Management and

Management ^and Surgical Treatment of Ruptured

Intracranial Aneurysms

PETER D.

MOYES, M.D., F.R.C.S.[C], Vancouver,

B.C.

ABSTRACT

The

advantages,

methods and results of

surgical

intracranial obliteration of aneur¬

ysms in conjunction with the use of intra¬

cranial or neck

ligation

of arteries were

studied in 177

patients

made up of the

following

groups:

(a)

internal carotid

aneurysms.48, (b)

anterior cerebral.an¬

terior

communicating.37, (c)

middle cere¬

bral.20, (b) basilar.two, (e) posterior

cerebral.one. The overall

mortality

rate

was 23%.

Following

conservative treat¬

ment, 69patientswithsubarachnoid hemor¬

rhage

without demonstrated aneurysms had a

mortality

rate of 30%. In this seven-

year

study

the value of team work involv¬

ing a second neurosurgeon, well-trained

nursing personnel

and expert anesthetists

was

amply

demonstrated.

rPHE treatment of

ruptured

intracranial aneur-

¦*¦ ysms constitutes one of the most

challenging

areas in

neurology

and neurosurgery

today.

Advo- cated

therapy

has

ranged

from

strictly

medical

treatment ofall

patients.irrespective

of the ageof the

patient,

^site of aneurysm, or

severity

and fre¬

quencyof

rupture.to surgical

treatmentwith

deep hypothermia

and total arrest of circulation.

Current Concepts ^est Aneurysm Surgery

Despite McKissock,

Paine and Walsh's1 ^con- clusion that there is no

proof

that the results of

surgical

treatment are any better than those of

conservative treatment in

comparable

groups of

patients,

most neurosurgeons,

rightly

^or

wrongly,

believe that the results of

surgical

treatment are

better and that the additional

security

andfreedom from

physical

restrictions

resulting

from successful

surgical

treatment are further factors

worthy

of consideration.

Some facts with

regard

to subarachnoid hemor¬

rhage

have become clear:

1. There is a

high early mortality.

We are not

likely

in the immediate future to reduce the ^num¬

ber of deaths that occur in the first 24 hours after

hemorrhage except

in those

patients

in whom localized hematoma is

present.

SOMMAIRE

L'auteur a etudie sur 117

patients

les avantages, methodes ^et resultats de Te- limination

chirurgicale

d'anevrismes intra-

craniens,

^{associee a la}

ligature

d'art&res intracraniennes ou cervicales. Les malades

ont ete repartis dans les groupes suivants:

(a)

anevrismesdela carotideinterne48cas,

(b)

cerebrale anterieure et communicante anterieure37cas,

(c)

c£r£bralemoyenne20 cas,

(d)

basilaire deux cas,

(e)

c£r£brale posterieure un cas. La mortalite

globale

a

et6 de 23%.

Apres

traitement conservateur, chez 69 maladesatteints

d'hemorragie

^sous-

arachnoidienne sans evidence

d'anevrismes,

la mortalite a atteint 30%. Cette

&ude, qui

^a couvert une

periode

^de sept ans, a

permis de d£montrer

amplement

la valeur du travail

d'equipe

comportant la

presence

d'un second

neuro-chirurgien,

de

personnel

infirmier competent et d'anesthesistes bien entrain£s.

From theDepartmentofSurgery (Neurosurgery), University

of British Columbia, Vancouver, B.C.

Presented in part at the 34th Annual Meetingof the Royal College of Physicians and Surgeons of Canada, Toronto, January 23, 1965.

2. The more severe the

hemorrhage

and the

worse the basic health of the

patient,

the worse are the results ofanykindoftreatment.

3.

Except

when ^a localized hematomais

present,

the purpose of

surgical

intervention is to

prevent

further

hemorrhage,

^{not to} treat the current

episode.

4. Patients who survive a subarachnoid hemor¬

rhage

and in whom no aneurysm can be demon¬

strated, despite adequate

visualization of both carotid and both vertebral arteries and their

branches,

appear to have ^a

good prognosis.2"4

5.

