Multiple mo`dane aneurizme
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- Annice Rodgers
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1 Broj 3 VOJNOSANITETSKI PREGLED Strana 249 S T R U ^ N I ^ L A N C I UDC Multiple mo`dane aneurizme Zoran Roganovi}, Goran Pavli}evi} Vojnomedicinska akademija, Klinika za neurohirurgiju, Beograd Cilj. Utvrditi faktore rizika za multiplicitet mo`danih aneurizmi, kao i klini~ke i terapijske specifi~nosti bolesnika sa solitarnim (SA) i multiplim aneurizmama (MA). Metode. Retrospektivna studija na 95 bolesnika sa SA i 22 bolesnika sa MA. Kod bolesnika sa SA i MA upore ivani su slede}i parametri: pol, uzrast, klini~ki status, lokalizacija i veli~ina aneurizme, u~estalost rekrvarenja i vazospazma, na~in i ishod le~enja, preoperativni interval, intraoperativna ruptura i postoperativne komplikacije. Rezultati. Aneurizme prednje komunikantne arterije ~ine 37,4% svih SA i 17,8% svih MA (p<0,05). Oko 44,2% svih aneurizmi srednje mo`dane i samo 19% svih aneurizmi prednje mo`dane arterije se javlja sa jo{ nekom aneurizmom (p<0,02). Prose~na veli~ina SA je 15,4 ± 11,8mm, a MA 9,8 ± 9mm (p<0,05). Operativno je le~eno 77,3% bolesnika sa MA i 78,9% bolesnika sa SA (p>0,05), a potpuno operativno zbrinjavanje klipom je, me utim, u~injeno kod 89,3% operisanih bolesnika sa SA i 47,1% operisanih bolesnika sa MA (p<0,01). Me u operisanim bolesnicima sa MA i SA se intraoperativna ruptura javljala u 36% i 17,6% (p>0,05), a ishemijske postoperativne komplikacije u 29,4% i 17,3% slu~ajeva (p>0,05). Dobar ishod tretmana je imalo 72,7% svih bolesnika sa MA i 69,5% sa SA, dok je me u operisanim bolesnicima dobar ishod imalo 76,5% sa MA i 70,7% sa SA. Zaklju~ak. Nema razlike u ishodu tretmana bolesnika sa MA i SA, ali je potpuno operativno zbrinjavanje zna~ajno ~e{}e kod SA. Multiple aneurizme su zna~ajno manje i imaju druga~iju teritorijalnu distribuciju nego solitarne. K lj u ~ n e r e ~ i : aneurizma, intrakranijalna; aa. cerebri; aneurizma, ruptura; angiografija mozga; krvarenje, subarahnoidno; neurohirur{ke procedure; postoperativne komplikacije; le~enje, ishod. Uvod Zbog brojnih rizika, vezanih za operativno le~enje, mo`dane aneurizme su veliki neurohirur{ki izazov, naro~ito ako, umesto jedne, postoji vi{e me usobno udaljenih aneurizmi. U takvim situacijama naj~e{}e je jedna aneurizma ve}a i simptomatska, dok se ostale dijagnostikuju slu~ajno, angiografski ili intraoperativno (1, 2). Svaka od multiplih aneurizmi mo`e rupturisati i uzrokovati subarahnoidno krvarenje. Zato se najpre identifikuje aneurizma koja krvari, a nakon toga se planira operativni tretman, tako da se mogu okludirati sve prisutne aneurizme (3). To bitno menja i uslo`ava terapijski postupak, jer su hirur{ki pristupi druga~iji, rizici ve}i, a ponekad je, radi zbrinjavanja svih aneurizmi, neophodno uraditi vi{e operacija (4). U ovom radu prikazujemo na{a iskustva sa faktorima rizika za nastanak multiplih aneurizmi, njihovom klini~kom evolucijom, operativnim zbrinjavanjem, ishodom le~enja i postoperativnim mortalitetom i morbiditetom, o ~emu u literaturi postoje razli~ita i neusagla{ena mi{ljenja (4Þ8). Metode Retrospektivnom studijom je obuhva}eno 117 bolesnika sa mo`danom aneurizmom, le~enih na Klinici za neurohirurgiju VMA: u 95 bolesnika je aneurizma bila solitarna (SA), a kod 22 bolesnika je postojalo 45 multiplih aneurizmi (MA), koje su klasifikovane kao simptomatske (klini~ka prezentacija rupturom ili kompresijom) ili nesimptomatske (otkrivene slu~ajno, pancefalnom angiografijom ili intraoperativno). Roganovi} Z, Pavli}evi} G. Vojnosanit Pregl 2002; 59(3): 249Þ254.
