Aneurysm

Importance of Neuropsychological
Evaluation After Surgery in
Patients with Unruptured
Cerebral Aneurysms
Shiro Ohue, M.D., Ph.D.,* Yoshihisa Oka, M.D., Ph.D.,† Yoshiaki Kumon, M.D., Ph.D.,*
Shinsuke Ohta, M.D., Ph.D.,* Saburo Sakaki, M.D., Ph.D.,*
Takao Hatakeyama, M.D., Ph.D.,‡ Toshitaka Shiraishi, M.D., Ph.D.,§
Sadanori Takeda, M.D., Ph.D.,¶ and Takanori Ohnishi, M.D., Ph.D.*
*Departments of Neurological Surgery, Ehime University School of Medicine, †Washokai
Sadamoto Hospital, ‡Uwajima City Hospital, §Ehime Prefectural Niihama Hospital, and
¶Saiseikai Imabari Hospital, Ehime, Japan

Ohue S, Oka Y, Kumon Y, Ohta S, Sakaki S, Hatakeyama T,
Shiraishi T, Takeda S, Ohnishi T. Importance of neuropsycholog-
ical evaluation after surgery in patients with unruptured cerebral
aneurysms. Surg Neurol 2003;59:269 –76.
BACKGROUND
We evaluated neuropsychological function before and
after surgery in patients with unruptured cerebral
aneurysms.
METHODS
Neuropsychological functions in 43 patients with unrup-
tured cerebral aneurysms were evaluated before and 1
month after surgery. The neuropsychological examina-
tion included the Mini-Mental State examination, “Kana-
hiroi” test, Kohs Block Design test, and Miyake’s Memory
test. Then, if scores of even a single test were decreased
1 month after surgery, the tests were performed again 5
months later. In 24 of the 43 subjects, cerebral blood flow
(CBF) was measured before and 1 month after surgery by
single-photon emission tomography.
RESULTS
The outcome in all patients was evaluated as good ac-
cording to the Glasgow Outcome Score (GOS). In 17 (40%)
of the 43 patients, neuropsychological function had dete-
riorated 1 month after surgery. The most sensitive test
applied was the Miyake’s Memory test. Of 14 patients
with neuropsychological deterioration 1 month after sur-
gery, 6 showed complete recovery, 5 showed partial re-
covery, and 3 still showed cognitive deterioration 6
months after surgery. Patients over 65 years old, those
with anterior communicating artery aneurysms, those
operated by interhemispheric approach, or those with
systemic diseases showed a greater tendency toward a
decline in postoperative neuropsychological function
than the other patients. The postoperative CBF and vas-
Address reprint requests to: Shiro Ohue, M.D., Ph.D., Department of
Neurological Surgery, Ehime University School of Medicine, Shitsukawa,
Shigenobu-cho, Onsen-gun, Ehime 791-0295, Japan.
Received February 28, 2002; accepted November 22, 2002.
© 2003 Elsevier Inc. All rights reserved.
360 Park Avenue South, New York, NY 10010 –1710
cular response in the frontal lobe of affected-side was
decreased in cases showing cognitive deterioration.
CONCLUSIONS
These results suggested that the neuropsychological out-
comes after surgery for unruptured cerebral aneurysms
were not satisfactory. © 2003 Elsevier Inc. All rights
reserved.
KEY WORDS
Neuropsychological evaluation, cerebral blood flow, unrup-
tured cerebral aneurysm, surgical outcome.
mprovement and availability of neuroradiologi-
I cal techniques such as computed tomography
(CT) and magnetic resonance imaging (MRI) have
resulted in more frequent detection of unruptured
cerebral aneurysms [14,16]. Many neurosurgeons
and neurologists advise preventive surgery for un-
ruptured aneurysms, at least under some circum-
stances, because prognosis of subarachnoid hem-
orrhage due to ruptured aneurysms is still poor
[17,18]. However, advising an individual patient
about whether to undergo preventive surgery for an
unruputured aneurysm represents a clinical di-
lemma [16]. The treatment of these aneurysms ul-
timately depends on the relative risk of subsequent
aneurysm rupture in untreated patients versus the
risk of surgical treatment [9]. A number of studies
[3,10,12,13] have reported low morbidity and mor-
tality rates of surgical intervention for unruptured
aneurysms according to the Glasgow Outcome
Scale (GOS) [6]. However, there have been few re-
ports about neuropsychological outcome after sur-
gery for unruptured aneurysms [4,11]. It is impor-
0090-3019/03/$–see front matter
doi:10.1016/S0090-3019(03)00043-0
270 Surg Neurol Ohue et al
2003;59:269 –76

