Abstract

Objective: To report the clinical outcome achieved through surgical clipping of ruptured cerebral aneurysms over 7 and half years period in tertiary care hospital of Pakistan.

Material and Methods: A retrospective study of Pakistani patients with ruptured intracranial aneurysms that were operated for clipping. The demographic details, characteristics of ruptured aneurysm, imaging of aneurysm, clinical course, progress and outcome were recorded. Fisher grading and Hunt and Hess criteria were used. Glasgow outcome scale (GOS) was used for final result. Data was recorded and analyze through SPSS version 21.

Results: 86 patients were recruited in 7 and a half year period. Mean age was 50 (SD, 14) years. There were 48 females and 38 males. There was no significant difference in the size of the ruptured aneurysms among both sexes. Two most common sites of rupture were the anterior communicating artery and middle cerebral artery. 11.6% patients had more than one aneurysm. The median door-to-treatment time with IQR was 48 hours. The majority of the patients presented with Grade II and III of Hunt and Hess criteria, while the Fischer grading was severe of Grade III and IV for most of them. The average follow-up was about 3 weeks, 39 out of 86 patients had low disability. Patients above the age of 40 had worse outcome. The mortality rate of the cross-sectional was 14% (12/86). There was no statistical significance seen in patients with GOS and H&H criteria, or GOS and Fischer grading. Post- operatively, 13 patients had hydrocephalus (13 patients), and among which 10 underwent VP shunt.

Discussion: A very low occurrence rate of aneurysm has been seen, which involve many factor, such as eligibility for surgery, financial hurdles, lack of awareness, lack of facilities, among others. The most common location for subarachnoid cerebral aneurysm in Pakistan is anterior communicating artery and second to it is middle cerebral artery. No statistical significance has been seen between Hunt and Hess grading system and outcome scale in this study, while some degree of association has been proven in other studies. Clinical outcomes have been better overall due to early intervention, if to observe factors, age and aneurysm size plays an important role with poorer results with age more than fifty as seen through Glasgow outcome scale. Other factors that matter are slow prognosis, severe clinical symptoms at time of admission and higher frequency of comorbidity. The clinical outlook shows that the most common complication of the clipping was hydrocephalus and wound infection in Pakistani population. Patients were not followed for long term outcome, hence it is a limitation of this study.

Conclusion: Despite the improvements in past two decades, there is a lack of infrastructure and awareness regarding cerebral aneurysm treatment and management in Pakistan. Moreover, alternative methods such as coiling is still not available in the majority of hospitals in Pakistan.

Keywords: Cerebral Aneurysm; Outcome; Subarachnoid Hemorrhage; Ruptured Intracranial; Aneurysm; Clipping

References

1. Bhagwati SN. “Incidence of subarachnoid hemorrhage from aneurysmal rupture in India”. Neurologia Medico-Chirurgica (Tokyo) 38 (1998): 128-130.
2. Wasay M., et al. “Stroke in South Asian countries”. Nature Review on Neurology 10 (2014): 135-143.
3. Oligvey CS. “Neurosurgical Clipping versus Endovascular Coiling of Patients with Ruptured Intracranial Aneurysms”. Stroke 34 (2003): 2540-2542.
4. Britz GW. “Clipping or coiling of cerebral aneurysms”. Neurosurgery clinics of North America3 (2005): 475-485.
5. Falk Delgado A., et al. “Clinical outcome after surgical clipping or endovascular coiling for cerebral aneurysms: a pragmatic meta-analysis of randomized and non-randomized trials with short- and long-term follow-up”. Journal of Neuro Interventional Surgery 9 (2017): 264-277.
6. Seibert B., et al. “Intracranial aneurysms: review of current treatment options and outcomes”. Frontiers in Neurology 2 (2011): 45.
7. Kassell NF., et al. “The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results”. Journal of Neurosurgery1 (1990): 18-36.
8. Kassell NF., et al. “The International cooperative study on the timing of aneurysm surgery: Part 2: surgical results”. Journal of Neurosurgery1 (1990): 37-47.
9. Sengupta R P., et al. “Scope of surgery for intracranial aneurysm in the elderly: a preliminary report”. British Medical Journal 2 (1978): 246-247.
10. Ross N., et al. “Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study”. Journal of Neurology and Neurosurgery Psychiatry4 (2002): 480-484.
11. , et al. “Clinical outcomes of surgical clipping for intracranial aneurysms in patients with a Hunt and Hess grade 4 or 5”. Arquivos de Neuro- Psiquiatria 74 (2016): 478-481.
12. Nisson PL., et al. “Surgical Clipping of Previously Ruptured, Coiled Aneurysms: Outcome Assessment in 53 Patients”. World Neurosurgery (2008): e203-e211.
13. Fisher CM., et al. “Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning”. Neurosurgery 6 (1980): 1-9.
14. Zhang F., et al. “The Prognosis Factors for Endovascular Coiling of Aneurysm in Patients with Ruptured Intracranial Aneurysm”. Journal of Craniofacial Surgery6 (2017): e535-e539.
15. Jennett B and Bond M. “Assessment of outcome after severe brain damage”. Lancet7905 (1975): 480-484.
16. Raja IA and Javaid MA. “Aneurysm 318 surgery in Pakistan”. Neurologia Medico-Chirurgica (Tokyo). 38 (1998): 134-137.
17. Zubair Tahir M., et al. “Cost-effectiveness of clipping vs coiling of intracranial aneurysms after subarachnoid hemorrhage in a developing country--a prospective study”. Surgical Neurology4 (2009): 355-360 discussion 360-361.
18. Spetzler RF., et al. “Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial”. Journal of Neurosurgery 8 (2019): 1-6.
19. Molyneux A., et al. “International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial”. Lancet 9342 (2002): 1267-1274.
20. Spetzler RF., et al. “The Barrow Ruptured Aneurysm Trial: 6-year results”. Journal of Neurosurgery3 (2015): 609-617.
21. Bhat AR., et al. “Subarachnoid hemorrhage in Kashmir: Causes, risk factors, and outcome”. Asian Journal of Neurosurgery2 (2011): 57-71.
22. St Julien J., et al. “Validation of an aneurysmal subarachnoid hemorrhage grading scale in 1532 consecutive patients”. Neurosurgery2 (2008): 204-211.
23. Yang H., et al. “Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?” Cell Transplantation 16 (2019): 963689718823517.
24. Taheri Z., et al. “Comparison of endovascular coiling and surgical clipping for the treatment of intracranial aneurysms: A prospective study”. Iranian Journal of Neurology1 (2015): 22-28.

Citation

Citation: Almas Ashraf., et al. “Clinical Course of Ruptured Cerebral Aneurysm at Tertiary Care Hospital in Pakistan". Acta Scientific Neurology 4.1 (2021): 22-28.

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Copyright: © 2021 Almas Ashraf., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.