Acta Neurochir (Wien) (1986) 82:92-101 9 by Springer-Verlag 1986
The Surgery of Middle Cerebral Artery Aneurysms E. Pfisztor, J. Vajda, J. Juhfisz, Sz. T6th, l~va Orosz, and M . Horvfith National Institute of Neurosurgery, Budapest, Hungary
Summary Aneurysms of the middle cerebral bifurcation represent an interesting entity among intracranial saccular aneurysms. Their shape, size, situation, and in particialar their relation to the middle cerebral trunk and its branches show wide variations. Topographical analysis of the angiograms offers a great deal of interest in planning surgery. Our experience with 289 patients with middle cerebral artery aneurysms operated on since 1977 are presented. Factors such as number of previous haemorrhages, timing of surgery, preoperative condition, major intraoperative bleeding or brain oedema and delayed postoperative deterioration play a major role in the outcome. Others such as severity of the subarachnoid bleed, age, size of the sac seem to have much less influence.
Keywords: Aneurysm; middle cerebral artery aneurysm; vasospasm; timing of surgery.
Introduction Despite much debate about the surgical attitude t o w a r d s r u p t u r e d o r silent, single o r m u l t i p l e , a v e r a g e size o r g i a n t i n t r a c r a n i a l a n e u r y s m s t h e r e is still n o consensus regarding the various aspects of the treatment of saccular and especially middle cerebral artery ( M C A ) a n e u r y s m s . T h e r e a r e n u m e r o u s p a p e r s 3, 5, 6, 8, 9, 10, II, 14, 15 d e v o t e d t o s u r g i c a l e x p e r i e n c e s w i t h M C A a n e u r y s m s in t h e l i t e r a t u r e a d v o c a t i n g a w i d e r a n g e o f methods of treatment. The present study was undertaken with the intention of analysing the characteristics of our experiences with surgical treatment of MCA aneurysms.
Material and Methods 1,080 patients with 1,259 aneurysms underwent 1,101 intracranial microsurgical operations since 1977 at the National Institute Of Neurosurgery, Budapest. 289 patients harboured one or more
aneurysms at the MCA bifurcation. This constitutes 26 percent of MCA aneurysms in our material. 297 operations were performed for MCA aneurysms on 289 patients. One patient had 2 operations following the rupture of the same MCA aneurysm on two occasions, 7 patients were operated in two stages for bilateral "mirror" MCA aneurysms. 24 patients had silent MCA aneurysms, 3 of them had ruptured aneurysm elsewhere. One bled three years before surgery. In a further 19 patients the MCA aneurysm never bled and was discovered as follows: - - accidentally in 3 cases, with brain tumours in 2 cases (glioblastoma and craniopharyngioma) and arteriovenous malformation in one case. - - Kephalalgia was the cause of investigating one patient. - - Cerebrovascular history led to angiographic discovery of a silent MCA aneurysm in I 1 occasions. - - 3 patients presenting with epilepsy had silent MCA aneurysm one of them was a giant lesion. - - The last case presented with transient aphasia following head trauma. A ball-shape hyperdensity on CT was proved to be a distal MCA aneurysm without any sign of recent subarachnoid haemorrhage (SAH). Patients were referred to us from other hospitals at various times after SAH and in differing clinical conditions. Angiography was performed by direct puncture of the left common carotid and by retrograde injection into the right brachial artery in most of the cases. No strict timing for surgery was followed. Since 1984, however, surgery in conscious patients or in those with space-oceupying haematoma (cases of ventricular tamponade were excluded) is preferred within 48 hours. Between the third and eighth days after SAH only those patients in excellent condition with meningeal signs and/or mild drowsiness only were operated on. Their angiograms do not show any vasospasm. After 8 days patients in a stable condition undergo surgery. Patients were put into various categories. The severity of the most recent aneurysmal rupture was graded as follows; Grade I: sudden headache without loss of consciousness or any serious or permanent neurological deficit. Grade II: epilepsy or loss of consciousness of short duration without serious focal deficit. Grade III: lasting unconsciousness with or without focal neurological deficit. Grade IV: unconsciousness for some hours accompanied by
