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Unruptured aneurysms in patients with transient ischemic attack or reversible ischemic neurological deficit
Unruptured aneurysms in patients with transient ischemic attack or reversible ischemic neurological deficit Report of eight cases
Kikuo Ohno*, Ryuta Suzuki*, Hiroyuki Masaoka’, ma* *, and Yutaka Inaba*.
Controversy persists regarding the management of unruptured intracranial aneurysms. Unruptured aneurysms are classified into the following three categories l,*: 1) multiple, in~dental aneurysms in patients with a sub~aehnoid hemorrhage; 2) symptomatic aneurysms, presenting neurological symptoms such as cranial nerve palsies; and, 3) incidental a~~~~srns, diagnosed when the patient is u~d~rgoing angiography for tumors, cerebral ischemia, or other various intracranial lesions. Surgical treatment is usually indicated for symptomatic unruptured aneurysms. However, the choice of the most adequate treatment for symptomatic aneurysms discovered incidentally may be difficult, since the natural history of them remains unclear. We report on eight patients with unruptured aneurysms, discovered during ~~giographical investigation of tr~sient ischemic attack (TIA), or reversible ischemic neurological deficit (RIND), and discuss treatment for unruptured aneurysms associated with TIA or RIND.
Between 1981 and 1987, 44 un~ptured aneurysms were discovered in 35 patients. They con-
Yoshiharu
Matsushima*,
Seiji Mon-
Thirty-five patients with unruptured aneurysms were treated between 1981 and 1987. Eight of them had either transient ischemic attacks or reversible ischemic neurological deficits as their presenting s~ptoms. Six of the eight patients underwent direct aneu~sm surgery. Alt eight patients are well, and have had no recurrent attack during the follow-up period ranging from 2 to 7 years. The feasibility af surgical treatment for such aneurysms associated with reversible ischemic symptoms is discussed. Key-words: Unruptured RIND, Surgical treatment.
aneurysm,
TX&
sisted of 17 multiple, incidental aneu~sms in 11 patients with a ruptured aneurysm, 9 symptomatic aneurysms and one incidental aneurysm in nine patients with third nerve palsy or TIA and 17 aneu~sms in 15 patients with intra~r~ni~ lesions, such as a brain tumor, cerebral ischemia, arteriovenous malformation, chronic subdural hematoma, or hypertensive intracerebral hemorrhage (Table 1). The results of our treatment of these aneu~sms proved excellent in 33 patients. As for two patients with multiple, incidental aneu~sms associated with a subarachnoid hemorrhage, their poor neurological con-
* ~e~ur~ent~f ~eur~urge~, Tokyo ~~~~c~~~ Dental ~nive~i~, Tokyo, and * * ~e~a~ent~f City Hospital, Y-n~~~, Japan.
~eurosurge~, F~jiyo~h~~a
Address for correspondence and reprint requem: Kikuo Ohno, Department of Neurosurgery, Tokyo Medical and Delental University,l-5-45 Yushinuz, Bunkyo-ku, Tokyo 113, Japan. Accepted 16.1.89 Clin Neurof ~euro~urg 1989. V&.91-3
229
dition after hemorrhage influenced the outcome. Twenty-five of the 35 patients underwent intracranial surgery and two patients were given a cartoid ligation. There was no operative mortality and the outcomes of 26 of the 27 patients operated on were excellent, although one patient still remained poor after surgery, due to a preoperative poor neurological condition.
Table 1. Summary of 35 patients with unruptured aneurysms Reasons for investigation
No. of patients
Multiple, in&.Iental aneurysms associated with a ruptured aneurysm
11
9
symptomaticaneurysrns ocuIomotor palsy TIA
6 3
Asymptomatic. incidental aneurysms TIA Brain tumor Subcortical hemorrhage AVM Chronic subdural hematoma BinasaIbemhmopGa EnhancedmassonCTscan
15 3 3 2 2 2 1 1 1
Abbreviations: TIA = transient iacbemic attack; RIND = reversible isdmmic neurological deficit; AVM = arteriovenous malformation.