Vasospasm

is one of the

major factors,

if not

the

major factor, responsible

for

mortality

and

morbidity,

andan

adequate

method of

dealing

with this response would

undoubtedly greatly

^enhance

our

ability

to deal with

ruptured

^aneurysms.

Certain

techniques

^are

being developed

and

applied

^{to the treatment} of intracranial aneurysms such as

electrocoagulation,5 pilojection,6

intra¬

luminal

manipulations7

and

deep hypothermia.8*9

One or more of these

techniques

^may prove

superior

tothose

presently

ⁱⁿ

general

use butvalid conclusions cannot

yet

be drawn aboutthem. How¬

ever, differences of

opinion

exist

concerning

the

techniques

^now

generally available,

and this com¬

munication will outline my

attempts

to use, to the best

possible advantage,

^{oneor more} ofthefollow¬

ing

methods: intracranial obliteration of the

aneurysm, reinforcement of the aneurysm

by muscle,

muslin or

plastic material,

and

ligation

of

a

proximal artery.either intracranially

^or in the neck.

Management ^of Intracranial Hemorrhage

at theVancouver General Hospital

When a

patient

with a

suspected

subarachnoid

hemorrhage

^{is seen}

by

^one of the members of the

Neurosurgical

Service of the Vancouver General

Hospital,

he or she is assessed

clinically

and the

diagnosis

^is confirmed

by

lumbar

puncture using

a

small-gauge

needle and

obtaining only

^a small

amount of

cerebrospinal

fluid. When doubt

exists,

xanthochromia or the presence of crenated red blood cells ⁱⁿ the

spinal

fluid will

usually provide positive

confirmation.

If the

patient

has focal

signs compatible

with ^an intracerebral

hematoma,

carotid

arteriography

^is

carried ^out as soon as

possible

and is followed

by craniotomy

if indicated. Otherwise the

patient

is well sedated if

restless,

and the blood pressure is reduced

by

^a moderate amount if elevated. He is maintained on

complete

bed rest and may be catheterized. The

nursing

^care

during

this

period

is very

important.

Carotid

arteriography

^is carried

out within 24 to 48 hours and should include

oblique

^views and

cross-compression

when ^an anterior

communicating

aneurysm is

suspected.

If

no aneurysm is discovered at this

examination,

vertebral

arteriography

^is carried out in 48

hours;

open brachial

retrograde arteriography,

^as de¬

scribed

by Kuhn,10

is

usually

done.

When the aneurysm is

located,

another neuro-

surgeon on the service is called upon to

help

de- cide whether or not

operation

should be carried out, what

type

of

operation

should be done and when it should be done. He also assists at the

operation.

I agree with Pool11 that

operation

should be carried out within seven

days

of

hemorrhage

if the condition of the

patient

warrants

it,

because the

danger

^{of recurrent}

hemorrhage beyond

^{this time}

is considerable. In the

interim,

the

patient

ismain¬

tained on

complete

bed rest and is well sedated.

Various factors must be considered when decid-

ing

^on the

timing

of

surgical

intervention in a pa¬

tient with

rupture

of an intracranial aneurysm.

Despite

the fact that the

danger

of recurrent

hemorrhage

is

great beyond

^seven

days,

it is still difficult to decide whether or not to

operate

in the first seven

days

because vascular spasm is

greater

during

this

period

than it is several weeks later.

provided

^recurrent

hemorrhage

has not occurred.

The

operation

is done to

prevent

recurrent hemor¬

rhage but,

ⁱⁿ

fact,

often increases the

degree

of spasm and this spasm is the

principal

factor in

postoperative mortality

and

morbidity.

The

timing

of

operation

is therefore decided after

weighing

thesetwofactors:

If,

^onclinical and

radiographical grounds,

considerable spasm seems to be

present,

one would be inclined to wait

longer

than ^seven

days;

if it is

slight,

one would

proceed

within the

seven-day period.

It must be remembered

that, except

when ^a

significant

intracranial hematoma is

present, attempts

to

prevent

recurrent

hemorrhage

may

cause further

damage by

virtue of retraction of

already

swollen

brain,

and

manipulation

of

already spastic

arteries.