2 Strana 250 VOJNOSANITETSKI PREGLED Broj 3 Za bolesnike sa SA i MA analizovani su i me usobno upore ivani slede}i parametri: pol, uzrast, klini~ki status, na~in le~enja i lokalizacija i veli~ina aneurizme. U~estalost rekrvarenja i vazospazma je analizovana kod 78 bolesnika sa rupturom SA i 19 sa rupturom jedne od MA. Parametri vezani za operativno le~enje (preoperativni interval, intraoperativna ruptura, postoperativne komplikacije, postoperativna hospitalizacija, ishod operacije) su upore ivani kod 75 operisanih bolesnika sa SA i 17 sa MA. Lokalizacija aneurizme je definisana kao: sliv a.cerebri anterior (ACA), sliv a.cerebri mediae (ACM), sliv a.basilaris (AB) ili sliv a.carotis internae (ACI), s tim {to je poslednja grupa obuhvatala i aneurizme oftalmi~ke, prednje horioidne i zadnje komunikantne arterije. Klini~ki status bolesnika je kvantifikovan od 0 dov, prema usvojenoj gradaciji po Hantu i Hesu (HHG) (9). Statisti~ka zna~ajnost dobijenih razlika je testirana izra~unavanjem standardne gre{ke (σ d ) i standardizovanog odstupanja (Z) razlike dveju aritmeti~kih sredina, kao i χ 2 testom i utvr ivanjem koeficijenta kontingencije. Rezultati Multiple aneurizme su postojale kod 18,8% bolesnika sa aneurizmama i ~inile su 32,1% svih tretiranih aneurizmi. Kod `ena ~ine 23,4%, a kod mu{karaca 13,2% svih aneurizmi, ali ova razlika nije statisti~ki zna~ajna (χ 2 =1,99; p>0,05). Prose~na starost bolesnika sa MA je 47,7 ± 9,4 godina, a onih sa SA 48 ± 12,8 godina (σd=2,4; Z=0,1; p>0,05). Naj~e{}a lokalizacija MA je na ACM, a SA na ACA (slika 1). Statisti~ka zna~ajnost postoji samo kod aneurizmi ACA, koje su ~inile 37,4% svih SA i 17,8% svih MA (χ 2 =5,41; DF=1; p<0,05; C=0,19) ,2 33,3 37,4 Solitarne Multiple ,4 28,6 17,8 7,7 6,7 ACM ACI ACA AB Sl. 1 Þ Lokalizacija solitarnih i multiplih aneurizmi Oko 44,2% svih aneurizmi ACM i samo 19% svih aneurizmi ACA se pojavljuje sa jo{ nekom aneurizmom (p<0,02) (slika 2): kada se angiografski doka`e simptomatska aneurizma ACA, verovatno}a da postoji jo{ neka aneurizma je zna~ajno manja nego kada se doka`e aneurizma neke druge lokalizacije. 50 % 44, , ACA AB ACI ACM ACA u odnosu na sve druge lokalizacije χ 2 =5,41, p<0,05, C=0,20 ACA u odnosu na ACM χ 2 =6,18, p<0,02, C=0,26 Sl. 2 Ù Udru`enost aneurizmi pojedinih lokalizacija sa multiplim aneurizmama Veli~ina aneurizme je merena intraoperativno i/ili angiografski, rekrvarenje je dokazivano kompjuterizovanom tomografijom (KT) mozga, a vazospazam Þ angiografski ili intraoperativno. Kona~ni ishod tretmana je kvantifikovan od 1 do 5, prema modifikovanoj Glazgovskoj skali ishoda (GOS), a kvalifikovan je kao dobar (GOS=4-5 kod bolesnika sa HHG = 0-II i GOS=3-5 kod bolesnika sa HHG=III-V) ili lo{ (9, 10). Klipovana aneurizma je smatrana potpuno zbrinutom, a nepotpuno operativno zbrinjavanje je podrazumevalo oblaganje ili eksploraciju aneurizme. Solitarne aneurizme su zna~ajno ve}e od MA (15,4 ± 11,8mm prema 9,8 ± 9mm; σd=0,21; Z=2,59; p<0,05), ali ne i od simptomatskih MA (13,5 ± 9,1mm; σd=0,28; Z=0,66; p>0,05). Simptomatske MA su zna~ajno ve}e od asimptomatskih (6,6 ± 7,5mm; σd=0,31; Z=2,25; p<0,05).
