Hino A, Fujimoto M, Iwamoto Y, Yamaki T, Katsumori T
Department of Neurosurgery, Saiseikai Shigaken Hospital, Ritto, Shiga, Japan.
Neurosurgery. 2000 Apr;46(4):825-30. doi: 10.1097/00006123-200004000-00011.
Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms.
We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information.
The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding.
In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.
蛛网膜下腔出血合并多发颅内动脉瘤的患者给神经外科医生带来了独特的挑战。除非所有动脉瘤都能通过一次开颅手术夹闭，否则外科医生必须准确确定哪个动脉瘤破裂。判断失误可能导致未治疗的真正破裂病变术后灾难性再出血。我们评估了破裂部位错误定位及随后再出血的风险，并记录了患者存在多发颅内动脉瘤时预测真正破裂部位的问题。
我们回顾了连续12年治疗的93例患者的记录，这些患者首次发生蛛网膜下腔出血且患有多发颅内动脉瘤。根据计算机断层扫描和血管造影结果确定破裂部位，每位患者在出血后2天内夹闭推测破裂的动脉瘤。同一手术中无法处理的其他动脉瘤在后期进行手术。回顾了所有患者的记录，作者在不了解患者临床信息的情况下，对所有计算机断层扫描和血管造影，包括一些患者进行的重复检查进行了回顾性重新评估。
76例患者（82%）在手术时或尸检时证实了破裂动脉瘤的位置。术前外科医生预测为破裂的动脉瘤，术中证实为破裂的有69例（91%），回顾性分析时为72例（95%）。6例未正确识别破裂动脉瘤的患者中有5例被认为只有一个动脉瘤。4例患者术后再出血，2例患者因再出血死亡。
在本报告系列中，动脉瘤手术后早期再出血的最常见原因是未能闭塞破裂的动脉瘤，通常是因为在初始血管造影中遗漏了该动脉瘤。结果不仅支持术前对所有颅内动脉进行细致的影像学检查，也支持在蛛网膜下腔出血的所有病例中，即使发现了一个可能的病变，也要对目标动脉瘤进行全面的手术检查。
