Nevrokirurgi

23-27 oktober 2006 Vitenskapelige forhandlinger Abstrakt nr: 17
SAH FROM ICA TRUNK ANEURYSMS
Meling TR 1 , Sorteberg A 1 , Slettebø H 2 , Bakke SJ 3 , Sorteberg W 1 .
1 Nevrokirurgisk avdeling, Rikshospitalet, 2 Nevrokirurgisk avdeling, Haukeland
Universitetssykehus, 3 Nevroradiologisk avdeling, Rikshospitalet.
OBJECTIVE: To evaluate patients with acute SAH from atypical
internal carotid artery (ICA) trunk aneurysms.
METHODS: A single-centre, retrospective study. Data analyzed were
patient age, sex, GCS, Hunt and Hess grade, Fisher grade, time from SAH to
hospitalisation, aneurysm size and location, collateral circulation, time from
hospitalisation to treatment, treatment type, complications and GOS at followup.
RESULTS: Between January 1998 to August 2005, 211 subjects
suffered ICA aneurysmal bleed. Of these, 14 patients (6.6%) had non-saccular
or atypical ICA aneurysms; 6 males, 8 females. Median age was 48 years
(range 30-68). 7 patients were in H&H grade 4 or 5. 7 patients were in Fisher
grade 3+4. Median time from SAH to hospitalisation was 14 hours, range 4-
93. All aneurysms were small and without relation to vessel bifurcations. 13
aneurysms were blister-like, 1 was ectasia. 13 patients underwent CTA and
angiography on arrival, 1 patient had a CTA only. The collateral circulation
was evaluated preoperatively, based on size of ACOM and PCOM, as well as
venous phase delay. Some patients also underwent ICA balloon occlusion
tests with TCD. Median time from hospitalisation to treatment was 16 hours
(range 2-401). 3 patients were treated with coils, 11 with surgical clipping. In
7 patients, the ICA was sacrificed. In all surgical cases (6 patients), this was
because of peroperative aneurysm rupture. The 7 patients treated with ICA
closure developed massive cerebral infarction, 2 directly post-op, 5 delayed. 6
subjects died (GOS 1), one survived in a very poor condition (GOS 3). In
contrast, of the 7 patients where the ICA was preserved, only one patient had
poor outcome (GOS 2).
CONCLUSIONS: ICA trunk aneurysms are difficult to treat and easily
rupture peroperatively (6 of 11). ICA trap ligation within 48 hours of a SAH
represents a terrible second insult to the brain, leading to a very poor outcome.
The criteria used for tolerance to ICA sacrifice in the elective setting may not
be valid in acute SAH.