Management cerebraler Aneurysmen - Erfassung des Therapieverlaufs in einer flexiblen Datenbank

INTRODUCTION The neurosurgical clinic and the neuroradiologic department of Philipps-University Marburg are specialised in diagnosis and therapy of neurovascular diseases. The neurosurgeons are particular skilled in skull-base-surgery. From May 1997 to December 1999 in total 223 patients with either cerebral Aneurysm (160 patients) or subarachnoid hemorrhage (SAB) of other cause (63 Patienten) were hospitalised. These patients formed the completely unselected population of the study. The study aimed to characterise this population and report their short-term outcome. METODS AND PATIENTS Data was acquired with a self-built electronic database. The database consits of linked tables and works with predefined values, automatic calculating and counting, selecting maximum settings. To take full use of the data summarising and cross-tables were implemented to automaticially group and count data. The patients with aneurysm have been grouped in ?local patients? and ?Cerebrovascular-Center Patienten? (CV-Patients) regarding to their address. The average age of patients with aneurysms was 49,1 (+/-14,9) years; complies to literature [61; 82; 93]. 2,5% of all and 0% of local patients were 18 years or younger; literature 0,5% [83]. 70% of patients were female; literature about 60% [43; 83]. CV-patients had significantly more often aneurysms located either near the skull-base (proximal A. carotis interna=ACI 24%) or in the vertebrobasilar circulation (35%) than local patients (8% / 18%); literature: posterior location 6-10% in operativ [61; 82; 181], 28-57% in interventional studies [21; 109; 175]. Admission of patients with posterior and skull-base aneurysms from more distant parts of the country is most likely caused by the combination of sophisticated neurovascular and neurosurgical experience. RESULTS COMPARED WITH PUBLICATIONS Patients with ruptured aneurysm were on discharge in 26% mild, in 22% severely handicaped or vegetative; literature: 9-17% mild [51; 82; 90; 131], 7-21% severely handicaped or vegetative [43; 51; 90; 131]. The mortality of our patients was 7,4%; Literatur mainly >20% [24; 43; 55; 82; 104; 134; 152; 158], within selected populations 16-18% [51; 90; 102], 8,4% [126], even 3,5% [131]. Patients with unruptured aneurysm were on discharge in 14,3% mild, in 11,4% severely handicaped, no patient died; literatur: Mortality 0-2,3% [53; 74; 86; 117; 141], morbidity 4-6% [51; 90; 102], but: Need for rehabilitation in 16,2% [74]. Our morbidity was higher as we didn?t apply any exclusion criteria and messured outcome early, morbidity is decreasing in the first months [43; 131; 139; 163]. Morbidity und mortality of operative und neurovascular treated patients were close to those of the total population. Single exeption: Operation 32%, intervention 14%, total population 26% mild handicapes with ruptured aneurysms. Our patients had low mortality irrespective of the location of their aneurysms. With aneurysms of the posterior circulation and of the carotid artery (including many proximal ACI aneurysms) our patients suffered less complications than those in published studies. Not only interventionel, also operative outcome was with posterior located aneurysms as good as with anterior aneurysms; contrary to literature [60; 82; 134; 139; 171]. The most likely reason for the good results with aneurysms to which a bad prognosis is often attributed is the interdisciplinary approach and the specialisation on skull-base operations in neurosurgery. CONCLUSION Every therapeutic approach shows good results when the correct indication is applied: Operativ therapy is gold standart for cerebral aneurysm and always indicated if none of the alternative therapeutic options offers lower longterm morbidity. Neuroradiologic therapy is less invasive but long term data on efficiancy is still laking. Intervention should therefore be considered if the aneurysm is e.g. posterior or proximal located or if the patient is to poor to stand an operation. Conservative therapy ist indicated, if the risk of active therapy is higher than the long term risk of SAH; e.g. extradural ACI aneurysms or short life expectancy. We don?t think endovascular and operativ therapy should be compared directly, as different indications apply. Some articles support our view [163]. A comparison of different regimes, using different indications is required, a simple comparison of neurovascular and neurosurgical results not helpful. Outcome of all aneurysm patients, not only the surgical or interventional treated ones matters [125]. Only a prospective, long term follow up multicenterstudy with randomising patients not to different therapies but to different management regimes, each implementing opera-tive, interventional and conservative therapy, will show how to treat most succesfull.