3 Broj 3 VOJNOSANITETSKI PREGLED Strana 251 Distribucija prema klini~kom statusu se ne razlikuje zna~ajno kod bolesnika sa MA i SA (slika 3). Prose~an HHG kod bolesnika sa SA (2,46 ± 1,43) i MA (2,54 ± 1,2) je sli~an (σd=0,29; Z=0,29; p>0,05). Nema razlike u u~estalosti MA kod bolesnika sa rupturom aneurizme (HHG=I-V) i kod onih bez rupture (HHG=0) (χ 2 =0,8; DF=1; p>0,05). komplikacije u 29,4% bolesnika sa MA i 17,3% sa SA (χ 2 =1,28; p>0,05). Dobar ishod tretmana je imalo 72,7% svih bolesnika sa MA i 69,5% sa SA, (tabela 2a) dok je me u operisanim bolesnicima dobar ishod imalo 76,5% sa MA i 70,7% sa SA (tabela 2b) Solitarne 36,4 35,8 Multiple 21,1 17,9 27,3 22,1 9,1 13,6 13,6 3,2 0 I-II III IV V HHG Sl. 3 Þ Klini~ki status bolesnika sa solitarnim i multiplim aneurizmama Nakon rupture u~estalost rekrvarenja je 26,9% za SA, a 26,3% za MA (χ 2 =0,01; DF=1; p>0,05), dok je u~estalost vazospazma 18,6% za SA, a 26,3% za MA (χ 2 =0,55; DF=1; p>0,05). Operativno je le~eno 77,3% bolesnika sa MA i 78,9% bolesnika sa SA (χ 2 =0,03; DF=1; p>0,05) (tabela 1a). Potpuno operativno zbrinjavanje klipom je, me utim, u~injeno kod 89,3% operisanih bolesnika sa SA i kod samo 47,1% operisanih bolesnika sa MA (χ 2 =16,45; DF=1; p<0,01; C=0,39) (tabela 1b). Diskusija Multiple aneurizme postoje kod 4Þ34% bolesnika sa aneurizmama (1, 2, 4, 8, 11), a u~estalost od 18,8%, dobijena u na{oj seriji, uklapa se u ove podatke. Na angiografskim serijama u~estalost MA zavisi od tehnike pregleda: 3,8% pri pregledu jedne ili obeju karotidnih arterija, a 11,3% pri pancefalnoj angiografiji (3). Na autopsijskim serijama je u~estalost ve}a i mo`e iznositi do 50%, ako se ra~unaju sve aneurizme ve}e od 1mm (4). Tabela 1 Le~enje bolesnika sa multiplim (M) i solitarnim (S) aneurizmama(χ 2 test) a b Na~in le~enja M S svega Operativno M S svega zbrinjavanje Operativan Potpuno Konzervativan nepotpuno Svega Svega χ 2 =0,03; p>0,05 χ 2 =16,5; p<0,01; C=0,39 Tabela 2 Ishod le~enja bolesnika sa multiplim (M) i solitarnim (S) aneurizmama (χ 2 test) a b Za sve bolesnike Za operisane Ishod M S svega Ishod M S svega Dobar Dobar Lo{ Lo{ Svega Svega χ 2 =0,09; p>0,05 χ 2 =0,23; p>0,05 Me u operisanim bolesnicima sa MA i SA nema zna~ajnih razlika u du`ini preoperativnog intervala (14,7 ± 11,4 i 14,9 ± 13,2 dana; σd=3,32; Z=0,06; p>0,05) i u du`ini postoperativnog le~enja (17,8 ± 9,5 i 13,3 ± 8,1 dana; σd= 2,87, Z=1,54, p>0,05). Intraoperativna ruptura je postojala u 36% SA i 17,6% MA (χ 2 =2,12; p>0,05), a ishemijske postoperativne Jedna ili vi{e dodatnih aneurizmi u odnosu na angiografski nalaz mogu se nekad uo~iti intraoperativno. Ovakve aneurizme ne moraju biti malih dimenzija, a ponekad su i uzrok krvarenja. Uzroci njihovog angiografskog neprepoznavanja su razli~iti: male dimenzije (tzv. baby aneurizma), spazam krvnog suda, tromboza, zaklonjenost velikom aneurizmom ili susednim velikim arterijama (12). Uva`avaju}i ova-
