Direct Intracranial Surgery of Anterior Communicating Artery Aneurysms.

Lee, Kyu Sung; Lee, Kyu Chang

Original Article

Journal of Korean Neurosurgical Society 1981;10(2): 543-556.

Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.

ABSTRACT

After the introduction of the surgical microscope, microsurgical direct intracranial approach became a standard technique for the treatment of ruptured intracranial aneurysms with satisfactory results. Nevertheless, aneurysms of the anterior communicating artery present particular difficulties, because of their critical location, prevalence of local vascular anomalies, serious circulatory disturbances of the perforating vessels after the rupture of the aneurysm or vasospasm, and their marked tendency to fatal recurrent hemorrhage. The authors analyzed 102 cases of anterior communicating artery aneurysms surgically treated in the Department of Neurosurgery, Yonsei University Hospital from 1971 throught August 1981. Of the 102 cases, 84 operations were performed by microsurgical pterional approach. The analysis and evaluation was made with particular emphasis on the microsurgical treatment. The results of analysis were summarized as follows. 1) The anterior communicating artery aneurysms ruptured most frequently in the 5th decade(37.2%), and 81.7% of the patients were in their 30s to 50s. Anterior communicating artery aneurysms were more common in men than women(60:42). 2) Presenting symptoms and signs of rupture of the anterior communicating artery aneurysms were headache(98.6%), stiff neck(95.1%), brief lapse of consciousness(83.4%), vomiting(81.8%), hypertension(41.6%), and impaired conscious level(34.3%). 3) The prechiasmatic projection of the anterior communicating artery was slightly mjore frequent than the interhemispheric projection(43:39) in our series. The aneurysms were fed by the left anterior cerebral artery in 55.9% and by the right in 33.3%. Angiographic vasospasm was noted in 45.1% and the incidence of the multiple aneurysm was 8.8%. 4) The brain CT scan showed subarachnoid hemorrhage in 47.3%, hydrocephalus in 43.7%, and cerebral infarction in 27.3%. The aneurysms appeared as enhancing small lesions when the diameter of the aneurysm was larger was larger than 10mm. The actual size of the giant aneurysm was measured more precisely with the CT scan than by the angiogram. 5) Patients in Botterell's Grade I and II occupied 70.2% of the microsurgically treated cases. Majority of cases(82.1%) were operated in the second to fourth weeks after the last bleeding. 6) All of the 84 microsurgically treated cases were operated by pterional approach, and the gyrus rectus resection was frequently performed. Clipping of the aneurismal neck was possible in 82.1% of the series. 7) Fourteen cases of postoperative vasospasm, 4 cases of intracranial hematoma, and 7 cases of serious electrolyte imbalance were found as the major postoperative complications. Four patients died of these major complications. 8) Operative mortality of the microsurgical pterional approach was 4.8% and the morbidity 5.9%. Mortality rate of 9 premature rupture cases was 11.1%. Among the 18 cases which were operated on without the aid of microscope before 1975, the mortality rate was 16.7%, and the morbidity, 44.4%.