Surgery of Cerebral Aneurysms and Postoperative Changes of Brain Substance due to Retraction

I.M. Godkov, V.V. Krilov

Sklifosovsky Research Institute of Emergency care, Moscow, Russia
Moscow State Medical-Stomatologic University, Moscow, Russia

 

The study goal has been determining an effect of brain retraction on development of ischemic complications, as well as postoperative outcomes.

Material and Methods. We carried out retrospective analysis of surgical treatment of 301 cases with subarachnoid hemorrhage (SAH), caused by a rupture of cerebral aneurysm. Mean age was 46.7±11.6 years. There were 149 males and 152 females. According to Hunt-Kosnik scale, a degree of state severity was Ia-III in 280 cases (93%) and IV-V in 21 patients (7%). Preoperative examination included cerebral angiography, CT of the brain, electroencephalography and transcranial Doppler. Open operations were performed on 1st-21st day after SAH in 192 cases (63.8%) and on the 22nd day and later in 109 cases (36.2%). Postoperative dynamics of a neurological state and outcomes were analyzed on the basis of CT data and the Glasgow Coma Scale (GCS), respectively.

Results. According to CT data, 34 (11.3%) out of 301 cases had preoperative changes, caused by brain retraction. They manifested themselves in foci of edema-ischemia with hemorrhagic soaking, which were located on a basal surface of the brain in projection of a surgical approach. Neurological disorders, represented by inhibited consciousness and focal hemispheric symptoms, were revealed in 28 (82%) out of 34 cases with changes due to brain retraction. There was no reliable dependence of outcomes on these changes. However, one could watch increase of a number cases with outcomes of the I, III and IV degree (according to GCS). A risk factor the above changes was brain retraction with duration of 110±20 min and more (R=0.19; p<0.04).

Conclusion. Intraoperative duration of brain retraction should be limited up to 90 min. If more durable retraction is necessary, it should be continued after weakening of spatulas pressure in order to provide brain reperfusion.