Outcome and Complications

Figures for surgical morbidity and mortality are very dependent on case selection and can be difficult to separate from general outcome figures. Mortality and morbidity following aneurysm surgery are, in the main, related to perforator or large vessel occlusion, brain retraction and cranial nerve traction injury. Five to 10% of cases are complicated by a major vessel occlusion and 50% of those who die following aneurysmal surgery have an infarct at post mortem. Intraoperative rupture, seen in 15-20% of cases, is associated with increased neurological morbidity and mortality.

The influence of aneurysmal location varies between series. Complications following anterior circulation aneurysm surgery are seen in 5% of PCOM artery cases, MCA 8%, ophthalmic 12%, ACOM 16% and ICA 17%. In expert hands, the overall mortality for posterior circulation aneurysms is about 5% and permanent morbidity about 12%. Complications are seen in 2% of aneurysms less than 5 mm, 7% if 6-15 mm and 14% if 16-25 mms in diameter [16]. Giant aneurysms particularly are associated with poor outcome and operative complications.

The operative mortality ranges from 0% in Hunt and Hess Grades I and II to 28% in Grades III and IV, although other studies show no significant difference in surgical outcome between poor- and good-grade survivors. Increasing age also tends to be a poor prognostic indicator for surgery, although good results can be achieved in patients older than 60 years. Mortality is 3% in the third decade, rising to 11% in the eighth decade, with a good outcome in only 50% of those aged 59 years and over.

Results of surgery for unruptured aneurysms have always been thought to be excellent, with a generally quoted risk of 1% mortality and 5% morbidity. More recently, the results of the ISUIA have challenged these figures, suggesting mortality (2.7%) and specifically morbidity (11.7%) associated with surgery for UIA may be considerably higher than first appreciated [4].

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