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Some Observations on the Surgery of Cerebrovascular Diseases
409
Some Observations on the Surgery of Cerebrovascular Diseases s. KOSTIC Neurosurgical University Clinic, Belgrade ( Yugoslavia)
During the past few years cerebrovascular diseases have been entering more and more into the domain of surgical treatment. This is largely due to new knowledge of these diseases, their pathogenesis, timely diagnosis, better pre-operative treatment and certain novelties and facilities in operative techniques. This success is reflected in the definite results and decreasing operative mortality. I t is especially marked in radical intervention in the case of aneurysms and arterio-venous malformations. However, notwithstanding the latest experiences, arachnoidal hemorrhage caused by vascular malformations, aneurysms and other diseases of unknown etiology is frequently still a source of considerable difficulty in making a timely and precise diagnosis, determination of surgical intervention and selection of operative methods. Furthermore the steadily increasing incidence of these diseases, their vague and acute development, serious sequelae and high mortality rate, obstruct clinical study and diagnosis. Similarly, recurrent and severe, often fatal, hemorrhage, not infrequently prohibits any kind of treatment. In order to gain better knowledge of these so-called negative characteristics of cerebrovascular diseases and of the difficulties arising in their treatment, we made an analysis of our own cases observed and treated at the Neurosurgical Clinic in Belgrade from 1961 to 1965. I must mention, however, that during this period we were unabe to admit to the Clinic all the cases of subarachnoidal hemorrhage. Although the actual number is far greater, we had during this period 94 cases admitted for acute subarachnoidal hemorrhage, most of them subcomatous or in a coma. During the same period we had 9,683 neurosurgical patients, among them 1232 operated for brain tumor or some other expansive intracranial process, and of this latter group the 94 cases of spontaneous hemorrhage constitute 7.63 %. During the past few years, this percentage of cerebrovascular diseases has been steadily and markedly growing at our Clinic. Our series of 94 cases included only aneurysms and vascular malformations of the brain with acute hemorrhage. Hemangiomas and angioblastomas, which were more frequent, as well as cases of subarachnoidal hemorrhage of uncertain etiology have not been included. In this series we determined the cause of spontaneous hemorrhage to be solitary or multiple aneurysms of various localization in 2/3rds of the total cases, while the remaining cases revealed various forms of vascular malformations.
410
s.
KOSTI~
In selecting the cases suitable for surgery we took into consideration the general condition of the patient, age, the time elapsed since the first symptoms of hemorrhage, angiographic findings, various malformations and, in individual cases of aneurysms, localization and number, and finally the degree of the patient’s consciousness on admission. According to these criteria, only 14 cases were found suitable for operation in this series during the period reviewed. They were 5 cases with aneurysms of various location, and 9 with vascular malformations suitable for extirpation. Of the14 radically operated patients, 2 died after a few days, one of acute cerebral edema, and the other of thrombosis. In the remaining patients of this series, we performed palliative operations of various kinds or applied only conservative medical treatment. In conclusion of the analysis of 94 patients suffering from vascular malformations and cerebral aneurysms with acute subarachnoidal hemorrhage, observed and treated at our Clinic between 1961 and 1965 we can state the following: 1. Serial cerebral angiography yields important data and facilitates the establishment ofa correct and timely diagnosis. 2. Subsequent and unexpected hemorrhage is frequent in the period of clinical observation, the outcome usually being fatal. 3. In spite of meticulous pre-operative treatment and more favorable conditions for surgery, the number of cases suitable for radical intervention is still restricted. 4. Cerebrovascular surgery is undoubtedly producing better and better results, however such cases require above all accurate and timely diagnosis, comprehensive pre-operative treatment and, given certain surgical indications, prompt surgical intervention and a carefully chosen operative method according to each individual case.
Some Observations on the Surgery of Cerebrovascular Diseases s. KOSTIC Neurosurgical University Clinic, Belgrade ( Yugoslavia)
During the past few years cerebrovascular diseases have been entering more and more into the domain of surgical treatment. This is largely due to new knowledge of these diseases, their pathogenesis, timely diagnosis, better pre-operative treatment and certain novelties and facilities in operative techniques. This success is reflected in the definite results and decreasing operative mortality. I t is especially marked in radical intervention in the case of aneurysms and arterio-venous malformations. However, notwithstanding the latest experiences, arachnoidal hemorrhage caused by vascular malformations, aneurysms and other diseases of unknown etiology is frequently still a source of considerable difficulty in making a timely and precise diagnosis, determination of surgical intervention and selection of operative methods. Furthermore the steadily increasing incidence of these diseases, their vague and acute development, serious sequelae and high mortality rate, obstruct clinical study and diagnosis. Similarly, recurrent and severe, often fatal, hemorrhage, not infrequently prohibits any kind of treatment. In order to gain better knowledge of these so-called negative characteristics of cerebrovascular diseases and of the difficulties arising in their treatment, we made an analysis of our own cases observed and treated at the Neurosurgical Clinic in Belgrade from 1961 to 1965. I must mention, however, that during this period we were unabe to admit to the Clinic all the cases of subarachnoidal hemorrhage. Although the actual number is far greater, we had during this period 94 cases admitted for acute subarachnoidal hemorrhage, most of them subcomatous or in a coma. During the same period we had 9,683 neurosurgical patients, among them 1232 operated for brain tumor or some other expansive intracranial process, and of this latter group the 94 cases of spontaneous hemorrhage constitute 7.63 %. During the past few years, this percentage of cerebrovascular diseases has been steadily and markedly growing at our Clinic. Our series of 94 cases included only aneurysms and vascular malformations of the brain with acute hemorrhage. Hemangiomas and angioblastomas, which were more frequent, as well as cases of subarachnoidal hemorrhage of uncertain etiology have not been included. In this series we determined the cause of spontaneous hemorrhage to be solitary or multiple aneurysms of various localization in 2/3rds of the total cases, while the remaining cases revealed various forms of vascular malformations.
410
s.
KOSTI~
In selecting the cases suitable for surgery we took into consideration the general condition of the patient, age, the time elapsed since the first symptoms of hemorrhage, angiographic findings, various malformations and, in individual cases of aneurysms, localization and number, and finally the degree of the patient’s consciousness on admission. According to these criteria, only 14 cases were found suitable for operation in this series during the period reviewed. They were 5 cases with aneurysms of various location, and 9 with vascular malformations suitable for extirpation. Of the14 radically operated patients, 2 died after a few days, one of acute cerebral edema, and the other of thrombosis. In the remaining patients of this series, we performed palliative operations of various kinds or applied only conservative medical treatment. In conclusion of the analysis of 94 patients suffering from vascular malformations and cerebral aneurysms with acute subarachnoidal hemorrhage, observed and treated at our Clinic between 1961 and 1965 we can state the following: 1. Serial cerebral angiography yields important data and facilitates the establishment ofa correct and timely diagnosis. 2. Subsequent and unexpected hemorrhage is frequent in the period of clinical observation, the outcome usually being fatal. 3. In spite of meticulous pre-operative treatment and more favorable conditions for surgery, the number of cases suitable for radical intervention is still restricted. 4. Cerebrovascular surgery is undoubtedly producing better and better results, however such cases require above all accurate and timely diagnosis, comprehensive pre-operative treatment and, given certain surgical indications, prompt surgical intervention and a carefully chosen operative method according to each individual case.