Department of Neurosurgery, Choaithram Hospital, Indore, Madhya Pradesh, India.
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Neurol India. 2020 Jan-Feb;68(1):132-140. doi: 10.4103/0028-3886.279675.
Development of cerebral infarcts following clipping of ruptured intracranial aneurysm is one of the major determinants of functional outcome in patients with subarachnoid hemorrhage (SAH). The aim of this study is to evaluate the factors affecting development of postoperative infarcts, its incidence, pattern, and functional outcome.
This study includes 118 patients of spontaneous SAH because of ruptured anterior communicating artery aneurysm, who underwent clipping. Relevant points in history, preoperative and intraoperative findings, and postoperative outcome are evaluated.
29 of 118 (24.5%) patients developed postoperative radiological infarcts. Approximately 37.9%, 17.2%, and 3.4% patients developed isolated infarcts, respectively, in anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territory. About 20.7% patients developed infarcts in deep perforator territory. Nine of 29 (31.3%) patients developed multiple-vessel territory infarcts. Patients with poor preoperative neurologic status, prior history of seizure, and history of intraoperative rupture had higher chances of development of infarcts. Development of infarct was irrespective of temporary clipping (TC), duration of clipping, and elective versus rescue clipping. Development of infarcts adversely affected the outcome in significant proportions. Among patients with infarcts, unilateral ACA territory infarcts showed best prognosis, whereas all patients with multiple territory infarcts and PCA territory infarcts died. Age or sex of the patients did not affect the functional outcome. Timing of development of infarcts has no influence on functional recovery.
Development of symptomatic infarct is the sole important predictor of functional outcome. A crowded neurovascular neighborhood and complex variations in local angioarchitecture make anterior communication (ACOM) territory predisposed to operative insults. Elective TC and aggressive management of cerebral vasospasm are recommended to prevent development of infarcts.
夹闭破裂颅内动脉瘤后发生脑梗死是蛛网膜下腔出血（SAH）患者功能预后的主要决定因素之一。本研究旨在评估影响术后梗死发生的因素、其发生率、类型和功能预后。
本研究纳入 118 例因前交通动脉动脉瘤破裂导致自发性 SAH 患者，均行夹闭术。评估病史、术前和术中发现以及术后结果的相关要点。
118 例患者中 29 例（24.5%）术后出现影像学梗死。约 37.9%、17.2%和 3.4%的患者分别出现单纯前循环梗死、单纯中循环梗死和单纯后循环梗死。约 20.7%的患者出现深穿支区域梗死。29 例中 9 例（31.3%）患者出现多血管区域梗死。术前神经功能状态较差、有癫痫病史和术中破裂史的患者发生梗死的几率更高。梗死的发生与临时夹闭（TC）、夹闭时间以及择期夹闭与紧急夹闭无关。梗死的发生对患者的预后有显著影响。在发生梗死的患者中，单侧前循环梗死的预后最好，而所有发生多血管区域梗死和后循环梗死的患者均死亡。患者的年龄或性别对功能预后无影响。梗死发生的时间对功能恢复没有影响。
症状性梗死的发生是功能预后的唯一重要预测因素。密集的神经血管结构和局部血管解剖的复杂变化使前交通动脉（ACOM）区域易受手术影响。建议选择性 TC 和积极管理脑血管痉挛以预防梗死的发生。
