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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 91-94

Posterior communicating artery aneurysms: Analysis of predictors of surgical outcome


1 National Neurosciences Mission, Adarsha Superspecialty Hospital, Manipal-Udupi, Karnataka, India
2 Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission22-Aug-2020
Date of Acceptance31-Aug-2020
Date of Web Publication3-Feb-2021

Correspondence Address:
Dr. Sumeet Narang
National Neurosciences Mission, Adarsha Superspecialty Hospital, Manipal-Udupi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_16_20

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  Abstract 


Background: Although aneurysms of the posterior circulation are not as common as those of the anterior circulation, the threat they pose can be reduced with timely surgical intervention. The study analyses factors that influence the outcome in surgically clipped posterior communicating artery (PCoA) aneurysms.
Methods: A retrospective analysis of 85 cases of surgically clipped PCoA aneurysms was carried out, taking into consideration, the presenting signs and World Federation of Neurological Societies (WFNS) grade at admission, the timing of the surgery and the outcome of the surgery as per the Glasgow Outcome Scale.
Results: About 56.8% of cases were clinically WFNS Grade I at admission. About 75.9% of all patients and 90% of patients who were Grade I and 74% of patients who were Grade II had a good recovery as per the Glasgow Outcome Scale. The overall mortality was 6.9%, and all patients who did not survive despite surgery were initially WFNS Grade IV patients.
Conclusion: A higher or clinically worse WFNS grade of subarachnoid haemorrhage at the time of admission in patients with PCoA aneurysms predicts a poor surgical outcome, regardless of the timing of the surgery.

Keywords: Aneurysm, outcome, posterior communicating artery, World Federation of Neurological Societies


How to cite this article:
Narang S, Kaur H, Dil JS, Raja A. Posterior communicating artery aneurysms: Analysis of predictors of surgical outcome. J Cerebrovasc Sci 2020;8:91-4

How to cite this URL:
Narang S, Kaur H, Dil JS, Raja A. Posterior communicating artery aneurysms: Analysis of predictors of surgical outcome. J Cerebrovasc Sci [serial online] 2020 [cited 2021 Sep 17];8:91-4. Available from: http://www.jcvs.com/text.asp?2020/8/2/91/308625




  Introduction Top


Intracranial aneurysms of the posterior circulation are as less common in comparison with those of the anterior circulation.[1],[2] However, aneurysms of the posterior circulation are subject to the same factors influencing the risk of rupture leading to a subarachnoid haemorrhage (SAH), such as age, gender, race and aneurysm size and position.[3],[4],[5],[6],[7] Although it is known that microsurgical clipping has been seen to provide a favourable outcome in patients with posterior communicating artery (PCoA) aneurysms,[8],[9],[10] parameters predicting the risks or affecting the outcome, which would have a definite impact on the management plan, have not been adequately objectified.

Objectives

The objective was to assess the relationship between the World Federation of Neurological Societies (WFNS) grade[11] of SAH at the time of admission of patients with PCoA aneurysms with the surgical outcome in those patients, as per the Glasgow Outcome Scale (GOS).[12]


  Methods Top


This was a hospital-based retrospective observational study of 85 patients admitted to the National Neurosciences Mission, Adarsha Super-specialty Hospital, Manipal, Udupi, Karnataka, India, with PCoA aneurysms, as diagnosed clinically and radiologically through computed tomography and digital subtraction angiography, managed surgically by microvascular aneurysm clipping.

Postoperatively, the patients were monitored and managed in the neurosurgical intensive care unit. Post-operative events and complications were observed and noted. The parameters observed in the study included: the signs at the time of presentation, WFNS grade at the time of presentation, the timing of the surgery, the outcome of the surgery according to the Glasgow Outcome Scale and the relationship between WFNS grade with the outcome.