4 Strana 252 VOJNOSANITETSKI PREGLED Broj 3 kva ograni~enja angiografije, hirurg mora intraoperativno proveriti sve pristupa~ne uobi~ajene lokalizacije aneurizmi (4). Kod oko 3,5% bolesnika postoje tri, kod 1,4% Þ ~etiri ili vi{e aneurizmi, ali u preko 90% slu~ajeva multiplicitet podrazumeva postojanje dveju aneurizmi: ipsilateralno u 21%, kontralateralno u 47%, u srednjoj liniji u 3%, a kod 29% slu~ajeva je jedna aneurizma u srednjoj liniji, a druga nije (4). Kod bolesnika koji su ina~e predisponirani za nastanak aneurizme rizi~ni faktor za MA su pu{enje i `enski pol (1), ~emu u prilog idu i na{i rezultati. Aneurizme perikalozne arterije su ~esto udru`ene sa jo{ nekom aneurizmom druge lokalizacije (u oko 1/3 slu~ajeva)(13, 14). Sli~na situacija je i sa aneurizmama oftalmi~ke, prednje horioidne i unutra{nje karotidne arterije, koje su ~esto bilateralne i simetri~ne (4, 11). Sporadi~no se pominje i ~esta udru`enost aneurizmi zadnje komunikantne arterije sa MA (2), dok je kod aneurizmi prednje komunikantne arterije takva udru`enost retka (u 12% slu~ajeva), a kod aneurizmi stabla AB i donjeg zida ACI skoro da ne postoji (4). Oko 50% MA je malih dimenzija (15), {to potvr uju i na{i rezultati. Kada se na angiogramu vide MA, neophodno je uz pomo} slede}ih kriterijuma identifikovati aneurizmu koja je krvarila (3, 4, 11): istorija bolesti (podaci o lokalizaciji glavobolje, prolaznoj hemiparezi, epi napadima i senzitivnim fenomenima), neurolo{ki nalaz (fokalni znaci lezije hemisfera ili nerava), ehoencefalografija (pomeranje srednje linije zbog hematoma), radionuklidni sken (lokalno smanjene mo`dane perfuzije ili infarkt), KT i NMR (hematom i fokalni edem oko rupturisane aneurizme), angiografija (4, 8, 11): ve}a i proksimalnija aneurizma krvari u 3/4 slu~ajeva; aneurizma koja krvari je obi~no nepravilnih kontura, sa bradavi~astom protruzijom fundusa i fokalnim spazmom okolnih sudova. Lobuliranost je znak nestabilnosti zida aneurizme i retko se javlja ako aneurizma nije rupturisala. Mortalitet nakon rupture lobulirane aneurizme je dvostruko ve}i nego nakon rupture glatke aneurizme (31% i 14%); ponekad, mada retko, aneurizma rekrvari tokom angiografije, te se na filmu vidi curenje kontrasta; ako u sklopu MA postoji aneurizma prednje komunikantne arterije, zadnje donje malomo`dane arterije ili ra~ve AB, najverovatnije je ona uzrok krvarenja. Prema podacima iz literature, rizik rupture je ve}i kod MA nego kod SA (7). Neokludirana MA mo`e kasnije biti uzrok rekurentnog krvarenja, a godi{nji rizik rupture je 10 puta ve}i nego za solitarne nerupturisane aneurizme (0,5% prema 0,05%) (6, 16). U na{oj seriji MA su se javljale sa sli~nom u~estalo{}u u bolesnika sa i bez subarahnoidnog krvarenja. Preovladava uverenje da sve MA treba operativno zbrinuti, jer rizik kasnijeg rekrvarenja iznosi 11,5% za 16 godina, {to je znatno vi{e od operativnog mortaliteta za nerupturisane aneurizme (oko 1%, uz primenu moderne