Of the 35 patients, eight underwent cerebral angiography for investigation of cerebral ischemic attacks and were found to have the aneurysms (Table 2). Six of the eight patients suffered from TIA and two had RIND. These patients consisted of four males and four females, and their ages ranged from 45 to 67 years, with an average age of 56 years. The aneurysms were located in the internal carotid artery in one, the middle cerebral artery in seven, and the distal anterior cerebral artery in two. Cerebral angiography demonstrated aneurysms and arteriosclerotic changes in the cerebral vessels but no apparent stenosis or occlusion to cause ischemic symptoms in any of the eight patients. There was no abnormal finding in the extracranial carotid arteries. CT scans revealed single or multiple lacunar infarctions in two patients with RIND and in two with TIA. The lacunar regions were not always related to the distribution supplied by the parent arteries of the aneurysms in these four patients. In three of the four other patients whose CT findings were normal, a middle cerebral artery aneurysm was found on the side contralateral to their transiently paralyzed extremities (patient nos. 2, 6 and 7 in Table 2). No cardiological or medical evidence was found to explain the ischemic symptoms in these three patients. The patients are classified in the category of symptomatic aneurysms in Table 1. Aneurysmal neck clipping was performed in
Table 2. Summary of eight patients with iachemic symptoms. Patient no.
Age/Sex (Years)
ClinicaI symptoms
Type of iscbemia
CT finding
Location of aneurysms
1
53/M
TIA’s
48/F
multiple LI normal
bilateral MCA’s
2 3
67/M
we&neseofIthand n~ofltband LOC, rt bemipkgia, dyaa&ria dyaaf&a, memory
It IC-Ach
4 5 6
62’F 49/M 45/F
TIA TIA
It distal ACA bilateral MCA’s It MCA
7 8
5&F 63&I
LOC, rt hemiparesis It hem&are&s LOC, weakness of rt hand It ImmipIegm numbness and weakneasofrthand
multiple LI LI LI normal
TIA TIA’s
normaI normaI
rt MCA It distal ACA
TIA RIND
It MCA
Abbreviations: TIA = transient ischemic attack; RIND = reversibk iscbemic neurologicaI deficit; MCA = middle cerebral artery; ACA = anterior cerebral artcry; IC-Ach = internal carotid-anterior choroidaI junction; LI = lacunar infarction; LOC = loss of consciousness; It = left; it = right.
230
six of these eight patients. A 53-year-old male with bilateral middle cerebral artery aneurysms refused operation, and a 67-year-old male was considered ineligible for operation due to his age, and because of marked arteriosclerosis of his cerebral vessels seen on angiography and multiple lacunar infarctions discovered on CT scan. Three patients with normal CT findings, who underwent operative treatment for middle cerebral artery aneurysms have not received any further medical treatment other than anticonvulsives after surgery. Three other patients were given acetyl salycilic acid postoperatively. There was no surgical morbidity in the six patients. A 62-year-old female had transient arrhythmia postoperatively and developed a small thalamic hemorrhage a year later. All eight patients are well, however, and had no recurrent attacks in the follow-up periods ranging from 2 to 7 years (Table 3). Discussion Unruptured aneurysms are often found by chance, as cerebral angiography is commonly used to investigate intracranial diseases. On the other hand, technical standards in aneurysm operations are markedly improved in the past 20 years and mortality related to the operation itself nowadays is nearly nil with the use of an operating microscope. A~ordingly, recent reports advocated that un~ptured aneurysms should be treated surgically’*3”, since the treat-
ment of aneurysms still presents difficulties when they rupture. It also should be noted, however, that unruptured aneurysms found in patients with ischemic cerebrovascular diseases involve controversial problems in their treatment. Segawa et al.* emphasized that the development of postoperative, ischemic neurological morbidity and other general complications after direct aneurysm surgery are unusually high in these patients. Incidental aneurysms associated with ischemic cerebrovascular diseases are found in 2.6% to 13% of patients with unruptured intracranial aneurysms4*’ and in 25% to 55% of patients with aneurysms discovered incidentally during angiographical investigation of various intracranial diseases or symptoms1,7,a. The incidence in the present study was respectively 23% and 53%. The incidental discovery of such aneurysms appears to be increasing. Since cerebrovascular diseases areone of the pathological processes of the vascular system, additional vascular involvement following surgery may be apt to occur in older patients, as in the case of the 62-year-old patient with arrhythmia and thalamic hemorrhage. This may be especially true in patients with a completed major to moderate stroke. As a matter of fact, however, when treating patients with a mild to transient ischemic stroke and an unruptured aneurysm, we find ourselves confronted with two almost contradictor therapeutic policies, whether to concentrate on pre-
Table 3. Summary of treatment in eight patients with ischemic symptoms. Patient no.
