Results and complications of surgical management of 809 intracranial aneurysms in 722 cases

Related and unrelated to grade of patient, type of aneurysm, and timing of surgery

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✓ Data from 722 consecutive cases with intracranial aneurysms were stored in a computer and later retrieved for analysis. Results and complications (including preoperative death and morbidity) of the surgical management of these patients were correlated with the Botterell grade of the patient in individuals with a recent subarachnoid hemorrhage (SAH), with the type of aneurysm, and with the timing of the surgical procedure. Patients with no SAH within 30 days prior to hospital admission were classified as “no SAH.” Approximately 30% of all patients had sustained more than one hemorrhage. Death and morbidity rates prior to surgery in good-grade patients with a recent SAH exceeded the risk of surgery itself. Rebleeding was the primary cause for death and morbidity in Grade 1 patients: 3% of Grade 1 patients died from a recurrent hemorrhage and 7% deteriorated to a lower grade. Deterioration from ischemia produced by vasospasm related or unrelated to rebleeding exceeded the risks of rebleeding in Grade 2 patients. There was an operative morbidity of 2% and mortality of 2% in patients who were classified as Grade 1 at the time of surgery, but an overall management morbidity of 3% and mortality of 6% in patients who were in Grade 1 at the time of hospital admission. Early surgery in Grade 1 patients was not associated with an increased incidence of delayed ischemia postoperatively. In Grade 2 patients, the operative morbidity and mortality was 7% and 4%, respectively, and the management morbidity and mortality 16% and 11%, respectively. Early surgery in this group was associated with a high frequency of postoperative delayed ischemia (particularly in patients with more than one SAH). Epsilon-aminocaproic acid appeared to protect against a rebleed, but was associated with a higher incidence of postoperative pulmonary emboli. Intraoperative complications were related both to the size of the aneurysm and to its location. Repair of multiple aneurysms did not adversely affect the result. The surgical approach, the importance of using a self-retaining brain retractor, and the technical complications in these cases are discussed.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Cerebral Vascular Research, Alfred Building, Room 4-437, St. Mary's Hospital, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schematic illustration of recommended positioning of the Yaşargil retractor. Note that the flexible arm is positioned in such a manner that it is supported by the scalp at Point A. The head of the bar of the fixation device which attaches the flexible arm to the operating table is placed relatively close to the operating table in order to avoid an excessive length of the flexible arm. The support rendered to the flexible arm at Point A gives considerable additional strength to the retractor which not only increases the life of the retractor but, more importantly, the precision of the instrument. The malleable retractor can be rotated about Point B for fine adjustments after the flexible arm has been positioned appropriately. The retractor not only retains the brain, but elevates it slightly, opening up the arachnoidal cisterns. See text for a more detailed description of retractor usage.

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    Conventional use of the Yaşargil retractor. The retractor is shown totally suspended and free of additional support other than the point where it is attached to the fixation bar. Used in such a manner, the retractor is vulnerable to movement by the surgeon, and excessive tension is required on the flexible arm in order to retain the brain out of the field of surgery.

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