Thereason

why

thepresence ofhematoma alters the situation with

respect

to

timing

is because such hematoma constitutes a

space-occupying

^mass,

which may increase insize

owing

^to osmoticattrac¬

tion of fluid. Since this mass can be removed

surgically,

its removal is

usually highly

beneficial and this benefit is

likely

to be

greater

thanthe dis-

advantage

of

possibly increasing

spasm.

Fig. 1..Patient in position with the scalp flap marked and the collar incision for carotid exposure already made.

The patient is lying ^on her back with her head turned 45°

to the left.

Operation

is

carried

out under

hypothermia, using

^a

temperature

of about 84° F. attained

by

means of a

cooling

blanket.

Hyperventilation

and the intravenous administration of ^{urea or} mannitol

are also used to shrink the brain and allow maximum exposure with minimum retraction. The carotid arteries are

exposed

in the neck for intra¬

cranial

operations

^on carotid and anterior com¬

municating

aneurysms, but not for

procedures

^on

middle cerebral aneurysms in which a

Mayfield clip

^can be

applied

to the middle cerebral

artery

itself for

temporary

occlusion. As soon as the aneurysm has been

obliterated, re-warming

is

commenced and

hyperventilation

is discontinued.

Papaverine

is

applied locally

to the vessels in

proximity

to the aneurysm. Some ofthe features of

a

procedure

carried out for the control of ^an aneurysm of the

right

internal carotid

artery

are

illustrated in

Figs.

1-3.

Case Material

The ^case material

presented

ⁱⁿ this communica¬

tion was that seen over a

period

of seven years

Fig. 2..Viewobtained withtherightfrontalloberetracted to expose (from.left to right) the right optic ^nerve, the internalcarotidarterywith the aneurysm projecting postero- laterally from it, and the third nerve in close lateral proximity to the aneurysm.

Fig. 3..Thesame view asthatillustrated in theprevious photograph, showing an Olivecrona clip occluding the neck of theaneurysm.

and consists of 108 cases in which aneurysms were

proved

and 69 in which subarachnoid hemor¬

rhages

occurred but in which ^no aneurysms were

found: a totalof 177cases. With

respect

to evalua¬

tion,

the

patients

have been divided into four

categories: good.no significant

residual ^neuro¬

logic deficit; fair.significant neurologic

^deficit

but able to lead

essentially

normal lives.that

is,

they

^{have resumed}

previous employment

^or

management

of ^a

household;

and

poor.unable

to resume their

previous occupation.

In a fourth

category

are

patients

who died as a result of the aneurysm no matter how

long

after

operation

death occurred

(Table I).

There were many more women than men in this series and

although

this is ^common to other

studies,

we have an

usually high percentage

ofwomen.

Our

mortality

^rateof

23%

in agroupof

surgically

treated

patients

with

ruptured berry

^aneurysmsmay

seem

high. However,

in other studies where

only

ideal

patients

were chosen for surgery and where

a lower

surgical mortality

rate

obtains, proportion- ately greater

numbers of

patients

died preopera¬

tively

^than died in this group,

thereby raising

the overall

mortality.

Hencethe end resultis much the

same.

TABLE I..Proved Berry Aneurysms Total108>Male28,Female80 Notsurgicallytreated. 25

Good. 2

Fair. 1

Poor. 1

Died. 21 Intracranialoperations. 78

Good. 49

Fair. 6

Poor. 5

Died. 18

Mortalityrate.23%

Carotidligationinneck. 5

Good. 2

Fair. 1

Poor. 1

Died. 1

Multiple Aneurysms

Eleven

patients

had

multiple

aneurysms; the

largest

number of aneurysms in a

single patient

was five. At

postmortem examination,

two

patients

were found in whom

rupture

of more than ^one aneurysm had occurred. In two

patients,

two aneurysms were attacked

intracranially

at

separate operations.

One is

doing

well and the otherisblind

as a result ofvitreous

hemorrhages

which occurred

at the time of theintracranial

bleeding.