Location of aneurysms bilat MCA’s It MCA It IC-Ach It distal ACA bilat MCA’s It MCA rt MCA It distal ACA
Treatment
neck clipping neck ciipping & ASA neck clipping & ASA neck clipping neck clipping neck clipping & ASA
Recurrence of symptoms
Rest&s
no no no
good good good good* good good good good
II0 il0
no n0
no
Follow-up period (yrs) 7 6 3 6 5 2 4 2
Abbreviations: bilat = bilateral; it = left; rt = right; MCA = middle cerebral artery; ACA = anterior cerebral artery; IC-Ach = internal carotid-anterior choroidal junction; ASA = acetyl salicylic acid. * Patient no. 4 had transient arrhythmia postoperatively and a left small thalamic hemorrhage a year later. 231
venting ischemic symptoms or on preventing an aneurysmal rupture. In such instances in our cases, we first opted for a radical operation of the unruptured aneurysms, and then concentrated on providing full remedies, such as prophylactic antiplatelet drugs. We do not dare to use these drugs alone without treating the aneurysms, although the increase of the risk of subarachnoid hemorrhage by administration of these drugs is unknown. Transient ischemic attack and RIND are reversible while completed strokes indicate cerebral damage that is usually not completely reversible. Therefore it is important to treat them early and to prevent recurrent attacks. We have experienced no postoperative morbidity in any of the six surgically treated patients with TIA and RIND, and obtained satisfactory outcomes. Thus, a radical operation of an aneurysm would be the preferable choice for patients with an unruptured aneurysm and TIA or RIND in order to treat associated ischemic accidents positively. In addition, it seems that the results in such patients differ from those in patients with completed stroke, as shown in the series of Segawa et al.2, although the number of cases is small in the present study. On the other hand, the age of the patient, the angiographical findings of cerebral vessels, the accompanying diseases, and the difficulties of surgery should be always taken into consideration, so as to prevent operative morbidity and postoperative complications. Therefore, the 67-year-old patient in the present study was excluded from operation. Multifactorial decision analysis of the management of incidental aneurysms, recently proposed by Van Crevel et ~i.~, may be helpful for such evaluations. Further, recent reports have noted that intracranial unruptured aneurysms may cause transient neurological symptoms’@‘s. These symptoms may be attributed to cerebral emboli from aneurysms10J2~14~16.Extracranial aneurysms of the internal carotid artery, which are usually large to giant, cause transient ischemic neurological symptoms “-19.Intracranial large or giant aneurysms often have clots in their domes that may migrate to the peripheral portions of the parent arteries and cause ischemic lesions’2-14. Also, several authors indicated that intracranial small unruptured aneurysms could be considered a thromboembolic source8J3,u),2*. 232
Hoffman et al. l3 reported on a case with recurrent TIA’s on the right side and a left unruptured saccular middle cerebral artery aneurysm which was 1 x 1 cm in size. By means of histological verification, they found a thrombus whithin the aneurysm sac and concluded that aneurysms should be included as a rare cause of TIA’s, and that aneurysmal neck clipping should be considered for a patient with TIA’s and an aneurysm that is neurologically located properly, and with no other etiology. Stewart et cd’s also found unruptured saccular aneurysms 3 to 4 mm in size in two patients with transient neurological deficits. The location of the aneurysms matched their symptoms, which disappeared after surgical treatment of their aneurysms. Therefore, they concluded that transient neuroiogical symptoms may be caused by an embolic process that can be attributed to the aneurysm. Likewise, Matsuzaki et uL8analyzed 14 patients with incidental aneurysms and ischemic cerebrovascular disease to ascertain the causal relationship, and indicated that it should be born in mind that an unruptured aneurysm can be a rare cause of TIA. We did not find a neuroradiological or operative evidence for a thromboembolic process in our patients. However, in the three patients with no abnormal finding on CI scans (nos. 2,6 and 7 in Table 2), the location of the aneurysms corresponded to the sides of the transient neurological symptoms, that did not recur in the followup periods from 2 to 6 years after the obliteration of the aneurysm neck and without the administration of acetyl salicylic acid. Therefore, we think that the TIA’s in these three patients were attributable to emboli from the um-uptured aneurysms. No other etiology to account for their symptoms was found. ElleP has recently reported a case in which magnetic resonance imaging delineated an intraluminal clot in a small unruptured middle cerebral artery aneurysm. Magnetic resonance imaging may provide more information about the relationship between unruptured aneurysms and ischemic symptoms. Thus, taking our experience and the findings of others into consideration, surgical treatment of unruptured aneurysms associated with TIA and RIND also would seem to be an appropriate therapy for ischemic symptoms in certain cases.