E. Pfisztor et al.: The Surgery of Middle Cerebral Artery Aneurysms serious vegetative disturbances, brain stem crisis and respiratory failures. The clinical state of patients was assessed preoperatively using two methods. Systemic hypertension or any other significant systemic disturbance capable of influencing cerebrovascular function was noted. Neurological signs such as paresis, aphasia were graded according to the above scale. The state of consciousness was separately scored. This form of assessment allowed us to grade patients both according to the Hunt-Hess and Glasgow Coma Scale for comparison. Patients underwent frontolateral, in some earlier cases frontotemporal craniotomies. Surgical details are described below. Surgery was performed by least 6 members of the surgical staff of the Institute. Postoperative treatment included intravascutar volumeexpansion controlled by central venous pressure. Clinical and CT observation was instituted. Postoperative angiography was performed only in those cases, where the aneurysmal sac was not opened widely after clipping. Follow-up data were collected during the three months prior to this publication. Postoperative mortality was calculated regardless of the time between surgery and death. Causes of poor outcome were recorded with special reference to those causes unrelated to surgery. Patients with no signs or symptoms were labelled "excellent". "Good" in our follow-up means insignificant signs or symptoms, including occasional seizures. These patients, however, retained full working capacity. Patients with significant signs or symptoms reasonably attributable to their disease which left them independent were scored "fair". Vasospasm seen on preoperative angiograms and delayed pre- or postoperative neurological deterioration attributable to vasospasm (D.A.V.) were also noted. Data processing was performed using Tektronix 4051 desk computer.
Surgical Procedure
Most of the aneurysms were approached via frontolateral craniotomy with the head almost in a vertical position. The reason for choosing this rarely mentioned position is anatomical. The MCA branching complex lies on the insula. The surface of the frontolateral region leads to the plane of the insula 7, L3,[6 The temporal operculum covers the insula laterally, while the frontal operculum is just in front of it (Fig. I). The two approaches to the insula without marked brain retraction or any resection need to follow this anatomical relationship. l. Elevating the frontolateral base and determining the Sylvian portion of the MCA trunk. The main MCA can be followed into the Sylvian fissure on the insular surface by gradual gentle retraction of the frontolateral convexity medially dividing the two sides of the Sylvian cistern distally. 2. The frontolateral convexity starting from the middle cerebral vein at its middle-third is gently pressed posteriorly. The Sylvian arachnoid is opened at this level. The temporal operculum is left in place while further frontolateral retraction allows inspection go under the temporal operculum to get to the MCA trifurcation. Since the temporal branch of the MCA joins the internal surface of the temporal operculum and the frontal branch follows the lateral aspect of the frontolateral-insular surface, this maneuvre is usually appropriate in displaying the MCA trifurcation, in this way the neck of the MCA aneurysm is freed and the branches can be identified.
93
RETRACTOR
B - f'~JI'J
MCA COMPLEX C
Fig. i. Anatomical sketches of the frontotemporal quarter of the right sided hemisphere. The level of the section is shown (A). B shows the normal relationship of the MCA branching to the frontal and temporal lobes. C Surgical situation with the head turned to the left, the frontolateral area is retracted medially giving way to the MCA complex. The frontolateral craniotomy is an adequate exposure
We analysed our angiographic data in detail and used them in choosing the appropriate surgical appproach, as follows: If the neck of the MCA aneurysm originates as a continuation of the main trunk pointing laterally, the sac is surrounded by one or both leaving branches. A space can usually be observed on AP films between the neck and one main branch. Our aim is then to work in this space first to avoid premature rupture and to save time while minimising the brain area explored. A cortical opercular artery leaving the main branch separated from the neck by even a tiny space as seen on the angiograms will therefore be our guide to the neck with relative safety (Fig. 2). If the neck deviates from the direction of the branching and the fundus lies superficially in the Sylvian