İntrakraniyal anevrizmalı olguların demografik, klinik ve radyolojik bulgularının incelenmesi: 107 olgu, tek merkez deneyimi

Yıl 2022, , 205 - 212, 01.04.2022

Sevil Arslan Hümeyra Kullukçu Albayrak , Mehmet Özgür Özateş , Atilla Kazancı , Ahmet Gürhan Gürçay , Oktay Gürcan Giyas Ayberk

https://doi.org/10.31362/patd.960696

Öz

Amaç: Anevrizma tanısı konularak yatırılan, cerrahi ve endovasküler tedavi uygulanan intrakraniyal anevrizmalı
olguların, demografik, klinik-radyolojik bulgularının ve bu bulgularla ölüm oranlarının ilişkisinin retrospektif olarak
incelenmesi amaçlandı.
Gereç ve yöntem: Kraniyal bilgisayarlı tomografi ile teşhis konulduktan sonra anevrizmaların lokalizasyonu,
bilgisayarlı tomografi anjiyografi veya dinamik serebral anjiyografi ile tesbit edilen 101 hastaya standart açık
mikrocerrahi, 7 hastaya ise endovasküler cerrahi yolla embolizasyon yapıldı. Geçici klip 30 sn ile 4 dk arasında
değişen sürelerde (ortalama 2 dk) kullanıldı. Kalıcı klip konulduktan sonra ponksiyon yapılarak anevrizma
boynunun tam olarak oblitere edildiği doğrulandı. İntraoperatif kontrollü hipotansiyon ve profilaktik antibiyotik
uygulandı.
Bulgular: Olguların 75’i (%70,09) kadın, 32’si (%29,9) erkekti. Kadın/erkek oranı 2,34 idi. Olguların yaş
ortalaması 51,9 saptandı. En sık görülen ilk şikâyet 75 hastada (%70,09) baş ağrısı ve kusma idi. 107 olgunun
85 (%79,4)’inde kraniyal BT’de SAK pozitif iken 22 (%20,5)’sinde negatif idi. En sık yerleşim yeri 49 olgu
(%45,79) ile orta serebral arter idi. Klinik vazospazm gelişen 23 olgunun Fisher sınıflamaları değerlendirildiğinde;
2 hastada Evre 1, 7 hastada Evre 2, 8 hastada Evre 3, 6 hastada Evre 4 tespit edildi. Vazospam gelişen
hastaların 18 tanesi eksitus olurken, bu hastaların 7 tanesi ilk 24 saat içinde, 5’i 24-48 saat içinde, 6’sı 48 saat
sonrasında opere edildi. 64 hasta operasyon sonrası sekelsiz olarak iyileşirken, 12 hastada hafif-orta düzeyde
sekel (hemiparazi, mitoz), 3 hastada şant ihtiyacı gerektiren hidrosefali gelişti. Hunt-Hess sınıflamasına göre
16’sı Evre 4-5 olan total 31 olgu eksitus oldu.
Sonuç: İntraserberal anevrizma tedavisinde sonucu etkileyen faktörlerin başında, ilk geliş anındaki nörolojik
muayene, anevrizmanın çoğul olması, Hunt-Hess Evre 4-5 kanamalar ve intraserebral hematom varlığı
gelmektedir. Tekrar kanama riski ve ameliyat sonrası vazospam ile güvenli mücadeleye olanak sağlaması
nedeni ile erken cerrahinin uygun tedavi zamanlaması olduğunu düşünmekteyiz.

Anahtar Kelimeler

Subaraknoid kanama, anevrizma, demografik özellikler, anevrizma tedavisi

Investigation of demographic, clinical and radiological findings of cases with intracranial aneurysm: 107 cases, single center experience

Öz

Aim: It was aimed to retrospectively examine the demographic, clinical-radiological findings of patients with
intracranial aneurysm who were hospitalized with the diagnosis of aneurysm and underwent surgical and
endovascular treatment, and the relationship between these findings and mortality rates.
Material and methods: After diagnosis with cranial computed tomography, the localization of aneurysms was
determined by computed tomography angiography or dynamic cerebral angiography, 101 patients underwent
standard open microsurgery, and 7 patients underwent embolization by endovascular surgery. Temporary clips
were used for 30 seconds to 4 minutes (average 2 minutes). Complete obliteration of the aneurysm neck
was confirmed by puncture after the permanent clip was placed. Intraoperative controlled hypotension and
prophylactic antibiotics were administered.

Results: 75 (70.09%) of the cases were female and 32 (29.9%) were male. The female/male ratio was 2.34.

