Clinical Analysis of Ruptured Middle Cerebral Artery Aneurysm with Intrasylvian Hematoma

초록

Purpose: The clinical course and outcome of ruptured middle cerebral artery (MCA) aneurysm with intrasylvian hematoma is generally poor than those of other subarachnoid hemorrhage (SAH). The purpose of this study is to analyze the clinical characteristics and prognosis in the patients, especially in compare with intraparenchymal hemorrhage or diffuse SAH. Materials and Methods From January 2009 to December 2012, we treated all 55 patients in ruptured MCA aneurysms by surgical clipping. We classified MCA aneurismal SAH into three types, which are diffuse SAH, intraparenchymal hematoma, and intrasylvian hematoma on the basis of computerized tomography (CT) findings. Intrasylvian hematoma (ISH, n=25) and intratemporal hematoma (ITP, n=5) group were defined as hematoma located in the sylvian fissure or temporal parenchyme larger than 30 mm diameter respectively, and the others were classified as diffuse SAH group (n=25). Results The poor grade SAH (Hunt and Hess 4 or 5) was prominent in ISH group (40%). The favorable result (Glasgow outcome scale, GOS 4 or 5) was found in 9 patients (36%) of ISH groups in compare with 21 patients (84%) of diffuse SAH groups. In three patients of ISH group, decompressive craniectomy within five days after clipping surgery was necessary because of enlargement of hematoma and brain swelling without evidence of aneurismal rebleeding, and the clinical outcomes were unfavorable (GOS 1, 3 and 5) Conclusion ISH group showed poor initial status and outcome, and is characterized by progression of brain edema surrounding the sylvian fissure, and increased intracranial pressure (ICP). Effective removal of blood clot is very difficult in ISH owing to fibrous adhesion of clots to small vessels, and it makes postoperative clinical course poor. The venous injury or brain retraction should be minimalized in surgical clipping to prevent progression of brain edema, and, if necessary, decompressive craniectomy be considered in management of I