fissure we would follow the frontal branch. In such cases the main trunk and the branching are expected behing the sac (Fig. 3). When the neck originates and the sac remains in the plane of the leaving branches or the fundus points upwards between the branches, the orthodox approach along the carotid and main MCA trunk is advised. It is particularly so if the latter is rather short or much adherence is expected between the fundus, especially an irregular one, and the branches. The orthodox approach may avoid dangerous dissection at the point of adherences of a weak fundus and any leaving MCA branches (Fig. 4). Spaces around the neck are freed first. Temporary clipping of the parent trunk and leaving arteries is used only as a last resort when rupture of the sac makes it impossible to clip the neck properly. This may be especially indicated in cases with a broad irregular neck requiring a clip curved in different planes. Even in such cases it has never been necessary to apply temporary clips on the distal branches of the MCA. Occluding the main MCA with a Ya~argil temporary clip along with mild suction was always enough to save the situation. When the neck is clipped, with a temporary clip on MCA, one can never be sure that the permanent clip is in the best position. Therefore we remove the temporary clip and loosen the permanent clip for a
94
E. P~isztor et al. : The Surgery of Middle Cerebral Artery Aneurysms
Fig. 2. Pre- (A) and postoperative (B) AP angiograms demonstrate the wide space between the sac pointing laterally and the temporal branch (lines). The clip was introduced safely along the dissected temporal branch (B)
Fig. 3. Pre- (A) and postoperative (B) AP angiograms show the space between the superficial sac and the distal frontal branch (circles). Clipping was along the freed frontal branch (B) spell to make the branches fill up again. This moment is most vital to avoid physiological stenosis of the lumen. This remains one of our primary arguments against regular temporary occlusion of any MCA branches during permanent clipping and also against clipping of a slack neck. Contralateral MCA aneurysms in bilateral cases were clipped on several occasions from the same unilateral craniotomy.
Results 158 f e m a l e s a n d 131 m a l e s w e r e o p e r a t e d o n f o r M C A a n e u r y s m s . T h e i r a v e r a g e age w a s 45 y e a r s f o r f e m a l e s a n d 44 f o r m a l e s . D i s t r i b u t i o n o f single, m u l t i p l e , g i a n t a n d silent lesions are s u m m a r i z e d o n T a b l e 1.
E. P~sztor et al.: The Surgery of Middle Cerebral Artery Aneurysms
95
Fig. 4. Pre-(A) and postoperative (B) AP angiograms.The sac is behind and between the distal branches (temporal: lines; frontal: circles). No attempt was made to dissect branches around the sac. Clip was introduced along the main trunk after its dissection (B)
Table l. 289 Cases of Middle Cerebral Artery Aneurysm
Table 2. Preoperative Grading of 265 Cases with SAH
No.
%
Male
Female
Single multiple
2l 3 76
74 26
107 24
106 52
From these Giant Silent
9 21
3 7
6 13
3 8
SAH caused by rupture of MCA aneurysm occurred in 265 cases. State of patients after SAH was assessed according to Hunt-Hess and Glasgow Coma Scale grading. Table 2 contains number of patients in each grade and their score using both methods of assessment. Patients in Hunt-Hess grade IV and V were put in one group labelled "IV". Also for practical simplification Glasgow Coma Scale group I and II were put in the group labelled "score 15". Outcome of operations for 265 ruptured MCA aneurysms is demonstrated in Table 3 and 4 regarding the two types of grading. Overall mortality in all of our cases is shown in Table 5. Predictably, surgery for multiple aneurysms carried the highest risk of a fatal outcome, while surgery for silent lesions was the least hazardous.
Hunt-Hess
Glasgow coma score Patient
Patient
Grade
No.
%
Score
No.
%
l
129
49
15
147
56
II
80
30
13-14
76
29
III
40
15
8-12
33
12
IV
16
6
9
3
<7
Table 3. Outcome of Surgery in Grading of Hunt-Hess (265 MCA Aneurysms with SAH) Grade
Favourable
Poor
Outcome
I
II III IV
No.
%
No.
%
114 70 27 7
88 88 68 44
15 l0 13 9
12 12 32 56
96
E. Pfisztor et al. : The Surgery of Middle Cerebral Artery Aneurysms
Table 4. Outcome of Surgery Related to Glasgow Coma Scale (265
Table 6. Causes of All 36 Deaths Among 289 MCA Aneurysm-Cases
MCA Aneurysms with SAH) Score
Favourable Outcome
15 13-14 8 12 <7
Causes
No.
Remarcs
Surgical failures
7
Ischaemia 5, rerupture 2
Delayed D,A.V.