  Results Top


Based on the authors' personal experiences with 571 cases of intracranial aneurysms that were admitted to the study hospital and operated upon, 14.8% of all cases, i.e., 85 cases, were diagnosed to be PCoA aneurysms [Figure 1].
Figure 1: Percentage of posterior communicating artery aneurysms

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Of those 85 cases, 94.1% of cases presented with subarachnoid haemorrhage, 22.4% of cases presented with oculomotor nerve (CN-III) palsy and 12% of cases presented with contralateral hemiparesis [Table 1].
Table 1: Presenting signs

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At the time of admission, 56.8% of patients presented in WFNS Grade I, 17% in Grade II, 12% in Grade III, 13.7% in Grade IV and none in WFNS Grade V [Table 2].
Table 2: World Federation of Neurological Societies' Grades at admission

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About 53% of the patients were operated within 1 week (between day 0 and 7) of ictus, 22.3% in the 2nd week (between days 8 and 14) and the remaining 24.7% were operated later after the 2nd week (beyond day 14) [Table 3].
Table 3: Timing of surgery

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About 87.9% of aneurysms were successfully clipped and the rest were dealt with by muscle wrapping or aneurysm trapping. Temporary clipping was employed in all cases.

On studying the surgical outcome as per the Glasgow Outcome Scale, 75.9% of the patients had a good recovery, 13.8% recovered with moderate disability, 2.3% had a severe disability, 1.1% were in a persistent vegetative state and the mortality observed was 6.9% [Table 4].
Table 4: Surgical outcome as per the Glasgow Outcome Scale

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On correlating the surgical outcome with the WFNS grade at admission, it was observed that most patients who were either WFNS Grades I or II at admission, either had a good recovery or a moderate disability; those who were WFNS Grade III had a poorer outcome in comparison and all patients who were WFNS Grade IV did not survive [Table 5].
Table 5: Relation between the World Federation of Neurological Societies Grade at admission and observed surgical outcome as per the Glasgow Outcome Scale

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  Discussion Top


Microsurgical clipping of intracranial aneurysms is probably the most common procedure performed by cerebrovascular surgeons around the world. Existing medical literature abounds in data on the overview of intracranial aneurysms such as their prevalence, natural history, factors associated with aneurysms, treatment options and their effectiveness.

PCoA aneurysms make up only a small proportion of all aneurysms studied by various investigators. One study has noted that PCoA aneurysms grow at a faster rate.[13] As it is known that aneurysm behaviour and management is location dependent[14] and that the posterior circulation requires special anatomical and technical considerations in surgical clipping,[15],[16],[17] the measure of effective management can only be objectified against the outcome after surgery.

In this paper, we have attempted to contribute to the knowledge of surgical management of aneurysms with specific consideration of the parameters associated with surgery for aneurysms of the PCoA.[18]

It was observed that SAH remains the most common form of presentation, although a considerable number of patients also presented with oculomotor nerve palsy.[19]

Three-fourth of all patients presented with a clinically low WFNS grade (Grade I or Grade II) at admission and a quarter in Grade III or IV, but that none in presented in Grade V could allow the speculation that perhaps those who would have been Grade V, probably never made it to the hospital in time or alive.

Although we have documented the various time periods in which surgical intervention was undertaken, as the timing of the surgery was not planned according to fixed criteria, rather on the clinical situation of individuals and other ancillary factors involved in the decision to operate (such as financial and social limitations faced by the patients or their families in this part of the world), no attempt was made to objectively correlate the effect that the timing of the surgery would have had on the outcome of the surgery, though it is evident from the gross overview that the correlation is minimal.

Overall, it was pleasing to note encouraging numbers reflecting a good recovery in patients operated for PCoA aneurysms in agreement with findings from Finland and South Korea.[8],[9] The most important parameter that did affect the surgical outcome in PCoA, just as observed by Hunt and Hess in their study of aneurysms back in 1968, was the clinical grade at the time of admission.[20] All patients who were Grade I or II at admission had either a good recovery or only a moderate disability and did not fare worse than that. However, patients with a poorer grade did not fare as well and all the patients who did not survive surgery were found to be patients who were Grade IV at admission. This finding also corroborates with Charles Drake's statement that mortality 'rose precipitously with the worsening condition of the brain' and also agreed that timing did not play a major role.[21]