In another

patient

^two aneurysms ^were attacked at the ^same

operation

but further

hemorrhage

occurred from

one of the ^aneurysms which had been

wrapped

but not

occluded,

and the

patient

died.

In this entire

series, only

those

patients

who re-

fused

operation,

^{or were} considered unsuitable for

operation,

were not treated

surgically. By

and

large, they

constituted a

poor-risk

group and the results in these

patients (Tables I, II,

III and

IV)

are not

representative

of the results obtainedinthe

non-surgical

^treatment of

ruptured

aneurysms.

Internal CarotidAneurysms

These involved either the

posterior

communicat-

ing artery

^or the bifurcation of the carotid

artery,

and were the commonest

type

ⁱⁿ this series

(Figs.

4 and

5). They

sometimes

presented

ⁱⁿ associdtion with a third-nerve

palsy

and

occasionally

with

contralateral hemiparesis,

butveryoftenthere were no

localizing signs.

Patients inthis group ^are some¬

times considered for

ligation

of the carotid

artery

in the neck without

intracranial

obliteration. This method is more effective when the aneurysm is so

far

proximal

^on the intracranial

position

of the

artery

that

difficulty

maybe

experienced

in

getting

around the neck of the aneurysm.

In one

patient

an internal carotid aneurysm was

obliterated

intracranially

^{but it was} evident that this area had not been the source of the hemor¬

rhage. Subsequent

vertebral

arteriography

demon¬

strated an aneurysm of the

posterior

inferior cere-

bellar

artery.

This

patient

refused ^a second opera¬

tion at the time but after

moving

away from Van¬

couver had ^a further

subarachnoid hemorrhage

and the aneurysm was

successfully obliterated.

In

Fig. 4..Arteriogram showingan internalcarotidaneurysm of thetype sometimes referred toas aposteriorcommunicat-

Ing aneurysm.

another

patient

a

wrapping procedure

^was carried

out and ^a further mild

hemorrhage

followed six

weeks later. The carotid

artery

was then occluded in the neck and shehas since donewell. In ^a third

patient

with a third cranialnerve

palsy

^an internal carotid aneurysm was

ligated

but at

operation

the aneurysm didnotappeartohave been

compressing

the nerve.

TABLE II..InternalCarotidAneurysms Total48,Male9,Female89

Notsurgicallytreated. 9

Good. 1

Fair. 1

Poor. 1

Died. 6

Intracranialoperations. 34

Good. 23

Fair. 1

Poor. 1

Died. 9

Mortalityrate.27%

Carotidligationinneck. 5

Good. 2

Fair. 1

Poor. 1

Died. 1

During operation,

several

patients

with internal carotid aneurysms died because the aneurysm had

been

sheared off from the

parent trunk, leaving

^a

hole in the arterial

wall,

and

ligation

of the

artery

had been necessary to control

hemorrhage.

When

improved patching techniques

^{such as that de¬}

scribed

by Carton,

Heifetz and Kessler12 are em¬

ployed, ligation

^{of the}

parent artery

will

probably

notoften benecessary in the future.

Thetreatmentofsomecarotidaneurysmssituated in a somewhat

postero-medial position

should be either carotid

ligation

in the neck alone ^or carotid

ligation

followed

by

intracranial

ligation

^or rein-

forcement.

Fig. 5..Arteriogramonthesamepatientafterobliterating

the neck of the aneurysm withan Olivecrona clip. Thiswas an uncomplicated operation, yetmarkedspasmofthecarotid arteryjust proximal to the aneurysm can be seen.

Vasospasm

will continue to cause death in some

patients

in this group until it can be

satisfactorily

overcome. It is

usually present

in the

artery

adjacent

^to the aneurysm but it can also be

fairly generalized throughout

the intracranial arteries and is often increased

by operative manipulation during ligation

of the aneurysm. Its exact cause is

not

known,

butit is

probably

^a

protective

mechan¬

ism induced

by

blood in the

cerebrospinal

fluid ^or

by

the aneurysm

itself,

and is accentuated

by operative

maneuvers; in

brief,

it is a result of a

combination offactors known and unknown. What¬

ever the cause,

postoperative

deaths are attributed

more often to vascular spasm than to any other factor.