9
Comatous patients
9
Rupture at opening
1
Poor
No.
%
No.
%
130 62 23 3
88 82 70 33
17 14 10 6
12 18 30 67
Unrelated to MCA aneurysm:
Table 5. Overall Mortality of MCA Aneurysms Surgery
No.
Now dead
Percent
All
297
36
12
Single
214
23
11
Multiple
83
13
16
From these Giant Silent
9 24
0 1
0 5
Causes of death in 36 cases who died up to the date of the completion of data entry were divided into two groups. 26 deaths were related to surgery, while in 7 cases death was attributable to surgical failures. The number of cases unconscious from the onset equals those of delayed postoperative D.A.V. (Table 6). The most important cause of death not related to surgery proved to be the rupture of another aneurysm left untreated in cases with multiple lesions.
With haematoma 7, without haematoma 2
Craniopharyngeoma, hypothalamic lesion 1, hepatic coma 1, pulmonal emboli 1, suicide 1
Rupture of other untreated aneurysm
The effect of age on the outcome of surgery was studied (Fig. 5). Results were not worse even in older age group if they were in Hunt-Hess I-II. Follow-up charts have been prepared in order to determine the factors which influence results other than the preoperative condition (Hunt-Hess). The effect of timing of surgery on the final results was analysed (Fig. 6 A-D). Though the number of patients operated on within 48 hours after the haemorrhage is low, this was the group with the best results. This is noteworthy as more than forty percent of these patients were in grade IV preoperatively. Considering the cases with early surgery, there was no poor outcome from Hunt-Hess grade I-II-III. Even from grade "IV", half of the patients were cured.
*289 CASESWITH HCA ANEURYSH*
+2
10
,2i
g
I!
HUNT-HESS Z HUNT-IiESS II
14
39
HUNT-HESS III
'1 20-29
'I 'I 30-39
40-49
50-59
lUlT-ItESS IV
60-69 YEARS
Fig. 5. Comparison of surgical results with respect to preoperative state in different age groups (expressed in decades). The width of the rectangles relates to the number of cases in each Hunt-Hess grade. Black area with the digits attached show the percentage of poor outcome in each group and grade. No significant difference can be found among the age groups
E. P~.sztoret al.: The Surgeryof Middle Cerebral Artery Aneurysms The number of patients cured in grade IV equals the number of all other grade IV patients, but there was only one of these cases now in excellent condition, who was operated upon late, namely after 2 days (Fig. 6 A). Our results were worse when surgery was performed between the third and seventh days after the last SAH. There was a disappointingly high percentage of poor outcome in group II, although this group was far less numerous than the similar group with delayed surgery (Fig. 6 B). Surgery between the first and second week scored better, even though the preoperative condition of the patients was less satisfactory. The majority of patients were in grade II, which relates to a preoperative vasopastic process, these patients have just suffered. This caused one fifth of them to have definite neurological signs and symptoms (Fig. 6 C). Most of our patients were operated on more than two weeks after the SAH. The majority of these were in grade I condition. Poor outcome was less frequent in all grades except in grade IV. Patients who died in grade I and II operated on after two weeks were largely victims of surgical failure or rupture of an untreated aneurysm elsewhere (Fig. 6 D). Four other factors, widely believed to worsen outcome, have been examined in the same way. Almost a quarter of patients with SAH had vasospasm on preoperative angiograms (Fig. 7). Poor outcome was more common in grades III and IV which underlines the role of careful timing of surgery, when vasospasm is seen at angiography. Vasospasm on angiograms was not seen within the first three days after SAH. The high incidence of vasospasm in our material can be explained by the high percentage of late angiography due to delayed admission. Almost half of these cases deteriorated in the preoperative period, which could be attributed to vasospasm (Fig. 6). We defined surgery "troubled" if one or more of the following occurred during the operation: 1. long (about 10 minutes or more) occlusion of parent vessels or a major branch, 2. brain resection was performed, 3. marked brain oedema was noted or 4. lasting major haemorrhage developed from the lesion. Even though half of the patients with "troubled" surgery were in grade I preoperatively, there was marked deterioration in a considerable proportion of them. Patients in a worse preoperative stage tolerated complicated surgery even less well (Fig. 8). Delayed postoperative D.A.V. caused the heaviest loss and disability from all factors examined (Fig. 9).