The mean age of the cases was 51.9 years. The most common first complaint was headache and vomiting in
75 patients (70.09%). While 85 (79.4%) of 107 patients were positive in cranial CT, SAH was negative in 22
(20.5%). The most common location was the middle cerebral artery with 49 cases (45.79%). When the Fisher
classifications of 23 patients with clinical vasospasm were evaluated, two patients were Grade 1, 7 patients
were Grade 2, 8 patients were grade 4, and 6 patients were grade 4v. While 18 of the patients who developed
vasospasm died, 7 of these patients were operated on within the first 24 hours, 5 within 24-48 hours, and 6
after 48 hours. While 64 patients recovered without sequelae after the operation, mild to moderate sequelae
(hemiparesis, mitosis) developed in 12 patients and hydrocephalus requiring shunt in 3 patients. According to
the Hunt-Hess classification, a total of 31 patients died, 16 of whom were Stage 4-5.
Conclusion: The main factors affecting the outcome in the treatment of intracerebral aneurysm are neurological
examination at the time of first presentation, multiple aneurysms, Hunt-Hess Stage 4-5 hemorrhages and the
presence of intracerebral hematoma. We think that early surgery can be used for appropriate treatment because
of the risk of re-bleeding and the safe fight against vasospasm after surgery.

Anahtar Kelimeler

Subarachnoid hemorrhage, aneurysm, demographic features, cerebral aneurysm treatment

