Jarl Rosenørn

Clinical Features and Outcome in 48 Patients with Unruptured Intracranial Saccular Aneurysms: A prospective consecutive study

During a 5-year period (1978-1983) the clinical features and operative morbidity/mortality were registered prospectively for all patients in Denmark with an unruptured symptomatic (27 patients) or incidental (21 patients) intracranial saccular aneurysm. A follow-up examination was performed 2 years after diagnosis of the aneurysm. Thirty symptomatic aneurysms in 27 patients most frequently involved the visual pathways or ocular motility (66%). The median diagnostic delay for patients with impaired visual acuity was 7 months but only 14 days for patients with impaired ocular motility. The localisation of the 30 symptomatic and 23 incidental aneurysms were: internal carotid artery (73% approximately 35%), anterior communicating artery (3% approximately 26%) and middle cerebral artery (7% approximately 35%). The diameters of 73% of the symptomatic aneurysms were greater than 10 mm, while the diameter of 74% of the incidental aneurysms were below 10 mm. The total operative morbidity and mortality were 15% and 4%, respectively. The mortality rate in the follow-up period was 10-11% mainly due to fatal bleeding from unoccluded aneurysms. In 21 survivors, a normal mental status was found in 43% and mild dementia was found in another 43%. The impaired visual acuity was unchanged in 67% of patients, while the ocular motility had normalised in 75%. A normal daily functional capacity was enjoyed by 57% while 43% had a moderate reduction, mostly due to visual disturbances.

Unruptured Intracranial Aneurysms: An Assessment of the Annual Risk of Rupture Based on Epidemiological and Clinical Data

From autopsy and neuroradiological studies a maximum prevalence of unruptured intracranial aneurysms (UA) of 0.5% in the general population is revealed. Studies concerning the incidence of aneurysmal subarachnoid haemorrhage (SAH) revealed 10 cases per 100,000 inhabitants per year. From these epidemiological parameters a minimum annual risk of 2% of rupture of an UA is calculated. It is in accordance with clinical studies, which also demonstrated an annual risk of UA rupture of at least 2%. No critical size of the UA predisposing to rupture has been found. Operation on diagnosed UA is recommended because of the serious prognosis after aneurysmal SAH (morbidity 20%-25% and mortality 50%-60%) and because the morbidity (4%) and the mortality (0%) after operative treatment of UA are very low.

Intracranial saccular aneurysms results of treatment in 851 patients

SummaryThe series studied comprises all 851 patients with symptom-producing intracranial saccular aneurysms admitted to the departments of neurosurgery in Denmark in the five-year period of 1970–1974. The series was divided into seven clinical stages according to Hunts classification. More than half of the patients were grouped in stages IV and V (Hunt grade 2–3). Of the patients, 76% were found primarily suitable for operation. The mortality within the individual stages was to a great extent independent of the time of operation.A total of 94% of the aneurysms were localized within the region of the carotid artery, with a roughly equal distribution among the internal carotid, anterior communicating, and middle cerebral arteries. Multiple aneurysms were found in 19% of the patients subjected to panangiography.There was a distinct correlation between the severity of the spasms and the clinical condition. The course of operation was complicated in 49% of the patients, the complications being equally distributed within the various clinical stages. The mortality for the patients who underwent operation (total 567) was 32%, and 80% of the deaths were due to direct or indirect consequences of aneurysmal bleeding.At the follow-up performed two to seven years after operation, 52% of the survivors were fully capacitated, 20% were partly capacitated, and 28% were incapacitated. Based on a retrospective analysis, we have started a comprehensive prospective study with registration of available parameters in patients with saccular aneurysms admitted to all departments of neurosurgery in Denmark.

The prognostic significance of intracerebral haematoma as shown on CT scanning after aneurysmal subarachnoid haemorrhage

In a prospective study of 1076 consecutive patients with aneurysmal subarachnoid haemorrhage (SAH), CT was carried out in 815 patients. CT visible intracerebral haematoma (ICH) was found in 42.6% of the 815 patients. There were no differences in age, pre-existing hypertension or sex between patients with or without ICH. Patients with ICH were in poorer clinical condition on admission, and had a poorer mental outcome and a higher mortality at the 2-year follow-up examination compared with patients without ICH. Of the 491 operated patients, there were in every group according to the clinical condition on admission fewer patients with a normal mental outcome and more fatal cases if an ICH was present after aneurysm rupture. This indicates that the acute brain dysfunction from SAH complicated by ICH is more likely to be followed by permanent cerebral damage compared to the corresponding acute cerebral dysfunction from SAH without ICH.