SAMSON DS,HODOSH RM,CLARK WK. Surgical management of unruptured asymptomatic aneurysms. J Neurosurg 1977; 46:731-4. SEGAWA H,SAITO I,KITAHARAS,SANO K. Treatment Of unruptured aneurysms. In: Proceedings of the Mt. Fuji workshop on CVD, Tokyo, 198759-62. HISISKANEN o. Risk of bleeding from unruptured aneurysms in cases with multiple intracranial aneurysms. J Neurosurg 1981; 55524-6. JOMIN M, LESOIN F, LOZES G, FAWAZ
Y. Unruptured cerebral aneurysms: Clinical analysis of 80 cases and its new classification. Brain and nerve (Tokyo) 1986; 38:693-700.
ASARI s,YAMAMOTO
References
A, VILLE'ITE L.
Surgical prognosis of unruptured intracranial arterial aneurysms. Report of 50 cases. Acta Neurochir (Wien) 1987; 84:85-8. SALAKAR JL. Surgical treatment of asymptomatic and incidental intracranial aneurysms. J Neurosurg 1980; 53:20-l. WIRTH FP, LAWS ER Jr, PIEPGRAS D, SCOT-I RM. Surgical treatment of incidental intracranial aneurysms. Neurosurgery 1983; 12:507-D. LOCKSLEY HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms, and arteriovenous malformations Section V, Part II. J Neurosurg 1966; 25:32168. MATSUZAKI T, FUKUOKA S, WADA K,TAKJSDA R. COinCidental aneurysm and ischemic cerebrovascular disease. Jpn J Stroke (Tokyo) 1981; 3:370-7. VAN CREVEL H,HABBEMA JDF,BRAAKMAN R. Decision analysis of the management of incidental intracranial saccular aneurysms. Neurology 1986; 36:1335-9. ANTUNES JL, CORRELL JW. Cerebral emboli from intracranial aneurysms. Surg Neurol 1976; 6:7-10.
COHEN
MM,HEMALATHACP,D'ADDARIO
RT,DOLDMAN
Embolization from a fusiforrn middle cerebral artery aneurysm. Stroke 1980; 11:158-61. HOFFMANWF,WILSONCB,TOWNSENDJJ. Recurrenttransient ischemic attacks secondary to an emboliiing saccular middle cerebral artery aneurysm. J Neurosurg 1979; 51:103-6. LITTLE JR, LOUIS PST, WEINSTEIN M, DOHN DF. Giant fusiform aneurysm of the cerebral arteries. Stroke 1981; 12:183-8. HW.
STEWART
RM, SAMSON
D, DIEHL J, HINTON R, DITMORE
Unruptured cerebral aneurysms presenting as recurrent transient neurologic deficits. Neurology 1980; 30:47-51. DUNCANAW,RUMIIAUGHCL,CAPLANL. Cerebralembolic disease: A complication of carotid aneurysms. Radiology 1979; 133:379&l. ALEXANDER E Jr,WIGSER SM, DAVIS CH. Bilateralextracranial aneurysms of the internal carotid artery. J Neurosurg 1966; 25:437-42. BODDIE HG. Transient ischemic attacks and stroke due to extracranial aneurysms of the internal carotid artery. Br Med J 1972; 3:802-3. WEBB RC Jr, BARKER WF. Aneurysms of the extracranial internal carotid artery. Arch Surg 1969; 99:501-5. QM.