Characteristics of 43 Patients with Unruptured Ce- basilar artery (BA), 1. Eight patients had multiple
1 rebral Aneurysms aneurysms. Aneurysmal size ranged from 3 to 15
NUMBER OF mm in diameter (mean, 6.0 mm). Twenty-nine of 43
PATIENTS patients had systemic diseases such as hyperten-
sion or ischemic heart disease.
Sex Female 31
Male 12 OPERATION
Age ⱕ64 30
ⱖ65 13
The site, size, and number of aneurysms and the
Site of aneurysms AcoA 14 (7) operative approach were estimated. Before opera-
MCA 17 (10) tion, all patients gave their informed consent to
ICA 21 (16) craniotomy and clipping.
ACA 3 (1)
BA 1 (1) EVALUATION OF SURGICAL
Size of aneurysms ⬍5 mm 20 (10) OUTCOME BY GOS
5–9 mm 28 (19)
⬎10 mm 8 (6)
The surgical outcomes 3 months after surgery in all
Number of aneurysms 1 35 patients were evaluated according to the GOS [6].
2 5
3 2
NEUROPSYCHOLOGICAL
5 1 EXAMINATIONS
Neuropsychological function was evaluated by the
Abbreviation: ACA, anterior cerebral artery; AcoA, anterior commu- following four tests: the Mini-Mental State examina-
nicating artery; BA, basilar artery; ICA, internal carotid artery; MCA, tion (MMSE), “Kana-hiroi” test, Kohs Block Design
middle cerebral artery; VA, vertebral artery. test, and Miyake’s Memory test. These tests were
Numbers in parentheses indicate number of patients with single an-
carried out individually by the same assessor be-
eurysm.
fore and 1 month after surgery. Although MMSE and
“Kana-hiroi” test were performed in all 43 patients,
tant to determine how surgery for unruptured Kohs Block Design and Miyake’s Memory tests were
aneurysms affects normal brain function when mak- carried out in 36 patients. If scores of even a single
ing the decision to perform surgery. We evaluated test decreased 1 month after surgery by over 20% of
changes of neuropsychological function and cere- those before surgery, the tests were repeated again
bral blood flow (CBF) before and after surgery in 43 5 months later.
patients with unruptured cerebral aneurysms. MMSE [2]. This test consisted of 11 components
including orientation, registration, recall, calcula-
tion, and language with maximum total score of 30.
Materials and Methods A score of less than 24 is suggestive of dementia.
PATIENTS This test is suitable for screening of posterior cere-
bral function [4].
Ninety-seven adult patients with unruptured cere-
bral aneurysms underwent surgery in our hospitals “KANA-HIROI” TEST [7]. In this test, subjects are
(Ehime University School of Medicine, Washokai asked to correctly pick out and circle the five Jap-
Sadamoto Hospital, Uwajima City Hospital, Ehime anese “kana” vowels while reading a story. The total
Prefectural Niihama Hospital, and Saiseikai Imabari number of kana letters in the story is 409, 61 of
Hospital) between 1996 and 1998. Neuropsycholog- which were vowels. The number of letters correctly
ical functions before and after the surgery for un- recognized in 2 minutes was scored. This test is
ruptured cerebral aneurysms were evaluated in 43 suitable for screening of frontal lobe function.
of these 97 patients. The remaining 54 patients were
KOHS BLOCK DESIGN TEST. This test consists of
not evaluated for neuropsychological function be-
asking subjects to reconstruct pattern of various
cause the informed consent for the examination
colored blocks. This test included more complex
was not obtained. The characteristics of these 43
questions than the Wechsler Adult Intelligence
patients are summarized in Table 1. The patients
Scale, revised, and is recognized as a standard clin-
were composed of 31 women and 12 men and
ical tool for detection of visuospatial disorganiza-
ranged in age from 35 to 75 years old (mean, 59.9).
tion located in the parietal lobe.
The distribution of aneurysms was as follows: an-
terior communicating artery (AcoA), 14 cases; mid- MIYAKE’S MEMORY TEST. This test is one of
dle cerebral artery (MCA), 17; internal carotid ar- paired associated tests. It consists of recalling 10
tery (ICA), 21; anterior cerebral artery (ACA), 3; pairs of related and unrelated words, respectively.
Neuropsychological Function after Aneurysmal Surgery
It is thought to be one of a recent memory test of
verbal materials. In normal volunteers, the score
was over 8 in related pairs and over 7 in unrelated
pairs.
CEREBRAL BLOOD FLOW STUDY
In 24 of 43 patients, cerebral blood flow (CBF) was
measured before and 1 month after surgery using
the 133Xe inhalation method and single photon
emission tomography (SPECT, 2000H-40, Hitachi, Ja-
pan) with a spatial resolution of 21.3 mm full-width
at half maximum and interslice separation of 12 mm
[22]. The regional CBF (rCBF) was calculated by the
Kanno and Lasen method [8] and measured in 24
cortical regions in affected-side cerebral hemi-
spheres under resting conditions and 15 minutes
after the intravenous administration of 1.0 g acet-
azolamide. The changes in rCBF (⌬rCBF, %) after
acetazolamide loading compared to the resting
level was calculated to estimate vascular response
to the stress. The 24 cortical regions were divided
to the following four areas: frontal, temporal, pari-
etal, and occipital lobes.
STATISTICAL ANALYSES
The data were statistically analyzed using the
Mann-Whitney test and the Wilcoxon signed-ranks
test to evaluate the factors of deterioration of neu-
ropsychological function and changes in cerebral
blood flow after surgery for unruptured aneurysms,
respectively.
Results
OPERATION
Surgery was performed by the pterional and inter-
hemispheric approaches in 39 and 6 cases, respec-
tively. Dominant-side pterional approach was used
in 17, and nondominant-side pterional approach
was used in 22 patients. Only 2 patients were oper-
ated on twice. A patient with AcoA and right MCA
aneurysms was treated by the interhemispheric
and right pterional approaches. Another patient
with AcoA, bilateral IC, and bilateral MCA aneu-
rysms was treated by clipping of aneurysms using
the bilateral pterional approach. For neck clipping
of AcoA aneurysm by the pterional approach, we
aspirated a small part of rectal gyrus around an
aneurysm in all cases. After the operation, low-
density areas were detected on CT scans in 3 cases.
Moreover, fluid collection in unilateral or bilateral
subdural spaces was found on CT after surgery in 7
cases.
Surg Neurol 271
2003;59:269 –76
Results of Neuropsychological Function 1 Month
2 After Surgery
NUMBER OF
NUMBER OF PATIENTS SHOWING
PATIENTS DETERIORATION
TESTS TESTED (%)
MMSE 43 0 (0%)
“Kana-hiroi” test 43 8 (19%)
Kohs Block Design 36 2 (6%)
test
Miyake’s Memory 36 11 (31%)
test
Total 43 17 (40%)
Abbreviation: MMSE, Mini-Mental State examination.
EVALUATION BY THE GOS
None of 43 patients had any neurologic deficits, and
all patients returned to their normal lives after
treatment. Therefore, the outcome in all patients
was evaluated as good according to the GOS.
NEUROPSYCHOLOGICAL
EXAMINATION AFTER SURGERY
Table 2 shows the postoperative neuropsychologi-
cal function 1 month after surgery in 43 patients
with unruptured aneurysms. In 17 (40%) of the 43
patients, the scores of one or more tests 1 month
after surgery decreased by over 20% from those
before surgery. Of these 17 patients, scores of only
one test worsened in 14; those of two tests wors-
ened in 2; and those of three tests worsened in 1
patient. The scores of the MMSE 1 month after
surgery showed no deterioration in any of the 43
patients. The scores of “Kana-hiroi” test were de-
creased in 8 (19%) of the 43 patients. The scores of
Kohs Block Design and Miyake’s Memory tests were
decreased in 2 (6%) and 11 (31%) of the 36 patients
who performed the tests, respectively. The distri-
bution of aneurysms in 17 patients with neuropsy-
chological deterioration was as follows: AcoA, 8
cases; MCA, 8; ICA, 4; ACA, 2. Four patients had
multiple aneurysms.
Fourteen of 17 cases with neuropsychological de-
terioration were evaluated again 6 months after sur-
gery (Table 3). Six (43%) of 14 cases with neuropsy-
chological deterioration 1 month after surgery
showed complete recovery to preoperative scores.
Although 5 patients (36%) showed partial recovery,
the remaining 3 patients (21%) still showed neuro-
psychological deterioration. In the “Kana-hiroi” and
Kohs Block Design tests, all patients showed com-
plete or partial recovery of the function. In the
Miyake’s Memory test, 4 showed complete recov-
ery, 2 showed partial recovery, and deterioration
continued in 4.
272 Surg Neurol Ohue et al
2003;59:269 –76

