Philadelphia Neurological Society, Section of Neurology and Psychiatry of the District of Columbia Medical Society and the Neuropsychiatric Section of the Baltimore County Medical Society

Abstract

Five cases in which operation revealed aneurysm of the posterior communicating artery of the circle of Willis were reported. In 4 of the cases cure was effected by clipping the arteries running into the aneurysms. The largest aneurysm was approximately 2.5 cm. and the smallest 1 cm., in diameter.In 4 cases there were the classic symptoms of spontaneous subarachnoid hemor¬ rhage with sudden generalized headache, later localizing to the eye and supraorbital region, with stiffness and pain in the legs and neck, and nausea. In each of the 4 cases, at the onset of headache or soon after, paralysis of the third cranial nerve developed. In 1 case there was no headache, but paralysis of the third nerve was present. In all cases evidence of hemorrhage from rupture of the aneurysm was disclosed by discoloration of the cerebral cortex or by blood in the spinal fluid.In 2 cases the aneurysm was disclosed by arteriography ; in 2 cases the contrast medium failed to show the lesion, and in 1 case no angiogram was made.Since the ultimate mortality from untreated intracranial aneurysm must be close to 100 per cent, it is necessary to attempt surgical cure of this lesion. Sudden headache, generalized or localized to the eye or the supraorbital region, accompanied with a paralysis of the third nerve, localizes the lesion to the intracranial position of the third nerve, back of the carotid artery. In this location, an aneurysm of the carotid or the posterior communicating artery must be suspected, and such symptoms are sufficiently localizing and diagnostic to warrant surgical exploration.The procedure of arteriography is not accurate enough to be dependable as a positive diagnostic test. Clinical examination alone should determine the diagnosis.As shown by these 5 cases, craniotomy, exploration and ligation of the supplying arteries are both feasible and life saving, since there was only 1 death in the 5 cases. discussion Dr. Walter Freeman, Washington, D. C. : Dr. Jaeger sent me a copy of this paper, and I was delighted beyond measure to know that something could be done in these cases. Neurologists have been rather helpless before the neurosurgeons showed a way of handling them. Of course, we are familiar with Dandy's pioneer exploits in the treatment of aneurysms, but in the case of the little thinwalled aneurysms, I have heretofore felt pretty hopeless.I wonder whether the cerebral circulation will stand either a clip or a temporary ligature on the carotid artery during the operation to prevent flooding of the wound at the time of operation? I believe that Dr. Jaeger mentioned the desirDownloaded From: http://archneurpsyc.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/31/2015