SAKAKIT,KINUGAWAK,TANIGAKET,MIYAMOTOS,KYOI K, UTSUMI s. Embolism from intracranial aneurysm. J Neurosurg 1980; 53:300;4. ELLER TW. MRI demonstration of clot in a small unruptured aneurysm causing stroke. J Neurosurg 1986; 65:411-2.
233
Kikuo Ohno*, Ryuta Suzuki*, Hiroyuki Masaoka’, ma* *, and Yutaka Inaba*.
Controversy persists regarding the management of unruptured intracranial aneurysms. Unruptured aneurysms are classified into the following three categories l,*: 1) multiple, in~dental aneurysms in patients with a sub~aehnoid hemorrhage; 2) symptomatic aneurysms, presenting neurological symptoms such as cranial nerve palsies; and, 3) incidental a~~~~srns, diagnosed when the patient is u~d~rgoing angiography for tumors, cerebral ischemia, or other various intracranial lesions. Surgical treatment is usually indicated for symptomatic unruptured aneurysms. However, the choice of the most adequate treatment for symptomatic aneurysms discovered incidentally may be difficult, since the natural history of them remains unclear. We report on eight patients with unruptured aneurysms, discovered during ~~giographical investigation of tr~sient ischemic attack (TIA), or reversible ischemic neurological deficit (RIND), and discuss treatment for unruptured aneurysms associated with TIA or RIND.
Between 1981 and 1987, 44 un~ptured aneurysms were discovered in 35 patients. They con-
Yoshiharu
Matsushima*,
Seiji Mon-
Thirty-five patients with unruptured aneurysms were treated between 1981 and 1987. Eight of them had either transient ischemic attacks or reversible ischemic neurological deficits as their presenting s~ptoms. Six of the eight patients underwent direct aneu~sm surgery. Alt eight patients are well, and have had no recurrent attack during the follow-up period ranging from 2 to 7 years. The feasibility af surgical treatment for such aneurysms associated with reversible ischemic symptoms is discussed. Key-words: Unruptured RIND, Surgical treatment.
aneurysm,
TX&
sisted of 17 multiple, incidental aneu~sms in 11 patients with a ruptured aneurysm, 9 symptomatic aneurysms and one incidental aneurysm in nine patients with third nerve palsy or TIA and 17 aneu~sms in 15 patients with intra~r~ni~ lesions, such as a brain tumor, cerebral ischemia, arteriovenous malformation, chronic subdural hematoma, or hypertensive intracerebral hemorrhage (Table 1). The results of our treatment of these aneu~sms proved excellent in 33 patients. As for two patients with multiple, incidental aneu~sms associated with a subarachnoid hemorrhage, their poor neurological con-
* ~e~ur~ent~f ~eur~urge~, Tokyo ~~~~c~~~ Dental ~nive~i~, Tokyo, and * * ~e~a~ent~f City Hospital, Y-n~~~, Japan.
~eurosurge~, F~jiyo~h~~a
Address for correspondence and reprint requem: Kikuo Ohno, Department of Neurosurgery, Tokyo Medical and Delental University,l-5-45 Yushinuz, Bunkyo-ku, Tokyo 113, Japan. Accepted 16.1.89 Clin Neurof ~euro~urg 1989. V&.91-3
229
dition after hemorrhage influenced the outcome. Twenty-five of the 35 patients underwent intracranial surgery and two patients were given a cartoid ligation. There was no operative mortality and the outcomes of 26 of the 27 patients operated on were excellent, although one patient still remained poor after surgery, due to a preoperative poor neurological condition.