tehnike) (3). Nepotpun hirur{ki tretman (okluzija samokrvare}e aneurizme) je prihvatljiv samo za starije bolesnike, bolesnike sa lo{im klini~kim statusom i sa izrazitim otokom mozga (4, 17). Da li }e se operativno zbrinjavanje obaviti u jednom ili dva hirur{ka akta, naj~e{}e zavisi od anatomske distribucije aneurizmi. Neki rezultati pokazuju da se jednom operacijom zbrinjava 90% bolesnika sa unilateralnim MA prednje cirkulacije, 60% bolesnika sa MA u prednjoj i zadnjoj ili samo u zadnjoj cirkulaciji i % bolesnika sa bilateralnim MA (17, 18). U na{oj seriji je operativno le~enje indikovano jednakom u~estalo{}u kod bolesnika sa SA i MA. Operativno zbrinjavanje svih MA je postignuto kod 47,1% bolesnika, {to odgovara pomenutim navodima iz literature, tim pre {to neke od aneurizmi (fuziformne aneurizme ACI, aneurizme ACI u kavernoznom sinusu) nisu mogle biti zbrinute na standardan na~in. Pterionalna kraniotomija je naj~e{}e dovoljna za pristup Vilisovom {estouglu, a klju~ za prikazivanje MA je dobra disekcija subarahnoidnih cisterni (bazalni deo Silvijeve cisterne, karotidna, hijazmatska i cisterna laminae terminalis). Kroz pterionalnu kraniotomiju se mogu prikazati i aneurizme ra~ve AB, distalne AB i prekomunikantnog segmenta zadnje mo`dane arterije, ali ne i druge aneurizme zadnje cirkulacije (4). Ponekad je neophodno modifikovati standardni pterionalni pristup: kod MA na distalnoj ACA kraniotomija mora uklju~iti interhemisfernu regiju (kombinovani pterionalno-frontalni ko{tani re`anj), a kod MA na ra~vi AB i ACM kombinuje se pterionalni pristup sa temporalnim (4). U principu, sve MA se mogu zbrinuti jednom operacijom ako su lokalizovane na ipsilateralnoj ACI, ACM ili ACA, na ra~vi AB i na kontralateralnoj bifurkaciji ACI, prekomunikantnoj ACA ili ACM pre bifurkacije (znatno re e i na kontralateralnoj zadnjoj komunikantnoj ili prednjoj horioidnoj arteriji). Operacija u dva akta je neophodna ako postoje aneurizme na ipsilateralnoj ACI ili ACM zajedno sa kontralateralnim aneurizmama zadnje komunikantne, prednje horioidne i po~etnog dela srednje mo`dane arterije (3, 4). Kod MA se pred neurohirurga intraoperativno postavlja tehni~ki problem: da li prvo preparisati aneurizmu koja je krvarila ili onu koja je najbli`a (3). Obi~no se prvo okludira rupturisana aneurizma i tako ukloni rizik intraoperativne rupture, a za to vreme se nerupturisana aneurizma pokrije mi{i}em. Klip na nerupturisanoj aneurizmi mo`e ote`ati disekciju glavne aneurizme (npr. klip na nerupturisanoj aneurizmi zadnje komunikantne arterije jako ote`ava disekciju rupturisane aneurizme ra~ve AB) (4). Postoperativne komplikacije, uglavnom ishemijske, su bile ~e{}e kod na{ih bolesnika sa MA, {to potvr uje neke podatke iz literature o multiplicitetu aneurizmi kao faktoru rizika za postoperativnu infarkciju (5). Ne{to du`a postoperativna hospitalizacija kod na{ih bolesnika sa MA mo`e, ta-