97 This complication occurred in one tenth of all cases with rupture, and even more disappointingly it harmed chances of grade I patients for survival. Over half of these patients became disabled or died. Catastrophic vasospastic complications were found most often among younger females operated on between the third and seventh postictal days. Many assume that endocrine factors play a part in the pathological reaction of cerebral arteries ~. A further factor is the number of SAHs, which has proved to be responsible for a poorer outcome in cases where two or more bleeds have followed each other. When, however, the severity of the most recent SAH was plotted against the outcome, no significant relation could be established. The only group in which outcome seemed to be influenced by the severity of the bleeding was that operated on within 48 hours. Surgical results in giant aneurysms are also not inferior to the others. A scrutiny into the possible relationship between the size of the sac and the outcome ended up with a negative answer. Urgent reoperation was performed in 12 patients (Table 7). The results of reoperation were poor mostly in cases, where the severe deterioration could be attributed to diffuse hypoxic oedema.
Discussion
It has been suggested recently that the Glasgow Coma Scale, which enjoys a deservedly widespread use in neurotraumatology, should also be the method of preoperative assessment of patients with ruptured aneurysm 4.12. The Hunt and Hess grading is still the most commmonly used for this purpose and generally serves as a basis of comparison for different clinical material in the literature. Since our grading regarded focal neurological deficit and level of consciousness separately we studied which of these grading systems was superior to the other in describing the same population of patients. The two grading systems proved to show surprisingly similar figures both in terms of distribution of patients in the preoperative grades and concerning surgical results. Thus, it seems justified in the future to compare groups of cases with ruptured aneurysms graded by these two methods. Although the probability of death from rerupture of an aneurysm declines in the older age group and operative risks increase in many ways, comparison of poor outcome in different age groups does not suggest abandoning surgery in the elderly.
98
E. P~isztoret al.: The Surgery of Middle Cerebral Artery Aneurysms ,285 CASES WITH RUPTURED~ A AN.
POOROUTCOHE
EXCELLE1(~, NT~
~
.m
OVERALL RESULTS
79"X fovorobl, 21X poor
tl
TTT
IV
NUMBER OF CASES : I 9
4
s
I
(~
'
,
Ill
I
600D
o
o
I
Ill
F~
o
o
II
II
DISk~LEP
o
I
O
4
3
DIED
A ,265 CASES WITH RUPTURED HCA AN. POOR OUTCOHE
EXCELLENT9 t
OVERALL RESULTS
,,
74Y, fovor~le
Fig. 6. Influence of timing on surgical results with respect to the preoperative state. The width of lines drawn between preoperative and recent states represents the number of patients in each group (see attached table). Direction of the lines drawn corresponds to the change of clinical state of the patients. More groups of wide lines running upwards on the chart express better results. Poor outcome (disabled and died) expressed in percentage of each Hunt-Hess grade (roman numbers) is shown. White area of rectangles belonging to each Hunt-Hess grade is in proportion to the number of patients cured in that grade. Black area of rectangles: patients became disabled or died from that same group. The circle diagram show the number of patients in each clinical stage as a percentageof all studied in this
28'/. poor
"i
,0
| ]T.IHBER OF CASES : 381
]
IV
TT
III
12
2
2
i
EXCEIJ.DTT
I
0
0
I
0
3
I
9
I
e e e
FAIR DIS/~I.B)
2
2
I
I
DIED
B Experience gained from study of the influence of timing o f surgery on the outcome seems convincing. A wider range of clinical stages m a y be considered for surgery within the first 48 hours, since curability of patients of inferior grades prior to early surgery is significantly higher than those of the same grades with later surgery. This period between the third and eighth days features a higher probability of D.A.V. In addition, early surgery eliminates the danger ofrerupture, which otherwise would be a major lethal factor. Authors advising resection or incision of the t e m poral pole for M C A aneurysms on the basis of angio-
graphy argue that this procedure does not cause any additional symptoms 3,11,14. One cannot afford, however, to loose the advantages o f exposure based on the normal a n a t o m y of the M C A branching. Angiographic data do not overrule the fact that the dissection of the M C A branches and division require working along the CSF space of the M C A complex. The lateral (temporal) approach gives a narrow view through the brain. Thus, it is likely that the leaving branches and the neck between them are going to overlap if the direction o f dissection crosses the Sylvian fissure instead of running parallel to its axis.