Table 1. Summary of 35 patients with unruptured aneurysms Reasons for investigation
No. of patients
Multiple, in&.Iental aneurysms associated with a ruptured aneurysm
11
9
symptomaticaneurysrns ocuIomotor palsy TIA
6 3
Asymptomatic. incidental aneurysms TIA Brain tumor Subcortical hemorrhage AVM Chronic subdural hematoma BinasaIbemhmopGa EnhancedmassonCTscan
15 3 3 2 2 2 1 1 1
Abbreviations: TIA = transient iacbemic attack; RIND = reversible isdmmic neurological deficit; AVM = arteriovenous malformation.
Of the 35 patients, eight underwent cerebral angiography for investigation of cerebral ischemic attacks and were found to have the aneurysms (Table 2). Six of the eight patients suffered from TIA and two had RIND. These patients consisted of four males and four females, and their ages ranged from 45 to 67 years, with an average age of 56 years. The aneurysms were located in the internal carotid artery in one, the middle cerebral artery in seven, and the distal anterior cerebral artery in two. Cerebral angiography demonstrated aneurysms and arteriosclerotic changes in the cerebral vessels but no apparent stenosis or occlusion to cause ischemic symptoms in any of the eight patients. There was no abnormal finding in the extracranial carotid arteries. CT scans revealed single or multiple lacunar infarctions in two patients with RIND and in two with TIA. The lacunar regions were not always related to the distribution supplied by the parent arteries of the aneurysms in these four patients. In three of the four other patients whose CT findings were normal, a middle cerebral artery aneurysm was found on the side contralateral to their transiently paralyzed extremities (patient nos. 2, 6 and 7 in Table 2). No cardiological or medical evidence was found to explain the ischemic symptoms in these three patients. The patients are classified in the category of symptomatic aneurysms in Table 1. Aneurysmal neck clipping was performed in
Table 2. Summary of eight patients with iachemic symptoms. Patient no.
Age/Sex (Years)
ClinicaI symptoms
Type of iscbemia
CT finding
Location of aneurysms
1
53/M
TIA’s
48/F
multiple LI normal
bilateral MCA’s
2 3
67/M
we&neseofIthand n~ofltband LOC, rt bemipkgia, dyaa&ria dyaaf&a, memory
It IC-Ach
4 5 6
62’F 49/M 45/F
TIA TIA
It distal ACA bilateral MCA’s It MCA
7 8
5&F 63&I
LOC, rt hemiparesis It hem&are&s LOC, weakness of rt hand It ImmipIegm numbness and weakneasofrthand
multiple LI LI LI normal
TIA TIA’s
normaI normaI
rt MCA It distal ACA
TIA RIND
It MCA
Abbreviations: TIA = transient ischemic attack; RIND = reversibk iscbemic neurologicaI deficit; MCA = middle cerebral artery; ACA = anterior cerebral artcry; IC-Ach = internal carotid-anterior choroidaI junction; LI = lacunar infarction; LOC = loss of consciousness; It = left; it = right.
230
six of these eight patients. A 53-year-old male with bilateral middle cerebral artery aneurysms refused operation, and a 67-year-old male was considered ineligible for operation due to his age, and because of marked arteriosclerosis of his cerebral vessels seen on angiography and multiple lacunar infarctions discovered on CT scan. Three patients with normal CT findings, who underwent operative treatment for middle cerebral artery aneurysms have not received any further medical treatment other than anticonvulsives after surgery. Three other patients were given acetyl salycilic acid postoperatively. There was no surgical morbidity in the six patients. A 62-year-old female had transient arrhythmia postoperatively and developed a small thalamic hemorrhage a year later. All eight patients are well, however, and had no recurrent attacks in the follow-up periods ranging from 2 to 7 years (Table 3). Discussion Unruptured aneurysms are often found by chance, as cerebral angiography is commonly used to investigate intracranial diseases. On the other hand, technical standards in aneurysm operations are markedly improved in the past 20 years and mortality related to the operation itself nowadays is nearly nil with the use of an operating microscope. A~ordingly, recent reports advocated that un~ptured aneurysms should be treated surgically’*3”, since the treat-
ment of aneurysms still presents difficulties when they rupture. It also should be noted, however, that unruptured aneurysms found in patients with ischemic cerebrovascular diseases involve controversial problems in their treatment. Segawa et al.* emphasized that the development of postoperative, ischemic neurological morbidity and other general complications after direct aneurysm surgery are unusually high in these patients. Incidental aneurysms associated with ischemic cerebrovascular diseases are found in 2.6% to 13% of patients with unruptured intracranial aneurysms4*’ and in 25% to 55% of patients with aneurysms discovered incidentally during angiographical investigation of various intracranial diseases or symptoms1,7,a. The incidence in the present study was respectively 23% and 53%. The incidental discovery of such aneurysms appears to be increasing. Since cerebrovascular diseases areone of the pathological processes of the vascular system, additional vascular involvement following surgery may be apt to occur in older patients, as in the case of the 62-year-old patient with arrhythmia and thalamic hemorrhage. This may be especially true in patients with a completed major to moderate stroke. As a matter of fact, however, when treating patients with a mild to transient ischemic stroke and an unruptured aneurysm, we find ourselves confronted with two almost contradictor therapeutic policies, whether to concentrate on pre-
Table 3. Summary of treatment in eight patients with ischemic symptoms. Patient no.
