Surgically treated cerebral aneurysms in south Trinidad: twenty years experience 1986-2005.

INTRODUCTION: For many years the treatment of cerebral aneurysms was surgical - clipping or wrapping. In recent years however, interventional radiology is available with techniques of coiling and stenting. The current treatment of any aneurysm is based on a combination of interventional and surgical techniques and in many cases the final treatment is interventional. It may be useful to document surgically treated aneurysms at San Fernando General Hospital serving a population area of half million in south Trinidad in the twenty years 1986-2005 before the advent of interventional radiology in Trinidad which became available in late 2005

The distribution of intracranial aneurysms at the University Hospital of the West Indies

Aneurysms of the brain were probably first recognized at necropsy by Morgagni in the 18th century. Autopsy data are at variance with the incidental findings in infancy and later life. Factors such as growth of aneurysm, size at equilibrium, clinical profile and radiological methods of detection play a role in determining the probability of an aneurysm being present and detectable in an individual at a given time. Most aneurysms do not rupture. Most intracranial aneurysms are found on the Circle of Willis (90 percent), the anterior communicating artery being most often quoted as the predominant site (30 to 35 percent). We have reviewed the cases presenting to the University Hospital of the West Indies between 1954 and 1997 in order to determine the distribution of intracranial aneurysms at that institution and potential management implications.(AU)

A comparison of early versus delayed surgery for ruptured intracranial aneurysms - abstract

The timing of surgical clipping for ruptured intracranial aneurysms has been a subject of debate for many years. Initial attempts at early surgery (within 24-72 hours) had disastrous results and led to the standard practice of delaying surgery for 7-10 days. The use of antifibrinolytic agents during this waiting period was shown to decrease the incidence of rebleeding but also seemed to cause increased frequency of ischaemic deficits and hydrocephalus. With the refinement of microneurosurgical techniques, early surgery for intracranial aneurysms underwent a rebirth in many centres over the last few years. This paper presents the experiences with aneurysm surgery at the Neurosurgical Unit Halifax, Nova Scotia over the four-year period 1984-1987. Ruptured aneurysms lead to subarachnoid haemorrhage in over 50 percent of the cases, arteriovenous malformations comprised 10 percent, and subarachnoid haemorrhage with normal angiography 25 percent of the total cases. During the period under review 25 patients presented with ruptured vertebrobasilar aneurysms and 211 patients presented with ruptured supratentorial aneurysms. The latter group form the basis for comparing results of early vs. delayed clipping for ruptured aneurysms. Despite the fact that the series comprised a consecutive, unmatched group of patients without any attempt at randomization, there were striking similarities in the mean ages, sex distribution and distribution of aneurysms at the various sites in the two groups being compared. Sixty-nine patients presented in good clinical condition after aneurysmal subarachnoid haemorrhage (Hunt & Hess Grades I and II). Twenty-nine patients (mean age 44.5 years) underwent early surgery and 40 (mean age 45 years) had delayed surgery. Despite the higher rebleed rate in the delayed group (12.5 percent vs. 0 percent) there was no statistically significant difference in the eventual outcome between the two groups (mortality rate and the quality of survival). Eighty-five of the patients had excellent outcomes. However, the length of hospital stay was significantly shorter in the patients operated on early (17 days vs. 30 days). Symptomatic vasospasm (40 percent) and hydrocephalus (10 percent) occurred with similar frequencies in both groups. Fifty-two patients presented in poor clinical condition after aneurysmal subarachnoid haemorrhage (Hunt & Hess Grades III and IV). Twenty-three patients (mean age 49.5 years) had early surgery and 29 patients (mean age 53 years) had delayed surgery. The mortality rate (approximately 25 percent) was similar in both groups. Rebleeding was the culprit in the delayed group (24 percent) whereas the surgical mortality was 26 percent in the early group. There was an equally high incidence of symptomatic vasospasm and hydrocephalus in both groups. The quality of survival was better in the early group but achieved statistical significance only in the number of patients making "excellent" recoveries (43 percent vs. 17 percent). The numbers of patients however were small. Aggressive treatment of acute hydrocephalus by ventricular drainage played a large part in improving the clinical status prior to surgery in the early group. As with previous studies (including a large co-operative series), we have been unable to show a really convincing advantage of early aneurysm surgery over delayed surgery if mortality rate and quality of survival are used as the basis of comparison. Clearly, a large scale randomized trial would have to be launched to answer this question conclusively. To answer the criticisms of ardent proponents of delayed surgery, however, we have confirmed that early surgery provides at least as good results. We have not found early surgery technically more difficult. It allows removal of large collections of subarachnoid blood and aggressive treatment of cerebral vasospasm and hydrocephalus and at the same time prevents rebleeding from the aneurysm. We feel early surgery will become more frequently used as newer methods of preventing cerebral vasospasm are discovered. The implications of our experiences to the situations that obtain in the Caribbean will be discussed (AU)

Berry aneurysms of the circle of Willis: results of an autopsy study at the University Hospital of the West Indies

A detailed study of berry aneurysms of the Circle of Willis, in a consecutive autopsy series, was conducted at the University Hospital during the 10-year period 1973 to 1982. There were 70 patients with berry aneurysms in a total of 3,650 autopsies, giving a prevalence of 1.9 percent. Of 70 cases, 66 had ruptured, all of which were fatal. In 75 percent of cases, the diagnosis was made at post-mortem. Sixty percent of patients had associated hypertension. Physical stress did not appear to be a precipitating factor in causing rupture. Aneurysms occurred equally in men and women but multiple aneurysms occurred most commonly in elderly hypertensive women. The peak age at occurrence was in the third and fourth decades. The majority of aneurysms (91 percent) were located in the anterior circulation, and 37 percent of those that had ruptured were situated in the middle cerebral artery. The results of our study are similar to those found in other autopsy series, thus defying the general opinion that berry aneurysms are uncommon in our population since many of the cases were undiagnosed during life (AU)

The syndrome of inappropriate secretion of antidiuretic hormone, associated with cerebral aneurysm

The case is presented of a 69-year-old woman with a long standing lesion at the base of the brain who terminally developed the classical findings of the inappropriate secretion of antidiuretic hormone. It is postulated that the lesion, in close proximity to the pituitary stalk, could have acted as an irritative focus, resulting in over-production of antidiuretic hormone (AU)