The long-term outcome in patients with multiple aneurysms

Incidence of late hemorrhage and implications for treatment of incidental aneurysms

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✓ The proper treatment of multiple and incidental aneurysms remains controversial because the long-term result of different modes of management is unclear. This report evaluates the long-term outcome (follow-up period averaged 7.7 years) in 182 patients with multiple aneurysms who suffered a subarachnoid hemorrhage (SAH) to document the incidence of late bleeding. Of the 182 patients, 132 were treated by bed rest and 50 by surgery (craniotomy) directed at only the ruptured aneurysm. Seventy of the patients with bed rest were alive after 6 months. Twenty-one of these conservatively treated patients (30%) suffered a late hemorrhage, which is equal to the previously reported average yearly rebleed rate (3%) with a single aneurysm of the anterior circulation. There was no evidence that a previously intact aneurysm had ruptured in SAH patients treated with bed rest, indicating that late hemorrhage was due to rerupture from the original aneurysm. Patients who were hypertensive and who had a large aneurysm had an increased risk of late rehemorrhage. A linear discriminant analysis was developed to predict late rebleeding. The fate of intact aneurysms was evaluated by following patients with multiple aneurysms treated by craniotomy directed only at the ruptured aneurysm. Of the 50 craniotomy patients, 38 were alive after 6 months. In this group, the minimal risk of rupture of an intact aneurysm is approximately 1% per year. The presence of hypertension increased the risk of late hemorrhage. In conclusion, patients with multiple untreated aneurysms managed by bed rest have a late rehemorrhage rate equal to that observed in patients with a single cerebral aneurysm; the data indicate that rupture of intact aneurysms is not insignificant.

Article Information

Dr. Winn is a recipient of Teacher-Investigator Research Award NS 004404 from the NINCDS.

Address for Drs. Almaani and Richardson: Atkinson Morley's Hospital, Wimbledon, England.

Address reprint requests to: H. Richard Winn, M.D., Department of Neurological Surgery, Harborview Medical Center, ZA-86, Seattle, Washington 98104.

© AANS, except where prohibited by US copyright law.

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Figures

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    Long-term outcome in 70 survivors in the conservatively treated group of patients.

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    Expected versus observed long-term mortality rate in conservatively managed patients with multiple aneurysms. Expected survival rate is based on a life insurance table for a British population by age and sex. Also shown is the long-term mortality rate for 364 conservatively treated patients with a single ruptured aneurysm.

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    Percentage of conservatively managed patients who rebled each year. Six patients (8.6%) were lost to follow-up review (LFU) by the 10th year. Lowest limit assumes that patients LFU are alive; the intermediate level assumes the patients LFU have died “natural” deaths (that is, unrelated to subarachnoid hemorrhage); and the highest level assumes that the patients LFU and the four patients dying of unknown deaths (unk. ND) rebled in the year they were lost. Average rebleed rates per decade for each group are also illustrated.

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    Relationship between the probability of late rebleeding in conservatively managed patients and the discriminative score. Discriminative score = −31 + 0.49 (diastolic blood pressure) + 4.7 (aneurysm size rated 1 to 3). Aneurysm size: ≤ 5 mm = 1; 6–10 mm = 2; > 10 mm = 3.

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    Long-term outcome in 38 survivors of the surgically managed group of patients.

References

  • 1.

    Almaani WSRichardson AE: Multiple intracranial aneurysms: identifying the ruptured lesion. Surg Neurol9:3033051978Almaani WS Richardson AE: Multiple intracranial aneurysms: identifying the ruptured lesion. Surg Neurol 9:303–305 1978

  • 2.

    Beatty RARichardson AE: The value of electroencephalography in the management of multiple intracranial aneurysms. J Neurosurg30:1501531969Beatty RA Richardson AE: The value of electroencephalography in the management of multiple intracranial aneurysms. J Neurosurg 30:150–153 1969

  • 3.

    Bigelow NH: Multiple intracranial arterial aneurysms. An analysis of their significance. Arch Neurol Psychiatry73:76991955Bigelow NH: Multiple intracranial arterial aneurysms. An analysis of their significance. Arch Neurol Psychiatry 73:76–99 1955

  • 4.

    Björkesten GTroupp H: Multiple intracranial arterial aneurysms. Acta Chir Scand118:3873911959/1960Björkesten G Troupp H: Multiple intracranial arterial aneurysms. Acta Chir Scand 118:387–391 1959/1960

  • 5.

    Drake CGGirvin JP: The surgical treatment of subarachnoid hemorrhage with multiple aneurysms in Morley TP (ed): Current Controversies in Neurosurgery. Philadelphia: WB Saunders1976 pp 274278Drake CG Girvin JP: The surgical treatment of subarachnoid hemorrhage with multiple aneurysms in Morley TP (ed): Current Controversies in Neurosurgery. Philadelphia: WB Saunders 1976 pp 274–278

  • 6.