Location of aneurysms bilat MCA’s It MCA It IC-Ach It distal ACA bilat MCA’s It MCA rt MCA It distal ACA
Treatment
neck clipping neck ciipping & ASA neck clipping & ASA neck clipping neck clipping neck clipping & ASA
Recurrence of symptoms
Rest&s
no no no
good good good good* good good good good
II0 il0
no n0
no
Follow-up period (yrs) 7 6 3 6 5 2 4 2
Abbreviations: bilat = bilateral; it = left; rt = right; MCA = middle cerebral artery; ACA = anterior cerebral artery; IC-Ach = internal carotid-anterior choroidal junction; ASA = acetyl salicylic acid. * Patient no. 4 had transient arrhythmia postoperatively and a left small thalamic hemorrhage a year later. 231
venting ischemic symptoms or on preventing an aneurysmal rupture. In such instances in our cases, we first opted for a radical operation of the unruptured aneurysms, and then concentrated on providing full remedies, such as prophylactic antiplatelet drugs. We do not dare to use these drugs alone without treating the aneurysms, although the increase of the risk of subarachnoid hemorrhage by administration of these drugs is unknown. Transient ischemic attack and RIND are reversible while completed strokes indicate cerebral damage that is usually not completely reversible. Therefore it is important to treat them early and to prevent recurrent attacks. We have experienced no postoperative morbidity in any of the six surgically treated patients with TIA and RIND, and obtained satisfactory outcomes. Thus, a radical operation of an aneurysm would be the preferable choice for patients with an unruptured aneurysm and TIA or RIND in order to treat associated ischemic accidents positively. In addition, it seems that the results in such patients differ from those in patients with completed stroke, as shown in the series of Segawa et al.2, although the number of cases is small in the present study. On the other hand, the age of the patient, the angiographical findings of cerebral vessels, the accompanying diseases, and the difficulties of surgery should be always taken into consideration, so as to prevent operative morbidity and postoperative complications. Therefore, the 67-year-old patient in the present study was excluded from operation. Multifactorial decision analysis of the management of incidental aneurysms, recently proposed by Van Crevel et ~i.~, may be helpful for such evaluations. Further, recent reports have noted that intracranial unruptured aneurysms may cause transient neurological symptoms’@‘s. These symptoms may be attributed to cerebral emboli from aneurysms10J2~14~16.Extracranial aneurysms of the internal carotid artery, which are usually large to giant, cause transient ischemic neurological symptoms “-19.Intracranial large or giant aneurysms often have clots in their domes that may migrate to the peripheral portions of the parent arteries and cause ischemic lesions’2-14. Also, several authors indicated that intracranial small unruptured aneurysms could be considered a thromboembolic source8J3,u),2*. 232
Hoffman et al. l3 reported on a case with recurrent TIA’s on the right side and a left unruptured saccular middle cerebral artery aneurysm which was 1 x 1 cm in size. By means of histological verification, they found a thrombus whithin the aneurysm sac and concluded that aneurysms should be included as a rare cause of TIA’s, and that aneurysmal neck clipping should be considered for a patient with TIA’s and an aneurysm that is neurologically located properly, and with no other etiology. Stewart et cd’s also found unruptured saccular aneurysms 3 to 4 mm in size in two patients with transient neurological deficits. The location