Kaynakça

• Kaynaklar 1. Canbaz B, Akar Z, Özçınar G. 251 opere intrakranial anevrizma olgusu. Türk Nöroşirürji Dergisi 1992;3;161-164.
• 2. Topkoru B, Egemen E, Solaroglu I, Zhang JH. Early Brain Injury or Vasospasm? An Overview of Common Mechanisms. Curr Drug Targets 2017;18(12):1424-1429. https://doi.org/10.2174/1389450117666160905112923
• 3. Osborn AG. Diagnostic Neuroradiology. Mosby 1994:936.
• 4. Meyer FB, Morita A, Puumala MR, Nichols DA Medical and surgical management of intracranial aneurysms. Mayo Clinic proceedings 1995;70:153-172. https://doi.org/10.4065/70.2.153
• 5. Solomon RA, Fink ME, Pile Spellman J. Surgical management of unruptured intracranial aneurysms. J Neurosurg 1994;80:440-446. https://doi.org/10.3171/jns.1994.80.3.0440
• 6. Frontera JA, Claassen J, Schmidt JM, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neyrosurgery 2006 Jul;59(1):21-7; discussion 21-7. doi: 10.1227/01.NEU.0000218821.34014.1B.
• 7. Kayhan Z. Klinik Anestezi. 2. ed, Logos; 1997; 428-34
• 8. Kassell NF, Torner JC, Haley Jr EC, Jane JA, Adams HP, Kongable GL. The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurgery 1990;73:18-16. https://doi.org/10.3171/jns.1990.73.1.0018
• 9. Weir B. Aneurysms affecting the nervous system. Baltimore Williams and Wilkins, 1994.
• 10. Ohman J, Heiskanen O. Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg 1989;70:55-60. https://doi.org/10.3171/jns.1989.70.1.0055
• 11. Milhorat TH, Krautheim M. Results of eraly and delayed operations for ruptured intracranial aneurysm in two series of 100 consecutive patients. Surg Neurol 1986;26:123-128. https://doi.org/10.1016/0090-3019(86)90364-2
• 12. Teber M. İntrakraniyal anevrizmalarda endovasküler tedavi. Erişim adresi: http://tader.Org/tader 43/33-42.pdf Erişim tarihi 19 Ocak 2011
• 13. Ghods AJ, Lopes D, Chen M. Gender differences in cerebral aneurysm location. Front Neurol 2012;3:78. https://doi.org/10.3389/fneur.2012.00078
• 14. Park SK, Kim JM, Kim JH, Cheong JH, Bak KH, Kim CH. Aneurysmal subarachnoid hemorrhage in young adults: a gender comparison study. J Clinc Neurosci 2008;15:389-392. https://doi.org/10.1016/j.jocn.2007.04.007
• 15. Alnaes MS, Isaksen J, Mardal KA, Rommer B, Morgan MK, Ingebrigtsen T. Computation of hemodynamics in the circle of Willis. Stroke 2007;38:2500-2505. https://doi.org/10.1161/STROKEAHA.107.482471
• 16. Le Roux PD, Elliott JP, Downey L, et al. Improved outcome after rupture of anterior circulation aneurysms: a retrospective 10 year review of 224 good-gratle patients. J Neurosurg 1995;83:39-49. https://doi.org/10.3171/jns.1995.83.3.0394
• 17. Rinkel GJ, Prins NE, Algra A. Outcome of aneurysmal subarachnoid hemorrhage in patients on anticoagulant treatment. Stroke 1997;28:6-9. https://doi.org/10.1161/01.str.28.1.6
• 18. Inagawa T, Yamamoto M, Kamiya K, Ogasawara H. Management of elderly patients with aneurmal subarachnoid hemorrhage. J Neurosurg 1998;69:332-339. https://doi.org/10.3171/jns.1988.69.3.0332
• 19. Prospective Studies Collaboration, Lewington S, Whitlock G, Clarke R, et al. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet 2007;370.1829-1839. https://doi.org/10.1016/S0140-6736(07)61778-4
• 20. Ostergaard JR, Hog E. Incidence of multiple intracranial aneurysms. Influence of arterial hipertansion and gender. J Neurosurg 1995;63:49-55. https://doi.org/10.3171/jns.1985.63.1.0049
• 21. Gambhir S, O'Grady G, Koelmeyer T. Clinical lessons and risk factors from 403 fatal cases of subarachnoid haemorrhage. J Clinc Neurosci 2009;16:921-924. https://doi.org/10.1016/j.jocn.2008.10.009
• 22. Yaşargil MG. Microneurosurgery. Stutgart, Georg Thieme Verlag, 1984, vol 1-vol 2. Vol-1: Microsurgical anatomy of the basal cicterns and vessels of the brain, diagnostic studies, general operative techniques and pathological considerations of the intracranial aneurysms. Vol-2: Clinical considerations, surgery of the intracranial anevrysms and results. E-Book ISBN:9783131734914
• 23. Juvela S. Risk factors for multiple intracranial aneurysms. Stroke 2000;31:392-397. https://doi.org/10.1161/01.STR.31.2.392
• 24. Chayette D, Chen TL, Bronstein K, Brass LM. Seasonal fluctuation in the incidence of intracranial aneurysm rupture and its relationship to chancing climatic conditions. J Neurosurg 1994;81:525-530. https://doi.org/10.3171/jns.1994.81.4.0525
• 25. Setzer M, Beck J, Hermann E, et al. The influence of barometric pressure changes and standard meteorological variables on the occurrence and clinical features of subarachnoid hemorrhage. Surg Neurol 2007;67:264-274. https://doi.org/10.1016/j.surneu.2006.06.060
• 26. Inagawa T. Seasonal variations in the incidence of aneurysmal subarachnoid hemorrhage in hospital- and community-based studies. J Neurosurg 2002;96:497-507. https://doi.org/10.3171/jns.2002.96.3.0497
• 27. Kopitnik TA, Samson DS. Managment of subarachnoid hemorrhage. J Neurol Neurosurg Psychiatry 1993;56:947-959. https://doi.org/10.1136/jnnp.56.9.947
• 28. Diringer MN. Managment of aneurysmal subarachnoid hemorrhage. Crit Care Med 2009;37:432-440. https://doi.org/10.1097/CCM.0b013e318195865a
• 29. Ohman J. Hypertension as a risk factor for epilepsy after aneurysmal subarachnoid hemorrhage and surgery. Neurosurg 1990;27:578-581. https://doi.org/10.1097/00006123-199010000-00012
• 30. Macdonald RL, Weir B: Cerebral Vasospasm. San Diego: Academic Press 2001: 387-389
• 31. Graff Radford NR, Torner J, Adams Jr HP, Kassell NF. Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the cooperative aneurysm study. Arc Neurol 1989;46:744-752. https://doi.org/10.1001/archneur.1989.00520430038014
• 32. Cahill J, Calvert JW, Zhang JH. Molecular mechanisms of early brain injury after subarachnoid hemorrhage. J Cereb blood Flow metab 2006;26(11):1341-53.
• 33. Pluta RM, Hansen-Schwartz J, Dreier J, Vajkoczy P, Macdonald RL, Nishizawa S, Kasuya H, Wellman G, Keller E, Zauner A, Dorsch N, Clark J, Ono S, Kiris T, Leroux P, Zhang JH: Cerebral vasospasm following subarachnoid hemorrhage: Time for a new world of thought. Neurol Res 2009;31(2):151-158
• 34. Grasso G, Alafaci C, Macdonald RL. Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives. Surg Neurol Int 2017;8:11. https://doi: 10.5152/trs.2018.581