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hands of experienced anesthesiologists and cerebrovascular surgeons, the operative mortality, even in grade III and IV patients, has now been reduced to 2 to 3 percent For a detailed account of the operative approach to each of the major classes of saccular aneurysm, the reader is referred to the monograph by Ojemann and colleagues Several alternative therapeutic measures are still being studied Among these, endovascular obliteration of the lumen of the aneurysm holds the most promise This has become the preferred approach for aneurysms that are surgically inaccessible for example, those in the cavernous sinus or for patients whose medical state precludes an operation Among several trials that have compared surgery with endovascular placement of coils in the aneurysm, several have shown a slight superiority of the latter For example, the International Subarachnoid Aneurysm Trial Group randomly assigned over 2000 patients to surgery or platinum coil placement; the overall rate of death or dependence at 1 year was 24 percent in the endovascular group and 31 percent in the operated group Doubtless, further studies will continue to clarify the relative bene ts of the treatment We would comment that the skill of the surgeon and the quality of postoperative care are major determinants of outcome; perhaps the simplicity of endovascular treatment and the improvements in the training of interventional specialists will prove its advantage over time Because of the current approach of ablating the aneurysm early, the previously popular use of anti brinolytic agents as a means of impeding lysis of the clot at the site of aneurysmal rupture has been generally abandoned Repeated drainage of the CSF by lumbar puncture is also no longer practiced as a routine One lumbar puncture is generally carried out for diagnostic purposes if the CT scan is inconclusive; thereafter spinal uid drainage is performed only for the relief of intractable headache or to detect recurrence of bleeding As mentioned earlier, patients with stupor or coma who have massive hydrocephalus often bene t from decompression of the ventricular system This is accomplished initially by external drainage and may require permanent shunting if the hydrocephalus returns The risk of infection of the external shunt tubing is high if it is left in place for much more than 3 days Replacement with a new tube, preferably at another site, reduces this risk Unruptured Intracranial Aneurysms Not infrequently, cerebral angiography, MRI, MRA, or CT scanning performed for an unrelated reason, discloses the presence of an unruptured saccular aneurysm Or, a second or third aneurysm is found during the angiogram to assess a ruptured one There is now a reasonable body of information about the natural history of these lesions Wiebers and colleagues observed 65 patients with one or more unruptured aneurysms for at least 5 years after their detection The only clinical feature of signi cance relative to rupture was aneurysmal size None of 44 aneurysms smaller than 10 mm in diameter had ruptured, whereas 8 of 29 aneurysms 1 cm or larger eventually did so, with a fatal outcome in 7 cases Two large studies have attempted to re ne these statistical data In the older Cooperative Study of Intracranial Aneurysms, none of the aneurysms less than 7 mm diameter had further trouble A more recent and quite sizable cooperative study that included 4060 patients and gathered data prospectively for 5 years, conducted by the International Study of Unruptured Intracranial Aneurysms Investigators, found an extremely low rate of rupture, about 01 percent yearly, for aneurysms smaller than 7 mm in diameter, an annual risk of 05 percent was
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found for aneurysms between 7 and 10 mm, and a risk ranging from 06 to 35 percent for lesions between 13 and 24 mm (depending on location) The risk ranged up to 10 percent for aneurysms greater than 25 mm diameter The yearly rates for rupture were higher in all categories if there had been prior bleeding from another site The location of the lesion also had great bearing on the risk of rupture, as did increasing age; notably, vertebrobasilar and posterior cerebral aneurysms bled at a rate many times higher than the others The importance of such data is underscored by the comparison to the risk of surgery and endovascular treatment, which begin to exceed the risk of bleeding within 5 years in the smaller aneurysms located in the carotid circulation Giant Aneurysms As has been stated, these are believed to be congenital anomalies even when there is considerable atherosclerosis in their walls They may become enormous in size, by de nition greater than 25 cm in diameter, but sometimes twice or more as large Most are located on a carotid, basilar, anterior, or middle cerebral artery They grow slowly by accretion of blood clot within their lumens or by the organization of surface blood clots from small leaks At a certain point they may compress adjacent structures, eg, those in the cavernous sinus, optic nerve, or lower cranial nerves The giant fusiform aneurysm of the midbasilar artery, with signs of brainstem ischemia and lower cranial nerve palsies, is a relatively common form Clotting within the aneurysm may cause ischemic infarction in its territory of supply Giant aneurysms may rupture and cause subarachnoid hemorrhage, but not nearly as often as saccular aneurysms This clinical observation has been con rmed by the International Study, referred to above Treatment is surgical if the lesion is symptomatic and it is accessible; treatment is with endovascular techniques if the lesion is in the vertebral or midbasilar artery Obliteration of the lumen, coupled with vascular bypass procedures, has been successful in the hands of a few cerebrovascular neurosurgeons, but the morbidity is high Some aneurysms can be ligated at their necks, others by trapping or by the use of an intravascular detachable balloon Drake has summarized his experience in the treatment of 174 such cases Ojemann and colleagues have also had singular success in treating these lesions by a combination of surgical techniques; in more than 40 cases, half of them trapped and half obliterated, there was not a single fatality Some have been wrapped in muslin or similar material with mixed results We have followed one such patient operated by T Sundt over 25 years ago Recent attempts at stabilizing the expansion of the aneurysm by stenting are under study
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