Results and complications of surgical management of 809 intracranial aneurysms in 722 cases. Related and unrelated to grade of patient, type of aneurysm, and timing of surgery

Abstract

Data from 722 consecutive causes with intracranial aneurysms were stored in a computer and later retrieved for analysis. Results and complications (including preoperative death and morbidity) of the surgical management of these patients were correlated with the Botterell grade of the patient in individuals with a recent subarachnoid hemorrhage (SAH), with the type of aneurysm, and with the timing of the surgical procedure. Patients with no SAH within 30 days prior to hospital admission were classified as "no SAH." Approximately 30% of all patients had sustained more than one hemorrhage. Death and morbidity rates prior to surgery in good-grade patients with a recent SAH exceeded the risk of surgery itself. Rebleeding was the primary cause for death and morbidity in Grade 1 patients: 3% of Grade 1 patients died from a recurrent hemorrhage and 7% deteriorated to a lower grade. Deterioration from ischemia produced by vasospasm related or unrelated to rebleeding exceeded the risks of rebleeding in Grade 2 patients. There was an operative morbidity of 2% and mortality of 2% in patients who were classified as Grade 1 at the time of surgery, but an overall management morbidity of 3% and mortality of 6% in patients who were in Grade 1 at the time of hospital admission. Early surgery in Grade 1 patients was not associated with an increased incidence of delayed ischemia postoperatively. In Grade 2 patients, the operative morbidity and mortality was 7% and 4%, respectively, and the management morbidity and mortality 16% and 11%, respectively. Early surgery in this group was associated with a high frequency of postoperative delayed ischemia (particularly in patients with more than one SAH). Epsilon-aminocaproic acid appeared to protect against a rebleed, gut was associated with a higher incidence of postoperative pulmonary emboli. Intraoperative complications were related both to the size of the aneurysm and to its location. Repair of multiple aneurysms did not adversely affect the result. The surgical approach, the importance of using a self-retaining brain retractor, and the technical complications in these cases are discussed.