Impact of Cardio-Pulmonary and Intraoperative Factors on Occurrence of Cerebral Infarction After Early Surgical Repair of the Ruptured Cerebral Aneurysms

OBJECTIVE: Delayed ischemic deficit or cerebral infarction is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study is to reassess the prognostic impact of intraoperative elements, including factors related to surgery and anesthesia, on the development of cerebral infarction in patients with ruptured cerebral aneurysms. METHODS: Variables related to surgery and anesthesia as well as predetermined factors were all evaluated via a retrospective study on 398 consecutive patients who underwent early microsurgery for ruptured cerebral aneurysms in the last 7 years. Patients were dichotomized as following; good clinical grade (Hunt-Hess grade I to III) and poor clinical grade (IV and V). The end-point events were cerebral infarctions and the clinical outcomes were measured at postoperative 6 months. RESULTS: The occurrence of cerebral infarction was eminent when there was an intraoperative rupture, prolonged temporary clipping and retraction time, intraoperative hypotension, or decreased O(2) saturation, but there was no statistical significance between the two different clinical groups. Besides the Fisher Grade, multiple logistic regression analyses showed that temporary clipping time, hypotension, and low O(2) saturation had odds ratios of 1.574, 3.016, and 1.528, respectively. Cerebral infarction and outcome had a meaningful correlation (gamma=0.147, p=0.038). CONCLUSION: This study results indicate that early surgery for poor grade SAH patients carries a significant risk of ongoing ischemic complication due to the brain's vulnerability or accompanying cardio-pulmonary dysfunction. Thus, these patients should be approached very cautiously to overcome any anticipated intraoperative threat by concerted efforts with neuro-anesthesiologist in point to point manner.