Anterior Cerebral.Anterior Communicating Aneurysms

In four

patients

in this group

(Table III) wrapping procedures

^werecarriedout to

strengthen

and

protect

the walls of aneurysms which seemed

too

large

^to obliterate. Muscle was used in the earlier cases but

recently

I have used

methacrylate

as described

by

Dutton.13 Three of the four are

doing

well. One died

following

^recurrent hemor¬

rhage

^afew

days

later after

operation.

Ihave^some-

TABLEIII..AnteriorCerebral.Anterior Communica-

ingAneurysms Total37,Male12,Female 25

Notsurgicallytreated.All 8 died Intracranialoperations

Good.. 18

Fair. 2

Poor. 2

Died.. 7

Mortalityrate.24%

Fig. 6..Marked vasospasm associated with an anterior communicating ^aneurysm before operative intervention.

times

placed

^a

clip

^{across the aneurysm at a} site other than the neck of the aneurysm if it

appeared

that

clamping

of the neck

(i.e.

^{near the}

parent

artery)

would

jeopardize

the

patency

of the anterior cerebral arteries. One of the four

patients

mentioned above did well after

operation

but suffered a further

hemorrhage

^at home as'a result of

rupture

of the aneurysm

proximal

to the

clip.

In similar situations I ^now

usually

^reinforce the whole aneurysm with

methacrylate.

However,

the

greatest

difficulties

experienced

ⁱⁿ

this group of 37

patients (Table III)

^were related

to vasospasm, and

operation

is

usually

deferred whenthe clinical and/or

arteriographic findings

^are

suggestive

of vasospasm

(Figs.

⁶ and

7).

The blood pressure is held at a level

approximately

20%

below the

patient's

normal

systolic

pressure until the clinical status has

improved,

unless re¬

current

hemorrhages

indicate that there is less

danger

in

operating.

It is in this

particular

group that the team

approach

afforded

by

the second neurosurgeon and

specialized nursing

facilities has been most

helpful

^and successful.

Middle Cerebral Aneurysms

More often than in othervessels middle cerebral aneurysms are associated with localized

neurologic deficit,

characterized

by varying degrees

of hemi-

paresis,

and

occasionally,

when the dominant hemi¬

sphere

is

involved,

the

patient

is also

dysphasic.

Two

patients

ⁱⁿ this group of 20

(Table

IVand

Fig. 8)

had not had ^recent subarachnoid hemor¬

rhage

but one had suffered a serious

hemorrhage

someyears

previously

andhisaneurysmwas

judged

to have increased in size inthe interim.

In addition to the

patients

included in the fore¬

going tables, during

this seven-year

period

I en¬

countered two

patients

with basilar aneurysms, both of whom died without

having

^had

operative intervention,

and one

patient

who hadan aneurysm of the

posterior

cerebral

artery.

In this last

patient,

Fig. 7..Anexample ofdiminishedvasospasm in thesame

patient asFig. 6 followingobliteration of the aneurysm. Fig. 8..Atypical aneurysm atthe trifurcation of the left middle cerebral artery.

TABLE IV.-MIDDLE CEREBRAL ANEURYSMS

Total 20, Male 5, Female 15 Not surgically treated.

Good..6 Died.5

Intracranial operations..14 Good.8

Fair.2 Poor.2 Died.2 Mortality rate-14%

the posterior cerebral artery was ligated just proxi- mal to the aneurysm with very little subsequent neurologic deficit.

Sui.1.cINom HEMORRHAGE WITHOUT DEMONSTRATED ANEURYSMS

In this group of patients with subarachnoid hemorrhage but without demonstrated aneurysm, the mortality rate was 30%. At postmortem ex- animation only rarely were very small discrete aneurysms found and in most cases the source of the bleeding was not revealed.

TABLE V.-SUBARACHNOID HEMORRHAGE WITHOUT DEMON- STRATED ANEURYSMS

Total 69, Male 24, Female 45 Conservativetreatment..66

Good.39 Fair.4 Poor.4 Died.19 Mortality rate-30%

Surgicallyexplored.