5 Broj 3 VOJNOSANITETSKI PREGLED Strana 253 ko e, da bude indirektni znak te`eg postoperativnog toka, ali je kona~an ishod le~enja bolesnika sa MA i SA ipak bio sli~an. Ovakve rezultate objavljuju i drugi autori (2, 17), mada ima i suprotnih mi{ljenja prema kojima su bolji rezultati nakon operacija SA (14, 16, 19). Zaklju~ak Bolesnici sa solitarnim i multiplim aneurizmama se me usobno ne razlikuju po polnoj i starosnoj strukturi, preoperativnom klini~kom statusu, du`ini preoperativnog intervala, ishodu le~enja i u~estalosti rekrvarenja, vazospazma i intraoperativne rupture. Multiplicitet ne spre~ava postavljanje indikacije za operativnim le~enjem aneurizme, ali je potpuno operativno zbrinjavanje multiplih aneurizmi zna~ajno re e nego solitarnih. Multiple aneurizme su zna~ajno manje od solitarnih. Simptomatska aneurizma ACA je retko udru`ena sa multiplim aneurizmama. LITERATURA 1. Qureshi AI, Suarez JI, Parekh PD, Sung G, Geocadin R, Bhardwaj A, et al. Risk factors for multiple intracranial aneurysms. Neurosurgery 1998 Jul; 43: 22Þ6. 2. Phuenpathom N, Ratanalert S, Sripairojkul B. Multiple intracranial aneurysms in Songklanagarind Hospital. J Med Assoc Thai 1998; 81: 75Þ9. 3. Fox JL. Management of aneurysms of anterior circulation by intracranial procedures. In Youmans JR ed. Neurological Surgery. Vol 3, Third edition, WB Saunders Co, Philadelphia, 1990; p. 1689Þ Yasargil MG. Microneurosurgery. Volume I. George Thieme Verlag, Stuttgart&New York, Lavine SD, Masri LS, Levy ML, Giannotta SL. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection. J Neurosurg 1997; 87: 817Þ Yamakawa H, Sakai N, Takenaka K, Yoshimura S, Andoh T, Yamada H, et al. Clinical analysis of recurrent subarachnoid hemorrhage after neck clipping surgery. Neurol Med Chir (Tokyo) 1997; 37: 380Þ5. 7. Yasui N, Suzuki A, Nishimura H, Suzuki K, Abe T. Long-term follow-up study of unruptured intracranial aneurysms. Neurosurgery 1997; 40: 1155Þ Rhoton AL, Jackson FE, Gleave J, Rumbaugh CT. Congenital and Traumatic Intracranial Aneurysms. Clinical Symposia 1977; 29: 1Þ Ogilvy CS, Carter BS. A proposed comprehensive grading system to predict outcome for surgical management of intracranial aneurysms. Neurosurgery 1998 May; 42: 959Þ Roganovi} Z, Pavli}evi} G, Tadi} R. Tretman arterijskih aneurizmi prednje mo`dane cirkulacije. Vojnosanit Pregl 2002; 59: 3Þ Smith RR, Miller JD. Patophysiology and clinical evaluation of subarachnoid hemorrhage. In Youmans JR ed. Neurological Surgery. Vol 3, Third edition, WB Saunders Co, Philadelphia, 1990; p. 1644Þ Roganovi} Z, Pavli}evi} G, ]irkovi} S, Markovi} Lj. Dijagnostikovanje subarahnoidnog krvarenja. Vojnosanitet Pregl 2001; 58: 599Þ Inci S, Erbengi A, Ozgen T. Aneurysms of the distal anterior cerebral artery: report of 14 cases and a review of the literature. Surg Neurol 1998; 50: 1Þ De Sousa AA, Dantas FL, de Cardoso GT, Costa BS. Distal anterior cerebral artery aneurysms. Surg Neurol 1999; 52: 128Þ Orz Y, Kobayashi