of the aneurysms matched their symptoms, which disappeared after surgical treatment of their aneurysms. Therefore, they concluded that transient neuroiogical symptoms may be caused by an embolic process that can be attributed to the aneurysm. Likewise, Matsuzaki et uL8analyzed 14 patients with incidental aneurysms and ischemic cerebrovascular disease to ascertain the causal relationship, and indicated that it should be born in mind that an unruptured aneurysm can be a rare cause of TIA. We did not find a neuroradiological or operative evidence for a thromboembolic process in our patients. However, in the three patients with no abnormal finding on CI scans (nos. 2,6 and 7 in Table 2), the location of the aneurysms corresponded to the sides of the transient neurological symptoms, that did not recur in the followup periods from 2 to 6 years after the obliteration of the aneurysm neck and without the administration of acetyl salicylic acid. Therefore, we think that the TIA’s in these three patients were attributable to emboli from the um-uptured aneurysms. No other etiology to account for their symptoms was found. ElleP has recently reported a case in which magnetic resonance imaging delineated an intraluminal clot in a small unruptured middle cerebral artery aneurysm. Magnetic resonance imaging may provide more information about the relationship between unruptured aneurysms and ischemic symptoms. Thus, taking our experience and the findings of others into consideration, surgical treatment of unruptured aneurysms associated with TIA and RIND also would seem to be an appropriate therapy for ischemic symptoms in certain cases.
SAMSON DS,HODOSH RM,CLARK WK. Surgical management of unruptured asymptomatic aneurysms. J Neurosurg 1977; 46:731-4. SEGAWA H,SAITO I,KITAHARAS,SANO K. Treatment Of unruptured aneurysms. In: Proceedings of the Mt. Fuji workshop on CVD, Tokyo, 198759-62. HISISKANEN o. Risk of bleeding from unruptured aneurysms in cases with multiple intracranial aneurysms. J Neurosurg 1981; 55524-6. JOMIN M, LESOIN F, LOZES G, FAWAZ
Y. Unruptured cerebral aneurysms: Clinical analysis of 80 cases and its new classification. Brain and nerve (Tokyo) 1986; 38:693-700.
ASARI s,YAMAMOTO
References
A, VILLE'ITE L.
Surgical prognosis of unruptured intracranial arterial aneurysms. Report of 50 cases. Acta Neurochir (Wien) 1987; 84:85-8. SALAKAR JL. Surgical treatment of asymptomatic and incidental intracranial aneurysms. J Neurosurg 1980; 53:20-l. WIRTH FP, LAWS ER Jr, PIEPGRAS D, SCOT-I RM. Surgical treatment of incidental intracranial aneurysms. Neurosurgery 1983; 12:507-D. LOCKSLEY HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms, and arteriovenous malformations Section V, Part II. J Neurosurg 1966; 25:32168. MATSUZAKI T, FUKUOKA S, WADA K,TAKJSDA R. COinCidental aneurysm and ischemic cerebrovascular disease. Jpn J Stroke (Tokyo) 1981; 3:370-7. VAN CREVEL H,HABBEMA JDF,BRAAKMAN R. Decision analysis of the management of incidental intracranial saccular aneurysms. Neurology 1986; 36:1335-9. ANTUNES JL, CORRELL JW. Cerebral emboli from intracranial aneurysms. Surg Neurol 1976; 6:7-10.
COHEN
MM,HEMALATHACP,D'ADDARIO
RT,DOLDMAN
Embolization from a fusiforrn middle cerebral artery aneurysm. Stroke 1980; 11:158-61. HOFFMANWF,WILSONCB,TOWNSENDJJ. Recurrenttransient ischemic attacks secondary to an emboliiing saccular middle cerebral artery aneurysm. J Neurosurg 1979; 51:103-6. LITTLE JR, LOUIS PST, WEINSTEIN M, DOHN DF. Giant fusiform aneurysm of the cerebral arteries. Stroke 1981; 12:183-8. HW.
STEWART
RM, SAMSON
D, DIEHL J, HINTON R, DITMORE
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