  Conclusion Top


Microsurgical clipping yields a good surgical outcome in patients with PCoA aneurysms, especially if they present with Grades I–III, whereas the outcome is poor in patients with Grades IV or V, regardless of the timing of the surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms--risk of rupture and risks of surgical intervention. N Engl J Med 1998;339:1725-33.  Back to cited text no. 1
    
2.
UCAS Japan Investigators, Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 2012;366:2474-82.  Back to cited text no. 2
    
3.
Wiebers DO, Whisnant JP, Huston J, Meissner I, Brown RD, Piepgras DG, et al. International study of unruptured intracranial aneurysms investigators. Unruptured intracranial aneurysms: Natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103-10.  Back to cited text no. 3
    
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Weir B, Disney L, Karrison T. Sizes of ruptured and unruptured aneurysms in relation to their sites and the ages of patients. J Neurosurg 2002;96:64-70.  Back to cited text no. 4
    
5.
Juvela S, Porras M, Heiskanen O. Natural history of unruptured intracranial aneurysms: A long-term follow-up study. J Neurosurg 1993;79:174-82.  Back to cited text no. 5
    
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Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: A systematic review and meta-analysis. Lancet Neurol 2011;10:626-36.  Back to cited text no. 6
    
7.
Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: A systematic review. Stroke 1998;29:251-6.  Back to cited text no. 7
    
8.
Thiarawat P, Jahromi BR, Kozyrev DA, Intarakhao P, Teo MK, Choque-Velasquez J, et al. Microneurosurgical management of posterior communicating artery aneurysm: A contemporary series from helsinki. World Neurosurg 2017;101:379-88.  Back to cited text no. 8
    
9.
Lee KC, Lee KS, Shin YS, Lee JW, Chung SK. Surgery for posterior communicating artery aneurysms. Surg Neurol 2003;59:107-13.  Back to cited text no. 9
    
10.
Khandelwal P, Kato Y, Sano H, Yoneda M, KannoT. Treatment of ruptured intracranial aneurysms: Our approach. Minim Invasive Neurosurg 2005;48:325-9.  Back to cited text no. 10
    
11.
Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988;68:985-6.  Back to cited text no. 11
    
12.
Jennett B, Bond M. Assessment of outcome after severe brain damage: A practical scale. Lancet 1975;305:480-4.  Back to cited text no. 12
    
13.
Chien A, Lau V, Yi Q, Chang W. Posterior communicating artery aneurysms demonstrate faster interval growth than other growing aneurysms. Neuroradiol J 2018;31:288-91.  Back to cited text no. 13
    
14.
Raaymakers TW, Rinkel GJ, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms: A meta-analysis. Stroke 1998;29:1531-8.  Back to cited text no. 14
    
15.
Yasargil MG. Micro neurosurgery: II. Clinical Considerations, Surgery of the Intra Cranial Aneurysms and Results. New York: Georg Thiemeverlag/Thieme Statton; 1984.  Back to cited text no. 15
    
16.
Golshani K, Ferrell A, Zomorodi A, Smith TP, Britz GW. A review of the management of posterior communicating artery aneurysms in the modern era. Surg Neurol Int 2010;1:88.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Xu Z, Kim BS, Lee KS, Choi JH, Shin YS. Morphological and clinical risk factors for the rupture of posterior communicating artery aneurysms: Significance of fetal-type posterior cerebral artery. Neurol Sci 2019;40:2377-82.  Back to cited text no. 17
    
18.
Zheng F, Dong Y, Xia P, Mpotsaris A, Stavrinou P, Brinker G, et al. Is clipping better than coiling in the treatment of patients with oculomotor nerve palsies induced by posterior communicating artery aneurysms? A systematic review and meta-analysis. Clin Neurol Neurosurg 2017;153:20-6.  Back to cited text no. 18
    
19.
Gaberel T, Borha A, di Palma C, Emery E. Clipping versus coiling in the management of posterior communicating artery aneurysms with third nerve palsy: A systematic review and meta analysis. World Neurosurg 2016;87:498-506.  Back to cited text no. 19
    
20.
Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968;28:14-20.  Back to cited text no. 20
    
21.
Drake CG. Intracranial aneurysms. Acta Neurol Latinoam 1977;23:43-68.  Back to cited text no. 21
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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