E. Pfisztor et al.: The Surgery of Middle Cerebral Artery Aneurysms figure. In the insert below the latter is shown as the percentage of all MCA aneurysms given in the subtitle. Overall results (favourable and poor) are demonstrated on the right side of the chart. A) With surgery within 48 hours lines go upwards representing uniformly good results except in half of the grade IV patients, B) With surgery between the third and seventh day lines running down appear which represent the occurrence of brain ischaemia due to D.A.V. C) Results of surgery between the first and second week are better, but the number of patients who died of vasospastic processes from all grades increases. D) Grade I and II patients cured dominate the outcome of surgery after two weeks as the danger of D.A.V. largely disappears
99
9 265 CASES WITH RUPTUREDHCA ANEURYSHS* POOR OUTCOME OVERALL RESULTS 86% f ~ o b l r 29X poor 12
08' i
"1 IN PERCENT
III
NUMBER OF CASES : 641
I
IV
16
17
@
@
EXCELLENT
1
O
i~
El
I
6
2
9
t
O 4
@
I 13
GOOD FAI~ DISABLED
3
4
DIED
C 'TURED HCA ANEUR'~
)
POOR OUTCOME
OVERALL RESULTS
89% favorable
I
I1% poor ,'
10
(5 IN PERCENT
I
NUMBER OF CASES : 128 ~
III
IV
s2
21
s
e
EXCELLD4T
6
8
5
G
4
8
8
0
1
2
I
0
G
2
3
1
GOOD FAIR DISABLED DIED
D
Neurosurgeons nowadays relying on modern neuroanaesthesia and monitoring are less reluctant to apply a temporary clip trusting in various methods of protecting brain from ischaemia 1~ Our results, however, suggest that protracted occlusion of major cerebral arteries alone or in conjunction with other factors can worsen the outcome of surgery. Injury of the intimal layer trapped between the blades of a temporary clip cannot be ruled out. The danger of clipping a neck slackened by extended use of temporary clips has already been mentioned. In spite of the satisfactory results of others who regularly use temporary clips, we
think, clips should be applied as briefly as possible and only as a last resort. The precise application of the clip onto the neck of the aneurysm is of paramount importance 2. From this point of view the technical details mentioned under surgical procedure may be of importance. The high percentage of cases with poor outcome among those in grade III after the 3rd postictal day suggests that surgery should have been delayed further. Close observation of patients in the postoperative period cannot be overestimated. This is particularly important in cases operated on within the first week
E. Pasztor et al.: The Surgery of Middle Cerebral Artery Aneurysms
100
9265 CASES WITH RUPTURED HCA AN.
POOR OUTCOHE --)
OVERALL RESULTS fovorebl. 20"/. poor
47
@
'I IN PERCENT NUNBER OF CA~.S :
ogl
16
I
I
9
rrr
la s
s e 4 ~ a
2 O
i t
I
IV
Fig. 7. Relationship between vasospasm seen on preoperative angiograms and re-
I ] EXCELLENT e [ 6000 e FAIR t [ azsl$1.~ z .~DIEO
suits of surgery. This condition seem to worsen outcome less than the clinical D.A.V. does and acts in grade III and IV. Symbols as on Fig. 6
*CASES WITH HCA ANEURYSHS:289* .,,.Imz,. I
POOR OUTCOHE
OVERALL RESULTS 26
68~ f'ovorabIr 32~ poor
38
IN PERCENT
NUHBER OF CASES : 85
Table 7. Outcome of Acute Reoperations
(12 Cases of MCA
Aneurysm ) Cause of reoperations
Cured
Disabled
Brain oedema Epidural blood Cerebral blood
I
2 1 1
Died
Ill
IV
13
I
1
3
7
7
1
O
?
