Cerebral Aneurysms Management

ANEURYSMS CAUSING COMPRESSIVE SYMPTOMS AND SIGNS

Aneurysms may present as a result of compression of adjacent neurological structures. An oculomotor (III) nerve palsy from a posterior communicating aneurysm often precedes rupture by a few days or weeks and indicates the need for urgent operative treatment.

A giant aneurysm (over 25 mm in diameter), causing compressive problems, seldom ruptures but the symptoms and signs are unlikely to resolve unless spontaneous thrombosis occurs.

INCIDENTAL ANEURYSMS

The appearance of high resolution CT and MR scanners and angiographic screening of patients with a strong family history of subarachnoid haemorrhage, has led to the detection of increased numbers of patients with incidental aneurysms (i.e. aneurysms not causing symptoms or signs). Studies suggest that risk of bleeding from a previously unruptured aneurysm approaches 1% per year, with aneurysms over 10 mm in diameter carrying the highest risk.

Operative mortality of aneurysm clipping in the absence of SAH is approximately 2%. Thus, younger patients (e.g. under 45 years) with an otherwise normal life expectancy may well benefit from operation.

When angiography after SAH reveals multiple aneurysms the neurosurgeon must decide whether to operate on the intact as well as the ruptured aneurysm. If accessible through the one craniotomy flap, most clip unruptured aneurysms at the initial operation, although in patients in poor clinical condition, delayed clipping at a second operation several weeks later minimises the risk of ischaemic complications.

Direct clipping and aspiration or excision of the sac provides the best treatment. In some patients the size of the aneurysm neck prevents clipping and either carotid occlusion (if a carotid aneurysm) or 'trapping' provide alternative methods. Prior to 'trapping', superficial temporal middle cerebral anastomosis may help prevent ischaemic complications.

Superficial temporal middle cerebral anastomosis (end-to-side)

Superficial temporal middle cerebral anastomosis (end-to-side)

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