Intracranial aneurysms

The modern history of the management of intracranial aneurysm encompasses little more than a quarter century. These are seen in 5% routine autopsies and those under 2 mm exist in 17% normal adult brain vasculature. One third of strokes are SAH and aneurysms account for 70% of these. Aneurysms rupture at a rate of 12/100.000 population/year, mostly on the 5th, and 6th decades. Given the high morbidity and mortality of these (43% from first haemorrhage if untreated), surgeons can attempt to avoid rebleeding for a week or more until surgery becomes safe and expand the ability to deal safely with most of them regardless of size or position. Early surgery has still an unacceptable morbidity and operation is usually planned between the 6th and 10th day after the first bleed. Early surgery is only indicated when there is a clot and deterioration. Conservative measures are reduction of blood pressure and use of antifibrinolysins and some minor surgical means whose practicality is still unknown. The recognition of warning leaks must be one of the significant factors for future treatment. Several surgical adjuncts are of considerable value, i.e., brain shrinking agents, microsurgical technique, induced hypotension. Aneurisms are classified as: small (less than 12 mm) large or bulbous (12-25 mm) and giant (greater than 25 mm). From 326 of small vertebral-basilar aneurysms the results were excellent in 246, good in 35, poor in 26 and 19 died. From 71 basilar aneurysms only 6 died, the results being excellent in 42, good in 10 and poor in 13. The management of giant anterior circulation (Table III) and posterior circulation (Table IV) aneurysms, involved various surgical procedures including carotid, middle cerebral, vertebral and basilar artery ligation, neck occlusion, wrapping or coating, as an overall result the outcome was good in 52 out of 63 gicunt anterior circulation giant aneurysms but was bad in 48 out of 91 posterior circulation giant aneurysms. The best results were obtained with 7 carotid-cavernous aneurysms (all good) and the worse results with 17 giant aneurysms of the basilar trunk at the superior cerebellar artery (11 poor, 6 good). A technique for the percutaneous occlusion of the basilar artery with a plastic Rommel type tourniquet is described (Fig 3). This allows the occlusion under local anesthesia. It has been used in 10 cases with 2 deaths STA-MCA by-pass proved to be useful for the progressive occlusion of the MCA in 3 cases of giant middle cerebral aneurysms.