S, Osawa M, Tanaka Y. Aneurysm size: a prognostic factor for rupture. Br J Neurosurg 1997; 11: 144Þ Raaymakers TW, Rinkel GJ, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis. Stroke 1998; 29: : 1531Þ Orz Y, Osawa M, Tanaka Y, Kyoshima K, Kobayashi S. Surgical outcome for multiple intracranial aneurysms. Acta Neurochir (Wien) 1996; 138: 411Þ Peerless SJ, Drake CG. Management of aneurysms of the posterior circulation. In Youmans JR ed. Neurological Surgery. Vol 3, Third edition, WB Saunders Co, Philadelphia, 1990; p. 1764Þ Orz YI, Hongo K, Tanaka Y, Nagashima H, Osawa M, Kyoshima K, Kobayashi S. Risks of surgery for patients with unruptured intracranial aneurysms. Surg Neurol 2000; 53: 21Þ7. Rad je primljen 5. III god.
6 Strana 254 VOJNOSANITETSKI PREGLED Broj 3 Abstract Roganovi} Z, Pavli}evi} G. Vojnosanit Pregl 2002; 59(3): 249Þ254. MULTIPLE CEREBRAL ANEURYSMS Background. To define risk factors for the multiplicity of cerebral aneurysms, as well as clinical and therapeutical characteristics of patients with single aneurysms (SA) and multiple aneurysms (MA). Methods. Retrospective study on 95 patients with SA and 22 patients with MA. For patients with SA and MA the following parameters were compared: gender, age, clinical state, aneurysmal localization and size, incidence of rebleeding and vasospasm, manner and outcome of treatment, preoperative interval, intraoperative rupture and postoperative complications. Results. Aneurysms on anterior communicating artery existed in 37.4% of SA and in 17.8% of all MA (p<0.05). As much as 44.2% of all aneurysms on middle cerebral artery and only 19% of all aneurysms on anterior communicating artery were associated with some other aneurysm (p<0.02). The average size of SA was 15.4 ± 11.8mm, and 9.8 ± 9mm for MA (p<0.05). Surgery was performed in 77.3% of patients with MA and 78.9% of patients with SA (p>0.05), but complete surgical clipping was performed in 89.3% of patients with SA and in 47.1% of patients with MA (p<0.01). Among operated patients with MA and SA, intraoperative rupture occured in 36% and 17.6% of cases, respectively (p<0.05) and ischemic postoperative complications were found in 29.4% and 17.3% of the cases (p>0.05). Among 72.7% of all patients with MA and in 69.5% of all patients with SA the outcome was good, while among surgically treated patients it was good in 76.5% and 70.7% of cases, respectively. Conclusion. The treatment outcome was similar for patients with MA and SA, but complete operative treatment is significantly more frequent for SA. Multiple aneurysms were considerably smaller and with different anatomical distribution in relation to solitary aneurysms. K e y w o r d s : intracranial aneurysm; cerebral arteries; aneurysm, ruptured; cerebral angiography; subarachnoid hemorrhage; neurosurgical procedures; postoperative complications; treatment outcome.
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