Problems in the Treatment of Asymptomatic Saccular Unruptured Cerebral Aneurysm

We studied problems in the treatment policies from our treatment experience with 229 cases of asymptomatic saccular unruptured cerebral aneurysm. We used clipping or coiling as needed where the aneurysm was larger than 3 mm, or was located in the dura, and the patient was younger than 70 years, had no serious general disease and had given informed consent. Clipping was used in 170 cases. The mean age was 57.7 years. In 1 case of a high-positioned basilar tip aneurysm, clipping was considered difficult during operation, so it was changed to coiling. Surgical complications were found in 9.4% of cases (transient: 5.3%, permanent: 4.1%). Venous damage occurred in 5 cases, chronic subdural hematoma in 3 cases, memory loss in 3 cases, tight clipping in 2 cases, aggravation of existing cerebral infarction in 1 case, diminution of vision in 1 case and spasm in 1 case. There were no deaths. In the cases of multiple aneurysm, complications were found frequently when surgery was done in 1 session. Coiling was used in 16 cases. The mean age was 63.3 years. In 1 case of a relatively wide neck basilar tip aneurysm, the stability of the coil was poor, so coiling was changed to clipping. Two cases required blood transfusion or suturing of blood vessels because of hematoma at the puncture site. In 1 case, a cholesterol crystal embolism developed. Combined treatment by clipping and coiling was used in 2 cases. Neither case was problematic. Conservative treatment was used in 41 cases. The mean age was 64.3 years. Sixteen cases were treated conservatively because the patients were older than 70 years. The remaining 25 cases were younger than 70 years but were treated conservatively because the aneurysm was located extradurally (10 cases), serious medical complications were found (5 cases) or treatment was indicated but no informed consent was obtained (10 cases). The aneurysm ruptured and the patient died in 2 cases in which no informed consent was obtained. Many of the complications in clipping are preventable, so more careful operative procedures are needed. With coiling, complications attendant upon catheterization pose problems. In 2 cases in which the conservative treatment was not given because informed consent was not obtained, the aneurysm ruptured and the patient died. A more positive attitude about obtaining informed consent on the part of neurosurgeons may be needed.