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Medical and surgical management of intracranial aneurysms
F B Meyer1, A Morita, M R Puumala
1Department of Neurologic Surgery, Mayo Clinic Rochester, MN 55905.
Insights
Aggressive management of intracranial aneurysms, particularly after subarachnoid hemorrhage (SAH), improves patient outcomes by preventing re-rupture and reducing complications. Early surgical intervention is increasingly favored for better results.
Area of Science:
- Neurosurgery
- Neurology
- Vascular Surgery
Background:
- Intracranial aneurysms affect 1-8% of the population, frequently leading to subarachnoid hemorrhage (SAH).
- SAH carries a high mortality rate, with significant disability among survivors.
Purpose of the Study:
- To review the medical and surgical management of intracranial aneurysms.
- To analyze the pathogenesis, clinical presentation, SAH management, and surgical indications.
Main Methods:
- Classification of aneurysms by cause, size, site, and shape.
- Review of clinical grading systems for SAH (Botterell, Hunt and Hess, WFNS).
- Analysis of surgical options including clipping, endovascular treatment, ligation, and wrapping.
Main Results:
- SAH is the most common manifestation, occurring in 90% of aneurysm cases.
- High mortality (8-60%) occurs before hospital admission; in-hospital mortality is 37%.
- Mayo Clinic data (1969-1990) on 1,947 patients showed favorable outcomes in 70% post-treatment.
Conclusions:
- Aggressive management of SAH is crucial for preventing re-rupture and vasospasm.
- Timely surgical intervention, based on clinical grade and patient condition, improves outcomes.
- Modern trends favor early surgical treatment for aneurysmal SAH.
Objective:
To examine the medical and surgical aspects of intracranial aneurysms, including the pathogenesis, clinical manifestations, management of subarachnoid hemorrhage (SAH), and indications for surgical intervention.
Design:
This review presents the classification of intracranial aneurysms, defines specific aneurysms, and analyzes the Mayo Clinic experience with surgical treatment of cerebral aneurysms.
Material And Methods:
Intracranial aneurysms are classified by cause, size, site, and shape. The clinical grading systems for SAH, the most common manifestation, are as follows: modified Botterell, Hunt and Hess, and World Federation of Neurological Surgeons. Surgical options are direct clipping, interventional neuroradiologic treatment, proximal ligation or trapping of aneurysms, and wrapping or coating of aneurysms. Although the timing of surgical intervention after SAH is controversial, it should be based on the clinical grade, site of the aneurysm, and patient's medical condition.
Results:
The frequency of intracranial aneurysms is estimated to be 1 to 8% in the general population, and 90% of patients have SAH. After SAH, 8 to 60% of patients die before they get to a hospital. After hospitalization, the mortality rate is 37%, severe disability is 17%, and outcome is favorable in 47%. The current trend for surgical treatment is early after SAH. The Mayo Clinic experience with 1,947 patients who underwent surgical treatment because of aneurysmal SAH or for aneurysmal repair between 1969 and 1990 is as follows: 1,445 had an excellent outcome, 231 had a good outcome, 171 had a poor outcome, and 100 died.
Conclusion:
Aggressive management can be beneficial for many patients with severe neurologic injury after SAH by preventing rerupture of the aneurysm, attenuating the severity and sequelae of vasospasm, and decreasing the surgical complications.