3
1
0
3
0
S
I
4
7
tl
3
EXCEU.B~T GOOD FAIR OISA~.~ DIED
Fig. 8. "Troubled" surgery has a considerable impact on the outcome. It affects patients within all grades but less those who are in a better preoperative condition. Symbols as on Fig. 6
after SAH. This is the most dangerous period for D.A.V., since the already existing vasospastic process may be complicated by surgical factors. All available medical treatment for D.A.V. has to be utilized immediately when neurological function or alertness begin to be impaired. According to our experience, however, in cases, when the ideal timing of surgery could not be followed, it may be very difficult for diffuse vasospastic brain oedema to be controlled. It
E. P/tsztor et al.: The Surgery of Middle Cerebral Artery Aneurysms
I01
(~I~ELLENT2{~
*265 CASES WITH RUPTUREDMCA AN.*
POOR OUT~I~
S3
OVERALLRESULTS 49~; foYoroblc
Fig. 9. D.A.V., which occurs in the postoperative period leads to the worst results. The majority of lines drawn tend to show up inferior postoperative conditions. Symbols as on Fig. 6
IN P~CEN'r
III
IV
NUMBER OF CASES : 29
2
e
e
e
( ~
2
I
0
16
3 4
S 0
t O
IB
4
4
2
I
may develop in a rapid form sometimes and raise the suspicion of space-occupying haemorrhage. Our cases remained (more or less) disabled following urgenreoperation for epidural or intracerebral haemorrhage. Reoperation, however, in order to decompress the brain stem in cases of diffuse hypoxic oedema had no merit whatsoever. References 1. Crompton MR (1962) Pathology of ruptured middle-cerebral aneurysms. Lancet 2:421-425 2. Drake CG, Friedman AH, Peerless SJ (1984) Failed aneurysm surgery. J Neurosurg 61 : 848-856 3. Heros RC, Ojemann RG, Crowell RM (1982) Superior temporal gyrus approach to middle cerebral artery aneurysms: technique and results. Neurosurgery 10:308-313 4. Lindsay KW, Teasdale GM, Knill-Jones RP (1983) Observer variability in assessing the clinical features of subarachnoid hemorrhage. J Neurosurg 58:57-62 5. Ojemann RG (1981) Management of the unruptured intracranial aneurysm (editoral comment). N Engl J Med 304:725-726 6. Pia HW (1979) Aneurysms of middle cerebral artery. In: Cerebral aneurysms. In: Pia HW (ed) Advances in diagnosis and therapy. Springer 7. RhotonAL(1980)Anatomyofsaccularaneurysms. SurgNeurol 14:59-66
0
EXCELLENT GOOD FAIR DISABLED DIED
8. Robinson RG (1971) Ruptured aneurysms of the middle cerebral artery. J Neurosurg 35:25-33 9. Silverberg GD (1984) Giant aneurysms: surgical treatment. Neurol Res 6:57-63 10. Suzuki J, Yoshimoto T, Kayama T (1984) Surgical treatment of middle cerebral artery aneurysms. J Neurosurg 61:17-23 11. Symon L (1982) Surgical management of middle cerebral artery aneurysms. In: Schmidek HH, Sweet WH (eds). Operative neurosurgical techniques, vol 2. Grune and Stratton, New York San Francisco London, pp 891-908 12. Teasdale GM, Lindsay KW, Knill-Jones RP (1983) Assessment of patients with subarachnoid hemorrhage. J Neurosurg 59: 550551 13. Umansky F, Juarez SM, Dujovny M, Ausman JJ, Diaz FG, Gomes F, Mirchandani HG, Ray WJ (1984) Microsurgical anatomy of the proximal segments of the middle cerebral artery. J Neurosurg 61:458-467 14. Wilson CB, Spetzler RF (1979) Operative approaches to aneurysms. Clin Neurosurg 26:232~47 15. Ya~argil MG, Smith RD, Gasser C (1978) Microsurgery of the aneurysms of the internal carotid artery and its branches. Prog Neurol Surg 9:58 121 16. Yeh YS (1984) Normal anatomy and aneurysms of the middle cerebral artery: A morphological, neuroradiological and clinical study. Neurol Res 6:41-48 Authors' address: Prof. Dr. E. Pb.sztor, National Institute of Neurosurgery, Amerikai fit 57, H-1145 Budapest, Hungary.
