Factors influencing outcome in surgical clipping of ruptured basilar aneurysms: A 10-year experience

Technical difficulty in clipping ruptured basilar apex aneurysms poses a tremendous decision-making challenge. Because endovascular coiling techniques are increasingly used, it is critical to examine contemporary series of these complex cases with respect to functional outcome. From 1987 to 1997, we treated 547 patients for subarachnoid hemorrhage (SAH), 48 of whom had ruptured basilar apex aneurysms. We retrospectively reviewed medical records and angiographic studies and assessed Glasgow Outcome Scale (GOS) scores at 3 months. Of the 48 patients with ruptured basilar apex aneurysms, 46 were treated by surgical aneurysm clipping (including 9% assisted by hypothermic circulatory arrest), one by wrapping and subsequent Guglielmi detachable coil (GDC) embolization, and one by Hunterian ligation. There was female predominance (37 female, 77%; 11 male, 23%) and the median age was 50 ± 13 years. Favorable 3-month outcome (GOS scores of 1-2) was achieved in 83% (40 patients), whereas 13% (6) had unfavorable outcome (GOS scores of 3-4) and 4% (2) died (GOS score of 5). Admission grade, aneurysm size, patient age, and experience of the surgeon were all important factors associated with poor outcome (GOS scores of 3-5). There was poor 3-month outcome in 16% of goodgrade patients (Hunt and Hess Grades I-III) compared to 25% in poor-grade patients (Hunt and Hess Grade IV; no Grade V patients underwent operation). Aneurysm sizes of less than 10 mm, 11 to 25 mm, and greater than 25 mm were associated with rates of poor outcome of 5%, 22%, and 50%, respectively. In 15% of patients less than 65 years of age there was poor outcome compared to 29% in patients older than 65 years of age. Finally, the incidence of poor outcome was 22% in the 23 patients undergoing surgery between 1987 and 1991 compared to 12% of the 25 patients treated between 1992 and 1997. Of the patients with available angiographic studies, complete obliteration was achieved in 82%. Six- to 8-year followup review of those with residual aneurysms demonstrated no recurrence or growth. Despite technical difficulties, favorable outcome can be achieved by surgical clipping of ruptured basilar apex aneurysms, with decreased rates of unfavorable outcome as surgical experience increases. Admission grade, size of the aneurysm, patient age, and experience of the surgeon should serve as important factors to influence decision making in the management of these aneurysms.