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(Stroke. 1999;30:1730-1731.)
© 1999 American Heart Association, Inc.
Letters to the Editor |
Trend in Outcome of Cerebral Aneurysmal Rupture Since 1985: A Proposal for Future Treatment
Department of Neurosurgery, Yamaguchi University, School of Medicine, Yamaguchi, Japan
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Introduction |
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 Top Introduction References |
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To the Editor:
Since 1985, we have been carrying out a population-based study of
cerebral aneurysms in the Yamaguchi prefecture of Japan. The
population of the area is approximately 1.5 million and has changed
little over the last 15 years. The crude annual incidence rate of
aneurysmal rupture has gradually increased from 1985 to 1997,
from 12.9/100 000 population in 1985 (95% CI, 11.2 to 14.8) to
15.5/100 000 in 1997 (95% CI, 13.5 to 17.8).1 Any
patient with cerebral aneurysmal rupture in Yamaguchi was
admitted to one of 28 neurosurgical centers, where surgery was
performed by well-trained neurosurgeons certified by the Japanese
Neurosurgical Society. Our interest has focused on whether the overall
management outcome for cerebral aneurysmal rupture, which is a
severe type of intracranial hemorrhage with high mortality, has
improved as a result of recent advances in surgical and management
techniques.2 The 3119 patients who were admitted with
cerebral aneurysmal rupture between 1985 and 1997 were enrolled
in the Yamaguchi Data Bank of Cerebral Aneurysm. The outcome
was estimated in terms of the Glasgow Outcome Scale3 at 6
months after aneurysmal rupture. The outcome trend is shown in
the
Figure
.
The proportion of patients with a favorable outcome (good recovery or
moderate disability) relative to that of patients with an unfavourable
outcome (severe disability, persistent vegetative state, or death) did
not change significantly during these 13 years.
Multivariate analysis was applied to these 3119
patients to determine which factors had the greatest influence on
outcome. Among 11 possible factors—patient age, sex, neurological
grade on admission, thickness of subarachnoid
hemorrhage, side of aneurysmal rupture,
aneurysmal location and size, number of aneurysms,
rebleeding, symptomatic cerebral vasospasm, and
hydrocephalus—the most important was the neurological grade on
admission, which was assessed in terms of Hunt and Kosnik (H&K)
grade.4 The trend for the proportion of patients with
severe aneurysmal rupture (H&K grades IV and V) and that for
patients with an unfavorable outcome were parallel (Figure). The next
most important factor was the occurrence of symptomatic
cerebral vasospasm, followed by a high patient age. Among the 3 most
important factors, severity of aneurysmal rupture and patient
age cannot be modulated by medical intervention. With regard to
cerebral vasospasm after aneurysmal rupture, no established
treatment for suppression of cerebral vasospasm has yet been developed,
although efforts to do so are continuing worldwide. Accordingly, we
anticipate that the outcome of cerebral aneurysmal rupture will
not improve dramatically in the near future. Recently, a screening
system known as "Brain Check-Up," for detection of unruptured
cerebral aneurysms by use of MR angiography, has been developed
in Japan.5 Cerebral aneurysms 5 mm or larger
can be easily detected by MR angiography. The operative outcome of
unruptured cerebral aneurysms is generally
excellent1 5 and the cost of performing the treatment is
much less than that for treating ruptured cerebral aneurysms.
Therefore, we propose that the screening system for detecting
unruptured cerebral aneurysms warrants further development and
that treatment involving aneurysmal neck clipping or
endovascular treatment to prevent rupture should be carried out if the
patient is aged <65 years.6 However, the cumulative rate
of rupture of cerebral aneurysms is less than that reported
previously.7 The issues requiring most urgent evaluation
are the size, shape, and location of unruptured cerebral
aneurysms that should be treated aggressively.
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References |
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TopIntroductionReferences |
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1. Yamashita K, Kashiwagi S, Kato S, Takasago T, Ito H. Cerebral aneurysms in the elderly in Yamaguchi, Japan: analysis of the Yamaguchi Data Bank of Cerebral Aneurysm from 1985 to 1995. Stroke.. 1997;28:1926–1931.
2. Kassell NF, Helm G, Simmons N, Phillips CD, Cail WS. Treatment of cerebral vasospasm with intra-arterial papaverine. J Neurosurg.. 1992;77:848–852.[Medline] [Order article via Infotrieve]
3. Jennet B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet.. 1975;1:480–484.[Medline] [Order article via Infotrieve]
4. Hunt WE, Kosnik EJ. Timing and preoperative care in intracranial aneurysm surgery. Clin Neurosurg.. 1974;21:79–89.[Medline] [Order article via Infotrieve]
5. Nakagawa T, Hashi K. The incidence and treatment of asymptomatic, unruptured cerebral aneurysms. J Neurosurg.. 1994;80:217–223.[Medline] [Order article via Infotrieve]
6. Chang HS, Kirino T. Quantification of operative benefit for unruptured cerebral aneurysms: a theoretical approach. J Neurosurg.. 1995;83:413–420.[Medline] [Order article via Infotrieve]
7.
The International Study of Unruptured Intracranial
Aneurysms Investigators. Unruptured intracranial
aneurysms: risk of rupture and risk of surgical intervention.
N Engl J Med.. 1998;339:1725–1733.
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  T. Vogel, R. Verreault, J.-F. Turcotte, M. Kiesmann, and M. Berthel Review Article. Intracerebral Aneurysms: A Review With Special Attention to Geriatric Aspects J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2003; 58(6): M520 - 524. [Abstract] [Full Text] [PDF]
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 Y. Yoshimoto, K. Yamashita, S. Kashiwagi, and S. Kato Treatment for Ruptured Aneurysms and Screening for Unruptured Aneurysms • Response Stroke, December 1, 1999; 30 (12): 2759 - 2768. [Full Text] [PDF]
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