(4.8%) patients. Temporary clip was used in 55 (44%) patients either during the dis- section or just before final clipping of the aneurysm. For giant aneurysms, multiple clips were used to reconstruct the par- ent vessel and its branches and maintain their patency. No patient required parent artery ligation with a revascularization procedure. Vessel patency was assessed using intraoperative angiography in three patients and using ICGA during the latter part of the series in 92 (73.6%) patients. Postoperative angiography was performed in 100 (75%) patients and cor- related well with ICGA in all cases. In two patients, a small residual neck (<5%) was visualized on postoperative angiography. These patients were followed-up, and there was no increase in the residual neck size in subsequent angiograms. COMPLICATIONS Complications and outcome of pa- tients are listed in Table 2. Clinical vaso- spasmwas managedwith triple H therapy and intra-arterial nimodipine infusion whenever deemed necessary. Speech and motor deficits improved completely in all patients, except in one patient who had persistent dysphasia at 12 months follow- up. Only five (4%) patients required ven- triculoperitoneal shunting for permanent CSF diversion. Postoperative meningitis was successfully treated with intravenous antibiotics. One patient with Hunt and Hess grade 5 died in the postoperative period due to multiple cerebral infarcts. OUTCOME
Figure 1: Shows preoperative anteroposterior (a), lateral (b), postoperative lateral (c), and (d) images of a patient with right MCA bifurcation aneurysm. The small perforator arising from the neck of the aneurysm is seen filling in the postoperative angiogram and is indicated by blue arrow.
had a worse outcome when compared to the patients with- out hematoma in the initial CT scan (P<0.001). There was no significant difference in outcome between patients with history of smoking, hypertension or diabetes mellitus, and those without these risk factors (Table 1). History of seizure, side (left or right), location (pre-bifurcation, bifurcation, or post bifurcation), intraoperative rupture, and use of tempo- rary clip during surgery did not have a significant difference on the final outcome at follow-up. Patients with bilateral MCA aneurysms and multiple intracranial aneurysms did not have a significantly different outcome compared to those with single aneurysm. CASE ILLUSTRATIONS Case 1 A 59-year-old lady was referred by a physician for management of a right MCA bifurcation aneurysm that was
Follow-up modified Rankin scores (mRS) were avail- able for 79.2% (52 patients); 55.3% had at least one-year follow-up (mean duration 34months). Angiographic follow- up was available for 45.4% patients. At last follow-up, 83.8% patients had good outcome (mRS 0 and 1), and 16.2%had an unfavorable outcome (mRS 2 to 6). Of the 45 patients in whom at least one-year angio- graphic follow-up was available, 97.7% showed complete obliteration of the aneurysm. Patients who were in a good clinical grade (Hunt and Hess 0 to 2) preoperatively had good outcome at follow-up, and the difference was signifi- cant (P<0.001). Patients with unruptured aneurysms had a better outcome at follow-up when compared to patients with ruptured aneurysms, although the difference was not significant (P=0.017). Patients with intracerebral hematoma
J La State Med Soc VOL 166 July/August 2014 163
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