    Goulden C: Methods of Statistical Analysised 2. New York: John Wiley and Sons1952 pp 378393Goulden C: Methods of Statistical Analysis ed 2. New York: John Wiley and Sons 1952 pp 378–393

  • 7.

    Hamby WB: Multiple intracranial aneurysms. Aspects of treatment. J Neurosurg16:5585631959Hamby WB: Multiple intracranial aneurysms. Aspects of treatment. J Neurosurg 16:558–563 1959

  • 8.

    Heiskanen O: Risk of bleeding from unruptured aneurysms in cases with multiple intracranial aneurysms. J Neurosurg55:5245261981Heiskanen O: Risk of bleeding from unruptured aneurysms in cases with multiple intracranial aneurysms. J Neurosurg 55:524–526 1981

  • 9.

    Heiskanen OMarttila I: Risk of rupture of a second aneurysm in patients with multiple aneurysms. J Neurosurg32:2952991970Heiskanen O Marttila I: Risk of rupture of a second aneurysm in patients with multiple aneurysms. J Neurosurg 32:295–299 1970

  • 10.

    Henderson WGTorner JCNibbelink DW: Intracranial aneurysms and subarachnoid hemorrhage — report on a randomized treatment study. IV-B. Regulated bed rest — statistical evaluation. Stroke8:5795891977Henderson WG Torner JC Nibbelink DW: Intracranial aneurysms and subarachnoid hemorrhage — report on a randomized treatment study. IV-B. Regulated bed rest — statistical evaluation. Stroke 8:579–589 1977

  • 11.

    Kaste MTroupp H: Subarchnoid haemorrhage: long-term follow-up results of late surgical versus conservative treatment. Br Med J1:131013111978Kaste M Troupp H: Subarchnoid haemorrhage: long-term follow-up results of late surgical versus conservative treatment. Br Med J 1:1310–1311 1978

  • 12.

    McKissock WRichardson AWalsh Let al: Multiple intracranial aneurysms. Lancet1:6236261964McKissock W Richardson A Walsh L et al: Multiple intracranial aneurysms. Lancet 1:623–626 1964

  • 13.

    McKissock WWalsh L: Subarachnoid haemorrhage due to intracranial aneurysms. Results of treatment of 249 verified cases. Br Med J 2:5595651956McKissock W Walsh L: Subarachnoid haemorrhage due to intracranial aneurysms. Results of treatment of 249 verified cases. Br Med J 2:559–565 1956

  • 14.

    Mount LABrisman R: Multiple intracranial aneurysms. N Engl J Med281:13071970 (Letter)Mount LA Brisman R: Multiple intracranial aneurysms. N Engl J Med 281:1307 1970 (Letter)

  • 15.

    Mount LABrisman R: Treatment of multiple aneurysms — symptomatic and asymptomatic. Clin Neurosurg24:1661701974Mount LA Brisman R: Treatment of multiple aneurysms — symptomatic and asymptomatic. Clin Neurosurg 24:166–170 1974

  • 16.

    Mount LABrisman R: Treatment of multiple intracranial aneurysms. J Neurosurg35:7287301971Mount LA Brisman R: Treatment of multiple intracranial aneurysms. J Neurosurg 35:728–730 1971

  • 17.

    Moyes PD: Surgical treatment of multiple aneurysms and of incidentally-discovered unruptured aneurysms. J Neurosurg35:2912951971Moyes PD: Surgical treatment of multiple aneurysms and of incidentally-discovered unruptured aneurysms. J Neurosurg 35:291–295 1971

  • 18.

    Nishioka H: Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section VII. Part I. Evaluation of the conservative management of ruptured intracranial aneurysms. J Neurosurg25:5745921966Nishioka H: Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section VII. Part I. Evaluation of the conservative management of ruptured intracranial aneurysms. J Neurosurg 25:574–592 1966

  • 19.

    Paterson ABond MR: Treatment of multiple intracranial arterial aneurysms. Lancet1:130213041973Paterson A Bond MR: Treatment of multiple intracranial arterial aneurysms. Lancet 1:1302–1304 1973

  • 20.

    Phillips LH IIWhisnant JPO'Fallon WMet al: The unchanging pattern of subarachnoid hemorrhage in a community. Neurology30:103410401980Phillips LH II Whisnant JP O'Fallon WM et al: The unchanging pattern of subarachnoid hemorrhage in a community. Neurology 30:1034–1040 1980

  • 21.

