A. Hino et al., False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage, NEUROSURGER, 46(4), 2000, pp. 825-830
OBJECTIVE: Patients with subarachnoid hemorrhage and multiple intracranial
aneurysms present a unique challenge to the neurosurgeon. Unless all aneury
sms can be clipped through a single craniotomy, the surgeon must accurately
determine which aneurysm has ruptured. Misjudgment may result in disastrou
s postoperative rebleeding from the untreated but true ruptured lesion. We
assessed the risk of false localization of the rupture site and subsequent
rebleeding and documented the problems in predicting the true rupture site
when patients have multiple intracranial aneurysms.
METHOD: We reviewed the records of a consecutive series of 93 patients trea
ted over a period of 12 years who presented with their first subarachnoid h
emorrhage and who had multiple intracranial aneurysms. The rupture site was
determined on the basis of computed tomographic and angiographic findings,
and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage
in each patient. Additional aneurysms that could not be accessed in the sa
me surgical session were operated on at a later stage. All patients' record
s were reviewed, and all computed tomographic scans and angiograms, includi
ng repeat studies performed in some patients, were retrospectively reevalua
ted by the authors, who had no knowledge of the patients' clinical informat
ion.
RESULTS: The location of the aneurysm that ruptured was verified at the tim
e of surgery or during the autopsy in 76 patients (82%). The aneurysm that
ruptured was the one predicted as ruptured by the surgeon before surgery in
69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 pa
tients in whom the ruptured aneurysm was not correctly identified were thou
ght to have only a single aneurysm. Four patients rebled after surgery, and
2 patients died as a result of the rebleeding.
CONCLUSION: In the reported series, the most common cause of rebleeding soo
n after aneurysm surgery was failure to obliterate the ruptured aneurysm, u
sually because it was missed on the initial angiogram. The results support
not only meticulous radiological investigation of all intracranial arteries
before surgery but also thorough surgical inspection of the target aneurys
m in all cases of subarachnoid hemorrhage even after one candidate lesion h
as been discovered.