Good..3 -Died.1

There are two theories as to the mechanism of subarachnoid hemorrhage without demonstrable source. One is that the aneurysm bleeds and then becomes thrombosed, in which case the patient theoretically should survive. The second theory, which postmortem examination tends to support, is that a small aneurysm actually destroys itself during the* bleeding and the hole seals itself off.

Microarteriography to demonstrate vessels in- visible to standard carotid arteriography is in the process of development, but whether such lesions are amenable to surgical attack with our present surgical techniques is not yet clear.

In the last three patients in Table V, in whom exploration was carried out because aneurysms were thought to have been demonstrated arterio- graphically, no aneurysm was found at operation.

DIscussIoN

The results of any form of treatment depend upon - many factors. The overall mortality rate of 23% for the group subjected to intracranial surgery seems high, but this is due in part to the policy that every patient was operated upon whose chances of survival were considered to be greater with surgical intervention than without.

In my experience, the influence of age, presence and degree of vascular hypertension, severity of hemorrhage and degree of vascular spasm is the same as that described by Botterell et al.14 except that the chronological age of the patient seems less important than is sometimes stated. For example, one patient, aged 70, had successful obliteration of an anterior communicating aneurysm: he was exceptionally healthy and had no evidence of atherosclerosis in either cerebral or other vessels.

In other words, the health of the vessels is more important than the chronological age of the patient.

The patients least suitable for surgical treatment are often those least suitable for an aggressive hypotensive regimen, but the judicious induction of moderate hypotension is a valuable adjunct in the management of these patients.

There is no single ideal intracranial approach to any particular type of aneurysm. A consideration of the various approaches has been omitted from this discussion because each neurosurgeon will use the approach that is most suitable for him.

Specific ways in which present results of treat- ment can be improved have been mentioned, but the most important lesson I have learned concerns the value of the team approach in which a second surgeon helps in the management of the patient, well-trained nurses are on hand in the ward and in the operating room, and good anesthesia has been assured. The results that can be achieved with techniques now generally available can be quite en- couraging and rewarding.

SUMMARY

The results of treatment of 177 patients including 108 patients with proved intracranial aneurysms are reported. The overall mortality rate among 78 pa- tients who had intracranial operations was 23%.

A concerted team approach is advocated in the management of each patient in order to achieve maxi- mum benefit from the methods of treatment at preseilt generally available.

I wish to thank Drs. F. A. Turnbull, P. 0. Lehmann, J. W. Cluff and G. B. Thompson for their help in the treatment of the patients referred to in this report.

REFERENCES

1. McKlssocK, W., PAINE, K. W. E. AND WALSH, L. S.:

J. Neurosurg., 17: 762, 1960.

2. PARKINSON, D.: Ibid., 12: 565, 1955.

3. DUNSMORE, R. H. AND POLCYN, J. L.: Ibid., 13: 165, 1956.

4. BJ6RKESTEN, G. AS'. AND TROUPP, H.: Ibid., 14: 434, 1957.

5. MIJLLAN, S.: Induced thrombosis in an aneurysm, paper presented at the Harvey Gushing Society Meeting, Los Angeles, April 20-22, 1964.

6. GALLAGHER, J. P.: J. Ncurosurg., 21: 129, 1964.

7. LUESSENHOP, A. J. AND VELASQUEZ, A. C.: Ibid., 21: 85, 1964.

8. USHLEIN, A. et al.: Ibid., 19: 237, 1962.

9. MACCARTY, C. S., MICHENFELDER, J. D. AND UIHLEIN, A.:

Ibid., 21: 372, 1964.

10. KUHN, R. A.: Ibid., 17: 955, 1960.

11. PooL, J. L.: Ibid., 19: 378, 1962.

12. CARTON, C. A., HEIPETE, M. D. AND KESSLER, L. A.: Ibid., 19: 887, 1962.

13. DUTTON, J.: Brit. Med. .T., 2: 597, 1959.

14. BOTTERELL, E. H. et al.: .T. Neurosurg., 15: 4, 1958.