    Pool JLPotts DG: Aneurysms and Arteriovenous Anomalies of the Brain: Diagnosis and Treatment. New York/Evanston/London: Harper & Row1965463 ppPool JL Potts DG: Aneurysms and Arteriovenous Anomalies of the Brain: Diagnosis and Treatment. New York/Evanston/London: Harper & Row 1965 463 pp

  • 22.

    Poppen JLFager CA: Multiple intracranial aneurysms. J Neurosurg16:5815891959Poppen JL Fager CA: Multiple intracranial aneurysms. J Neurosurg 16:581–589 1959

  • 23.

    Pouyanne H: Les anévrysmes sacculaires multiples du système carotidien supra-clinoidien. Étude anatomoclinique et thérapeutique. Neurochirurgie19 (Suppl 1):3961973Poppen JL Fager CA: Multiple intracranial aneurysms. J Neurosurg 16:581–589 1959

  • 24.

    Pouyanne HRiemens VGuerin Jet al: Les anévrysmes sacculaires multiples du système carotidien. Indications et résultats de l'abord direct. Neurochirurgie16:25321970Pouyanne H Riemens V Guerin J et al: Les anévrysmes sacculaires multiples du système carotidien. Indications et résultats de l'abord direct. Neurochirurgie 16:25–32 1970

  • 25.

    Richardson AEJane JAPayne PM: Assessment of the natural history of anterior communicating aneurysms. J Neurosurg21:2662741964Richardson AE Jane JA Payne PM: Assessment of the natural history of anterior communicating aneurysms. J Neurosurg 21:266–274 1964

  • 26.

    Richardson AEJane JAYashon D: Prognostic factors in the untreated course of posterior communicating aneurysms. Arch Neurol14:1721761966Richardson AE Jane JA Yashon D: Prognostic factors in the untreated course of posterior communicating aneurysms. Arch Neurol 14:172–176 1966

  • 27.

    Samson DSHodosh RMClark WK: Surgical management of unruptured asymptomatic aneurysms. J Neurosurg46:7317341977Samson DS Hodosh RM Clark WK: Surgical management of unruptured asymptomatic aneurysms. J Neurosurg 46:731–734 1977

  • 28.

    Shyrock HSSiegel JS: The Methods and Materials of Demography. New York: Academic Press1976577 ppShyrock HS Siegel JS: The Methods and Materials of Demography. New York: Academic Press 1976 577 pp

  • 29.

    Wiebers DOWhisnant JPO'Fallon WM: The natural history of unruptured intracranial aneurysms. N Engl J Med304:6966981981Wiebers DO Whisnant JP O'Fallon WM: The natural history of unruptured intracranial aneurysms. N Engl J Med 304:696–698 1981

  • 30.

    Winn HRBerga SLRichardson AEet al: The natural history of vertebral basilar (VBA) aneurysms. Stroke12:1201981 (Abstract)Winn HR Berga SL Richardson AE et al: The natural history of vertebral basilar (VBA) aneurysms. Stroke 12:120 1981 (Abstract)

  • 31.

    Winn HRRichardson AEJane JA: Late morbidity and mortality in cerebral aneurysms: a ten-year follow-up of 364 conservatively treated patients with a single cerebral aneurysm. Trans Am Neurol Assoc 98:1481501973Winn HR Richardson AE Jane JA: Late morbidity and mortality in cerebral aneurysms: a ten-year follow-up of 364 conservatively treated patients with a single cerebral aneurysm. Trans Am Neurol Assoc 98:148–150 1973

  • 32.

    Winn HRRichardson AEJane JA: The long-term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: a 10-year evaluation of 364 patients. Ann Neurol 1:3583701977Winn HR Richardson AE Jane JA: The long-term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: a 10-year evaluation of 364 patients. Ann Neurol 1:358–370 1977

  • 33.

    Winn HRRichardson AEO'Brien Wet al: The long-term prognosis in untreated cerebral aneurysms: II. Late morbidity and mortality. Ann Neurol4:4184261978Winn HR Richardson AE O'Brien W et al: The long-term prognosis in untreated cerebral aneurysms: II. Late morbidity and mortality. Ann Neurol 4:418–426 1978

  • 34.

    Winn HRTaylor JKaiser DL: The prevalence of asymptomatic incidental aneurysms: review of 4568 arteriograms. Stroke14:1211983 (Abstract)Winn HR Taylor J Kaiser DL: The prevalence of asymptomatic incidental aneurysms: review of 4568 arteriograms. Stroke 14:121 1983 (Abstract)

  • 35.

    Wood EH: Angiographic identification of the ruptured lesion in patients with multiple cerebral aneurysms. J Neurosurg21:1821981964Wood EH: Angiographic identification of the ruptured lesion in patients with multiple cerebral aneurysms. J Neurosurg 21:182–198 1964

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