Seasonal variation of aneurysmal subarachnoid haemorrhage

SummaryIn a prospective consecutive series of 1,076 patients with aneurysmal subarachnoid haemorrhage (SAH) admitted to the 6 Danish neurosurgical departments in the 5-year period April 1, 1978 to March 31, 1983 a significantly higher seasonal incidence of SAH was seen during spring and autumn compared to summer and winter. No significant seasonal differences in monthly mortality or between females and males were registered. Contrary to several other studies concerning cerebral apoplexy excluding SAH no explanation to the seasonal variation was obtained from differences in weather conditions. A correlation between seasonal variation of aneurysm rupture and physical activity is possible.

Clinical features and outcome in females and males with ruptured intracranial saccular aneurysms

Of 1076 patients with aneurysmal subarachnoid haemorrhage 674 were females and 402 males. No significant differences between females and males were seen as regards age, clinical condition on admission, pre-existing arterial hypertension and number of rebleeds. Angiographically demonstrated vasospasm was seen with a significantly higher incidence in females (p < 0.05) which may possibly explain a significantly poorer outcome in females compared with males (p < 0.05), despite the much higher rate in females of internal carotid artery aneurysms which have a significantly better prognosis compared with aneurysms at other sites.

Patients with ruptured intracranial saccular aneurysms: Clinical features and outcome according to the size

In the prospective consecutive Danish Aneurysm Study 192 patients (19%) had a ruptured intracranial aneurysm (RA) with a maximum diameter < 5 mm (small). In 524 (51%) and 306 patients (30%) the size was 5-10 mm (medium) and 11-24 mm (large), respectively. More patients with large RA (35%) were unconscious more than 1 h after the bleeding and had more CT-visualized haematomas (49%) compared with the patients with small RA (28 and 34%) and medium RA (27 and 37%). After 2 years, more patients with small RA and medium RA had resumed their previous occupation (49 and 49%), regained a normal daily functional capacity (55%, 55%) and normal mental outcome (29 and 32%) compared with the patients with large RA (34, 44 and 23%). The mortality was 47, 39 and 51% for patients with small, medium and large RA, respectively. With also a very serious prognosis after rupture of aneurysms of 10 mm or less and even less than 5 mm we also recommend surgical treatment of unruptured aneurysms of these sizes.

The influence of unruptured intracranial aneurysms on life expectancy in relation to their size at the time of detection and to age.

A theoretical evaluation of the lifetime probabilities of different outcomes in patients with unruptured intracranial aneurysms (UA) has been made using a life table method. The calculations were performed for aneurysm presenting ages from 20 to 70 years of age for men and women assuming an annual risk of aneurysm rupture of 1%, 2% and 3% and a rate of mortality after rupture of 50%. At 10, 20, 30, 40, 50 and 60 years after the diagnosis of an UA the probability of survival without bleeding is reduced below the expected probability of survival according to the life tables by the following percentages (assuming an annual risk of bleeding of 2%): 19%, 34%, 46%, 56%, 64% and 72%, respectively. A survey of the lifetime probabilities of four different outcomes for patients with an UA indicates a substantial reduction in life expectancy after the diagnosis of an UA. In most ages the surgical risks are more than balanced by the risks associated with an untreated unruptured aneurysm.

The impact of rebleeding on the life time probabilities of different outcomes in patients with ruptured intracranial aneurysms. A theoretical evaluation.

SummaryIn order to strengthen patient-information a theoretical evaluation of the impact of rebleeding on the life time probabilities of different outcomes in patients with an aneurysmal subarachnoid haemorrhage (SAH) has been made using a life table method. The calculations were performed for SAH-presenting ages from 20 to 70 years assuming a rate of rebleeding of 50% in the first 6 months after the initial bleeding with a mortality rate of 70%, and the following years an annual rate of rebleeding of 3%, and with a mortality rate of 60%. A survey of the life time probabilities of the 4 different outcomes after an aneurysmal SAH shows the great life time reducing effect of rebleedings in all SAH-presenting ages.

Antifibrinolytic Therapy in Patients with Aneurysmal Subarachnoid Haemorrhage

In a prospective consecutive non-randomised study including 1076 patients with ruptured intracranial aneurysms 205 patients received epsilon aminocraproic acid (EACA) and 871 did not. No significant differences between the two groups concerning clinical condition on admission, sex, age, localisation and size of the aneurysms were seen. No cases of rebleeding (RB) were observed within the first 4 days in the EACA treated patients, but within the first 48 hours, which is the optimal period recommended for operation of patients in good clinical condition, this difference of the rates of RB between EACA treated and not treated patients is not significant. A significantly lower rate of RB was observed in the EACA group within the first 2 weeks, but no significant differences in morbidity and mortality were found at the 2-year follow-up examination.