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Treatment for Serious Cases of Ruptured Intracranial Aneurysms with Severe Subarachnoid Clot Makoto MIZUNO 1 , Nobuyuki YASUI 1 , Akifumi SUZUKI 1 , Hiromu HADEISHI 1 , Shigeyoshi NAKAJIMA 1 , Takeshi SANAPEI 1 , Hiroyuki OHTSUKI 1 , Ichiro SAYAMA 1 1Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-Akita Keyword: Serious subarachnoid hemorrhage , Ruptured intracranial aneurysm , Treatment , Surgical indication , Pathophysiology. pp.525-530
Published Date 1991/6/10
DOI https://doi.org/10.11477/mf.1436900271
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Abstract

Forty-one serious cases of ruptured intracranial aneurysms with severe subarachnoid clot were clinical-ly analyzed, with special emphasis on the prognosis, pa-thophysiology, and surgical indications. All cases had thick subarachnoid clot without concurrent intracere-bral hematoma and/or intraventricular hematoma caus-ing mass signs on the CT scan. In this series, 23 cases underwent radical surgery while in the acute stage, 18 cases were treated conservatively (including 5 cases tre-ated only by continuous ventricular drainage) . The criterion for determining the degree of severity was de-fined as either a “semicoma” or “coma” state just prior to radical surgery for the radically-operated group, with the same designations for the conservative group at their time of admission.

All patients except two in the conservatively-treated group died clue to primary brain damage caused by massive subarachnoid hemorrhage. The two remaining cases died from other complications. On the other hand, the outcome for the 23 surgically-treated patients was as follows : Three (13%) fully recovered ; three (13%) were capable of self-management ; eight (34.8%) were partially or fully dependent. Nine (39.1%) , died. In the radically-treated group, pre-operative factors that might predict clinical outcome were investigated. Those fac-tors were the neurological grade, the brain-stem re-sponse, the response after the rapid administration of 20% Mannitol (300 - 900 ml) , and the length of time from the last bleeding episode to the time that radical surgery was performed. It was recognized that there was no relationship between the neurological grade just prior to radical surgery and the outcomes in the serious cases. Results were good for patients in the following subgroups : 1) In which neurological symptoms im-proved after the rapid administration of 20% Mannitol, even though the patient was still comatose ; 2) In which brain-stem responses such as the ciliospinal re-flex were preserved ; 3) In which radical surgery could be performed within four hours of the last bleeding epi-sode.

If early surgery is performed when any of the above three conditions exist, a completely successful surgery can be expected. In addition, it is important to empha-size that our experience shows that most unfavorable results can be eliminated by the evacuation of the sub-arachnoid clot, especially in the perimesencephalic cist-ern. This treatment could prevent the occurrence of vasospasm and release pressure to the brain-stem.


Copyright © 1991, Igaku-Shoin Ltd. All rights reserved.

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電子版ISSN 1882-1251 印刷版ISSN 0301-2603 医学書院

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