Yasui et al. reported
cases, the natural course of the aneurysms was observed without
that the overall rupture rate was 2.3%/year and that
surgical treatment. During the follow up period of in total 2,610
months (217.5 years), seven of these aneurysms ruptured, resulting in the size of these aneurysms was less than 9 mm in 11 of
a rupture rate of 3.2%/year. Three of these seven aneurysms were less the 22 cases developing SAH. In five cases, aneurysms
than 10 mm in diameter. The likelihood of an unruptured cerebral
were even smaller than 5 mm [5, 6]. In 1998, the In
aneurysm to rupture was not exceedingly low. Since the risk of rup
ture and the morbidity related to surgical treatment cannot be pre ternational Study of Unruptured Intracranial Aneur
dicted by size alone, the morphology, location and condition of the ysms (ISUIA) reported that the rupture rate of cere
patients should be considered when treating unruptured cerebral
bral aneurysms smaller than 10 mm was unexpectedly
aneurysms.
low with 0.05%/year [2]. Although there was criticism
Keywords: Unruptured cerebral aneurysms; multi center study.
that a rather large number of patients with unruptured
aneurysms had been excluded from the study after
surgeons had indicated a high likelihood of rupture,
Introduction
and only the remaining patients were followed to ana
Subarachnoid hemorrhage (SAH) due to rupture of lyze the natural history [1], this report had rather a big
a cerebral aneurysm is a serious disorder with a high impact on the general public. For example, the Chi
mortality and morbidity in spite of recent develop cago Tribune of December 10, 1998 reported that "A
ments in the management ofSAH. Therefore it may be landmark study published Wednesday concludes that
reasonable to prevent disastrous SAH and treat cere brain aneurysms are better left untouched" and "the
bral aneurysms before their rupture. With the preva study found that most small aneurysms won't rupture
lence of non-invasive methods to detect the cerebral and attempts to repair them surgically are not worth
aneurysm, such as MR angiography, we have experi the risk." Even though these comments did not accu
enced increasing opportunities to treat patients with rately reflect the contents of the report, treatment
4 T. Tsukahara et al.
indications for unruptured cerebral aneurysms have than 10 mm and two with blebs were even smaller than
been markedly influenced by this report. Surgical 5 mm. Four of these seven aneurysms were found in
treatment of unruptured cerebral aneurysm is some cidentally and classified into group IV. The remaining
times unavoidably accompanied by complications, three cases were as follows: two were symptomatic
and postoperative results may differ between aneur aneurysms (headache and visual disturbance) and one
ysms being influenced not only by size but also by lo was accompanied by cerebral ischemic disease.
calization, morphology and the medical condition of The results of the treatment were analyzed after the
the paient. In 1999, a multi-center study on the treat aneurysms had been divided according to the age of
ment ofunruptured cerebral aneurysms was organized the patients, size and location of the aneurysms and
to accumulate basic data to establish management their clinical manifestations.
guidelines for unruptured cerebral aneurysms. The Age (Fig. 5a); Outcome of patients at age 80 or more
study was supported by a Health Science Research was worse, although the number of surgically treated
Grant from the Japanese Ministry of Health, Labor patients in that age group was small.
and Welfare. Size (Fig. 5b); A greater number of patients with
neurological deterioration was reported in patients
with an aneurysm larger than 15 mm, although a
greater number of neurological improvements was
Materials and Methods
also observed in patients with larger aneurysm.
Between 1999 and 2000, a total of 427 patients with unruptured Location (Fig. 5c); A greater number of patients
cerebral aneurysms were documented in five Japanese national hos with neurological deterioration was reported among
pitals. Follow-up study of these registered patients is currently going
patients with aneurysms involving the basilar bifurca
on. For 145 aneurysms in 110 cases the natural course of the aneur
ysms was observed without surgical treatment. Other cerebral aneur tion compared to those with aneurysms at other sites.
ysms were treated surgically either by craniotomy in 295 cases or by Clinical manifestation (Fig. 5d); In groups I and II,
endovascular coil embolization in 22 cases. Age distribution of all,
the preoperative medical condition of the patients and
surgically treated and untreated patients is shown in Fig. la, band c,
accompanying diseases significantly influenced patient
respectively. Patients aged 60~69 comprised the peak in each group,
although patients of younger age tended to receive surgical treatment outcome. In group III, cranial nerve palsies caused by
while the older group remained untreated. Size of the cerebral aneur aneurysms smaller than 10 mm had improved post
ysms is shown in Fig. 2a (surgically treated group) and b (untreated
operatively in nine cases. However, neurological defi
group). Aneurysm size was larger in the treated patients. The loca
tions of cerebral aneurysms are shown in Fig. 3a (surgically treated cits caused by aneurysms larger than 25 mm had
group) and b (untreated group); unruptured cerebral aneurysms were mostly worsened after surgery. In our study, a total of
also categorized into four groups by clinical manifestations (Fig. 4a
119 aneurysms were registered as incidental aneurysms
and b): group I; unruptured cerebral aneurysms accompanied by
ruptured aneurysm (23 untreated and 67 treated aneurysms), group in group IV. Aneurysmal size was as follows: 2 to
2; unruptured cerebral aneurysms with other intracranial lesions (32 5 mm in 38 cases, 6 to 9 mm in 42 cases, 10 to 24 mm
untreated and 97 treated aneurysms), group 3; symptomatic un
32 cases and larger than 25 mm in 3 cases. The per
ruptured cerebral aneurysms (12 untreated and 75 treated aneu
centage of incidentally detected aneurysms measuring
rysms), group 4; incidentally found unruptured cerebral aneurysms
(42 untreated and 77 treated aneurysms). less than 10 mm was 67% (80 cases). In one of the 80
cases, aneurysmal size increased over 48 months and
clipping of aneurysm was performed. Of 119 incidental
Results cases, 77 cases were treated surgically and 42 cases re
mained untreated. In four of the 42 untreated cases,
Neurological deterioration occurred after treatment the aneurysms had ruptured. In three cases, the size of
in 31 (9.8%) of 295 craniotomies and 3 (13.6%) of 22 the aneurysms were larger than 10 mm and the out
endovascular treatments. There was no SAH reported come was extremely poor. Two patients died immedi
after the craniotomies and one case of SAH after en ately after the rupture and one patient remained in a
dovascular treatment. For 145 aneurysms in 110 cases, persistent vegetative state despite surgical treatment.
the natural course of the aneurysms was observed In one patient with three aneurysms measuring less
without treatment. During an overall follow-up period than 5 mm each and with bleb, SAH was reported.
of altogether 2,610 months (217.5 years), seven of these Outcome after surgery is shown in Fig. 6. Although
aneurysms ruptured, leading to a rupture rate of3.2%/ the outcome was evaluated by Glasgow outcome
year. Three of these seven aneurysms were smaller scale, 75 of 77 patients showed good recovery, six