3 Results of Neuropsychological Function 6 Months After Surgery

PATIENTS SHOWING FOLLOW-UP NEUROPSYCHOLOGICAL FUNCTION 6 MONTHS

DETERIORATION PATIENTS AFTER SURGERY (%)
1 MONTH 6 MONTHS AFTER COMPLETE PARTIAL NO
TESTS AFTER SURGERY SURGERY IMPROVEMENT IMPROVEMENT IMPROVEMENT
MMSE 0 — — — —
“Kana-hiroi” test 8 6 4 (67%) 2 (33%) 0 (0%)
Kohs Block Design test 2 2 2 (100%) 0 (0%) 0 (0%)
Miyake’s Memory test 11 10 4 (40%) 2 (20%) 4 (40%)
Total 17 14 6 (43%) 5 (36%) 3 (21%)
Abbreviation: MMSE, Mini-Mental State examination.

FACTORS OF DETERIORATION OF CBF STUDY BEFORE AND AFTER

NEUROPSYCHOLOGICAL FUNCTIONS SURGERY
Table 4 shows the factors of deterioration of neu- Table 5 shows changes in rCBF in 24 patients before
ropsychological function 1 month after surgery. and 1 month after surgery. In cases showing dete-
There were statistically significant differences (p ⬍ rioration, although the resting rCBF in frontal lobe
0.05) in decreases in neuropsychological functions before surgery was 48.7 ⫾ 3.6 ml/min/100 g (mean ⫾
between younger (under 64 years old) and older S.D.), after surgery it decreased to 44.6 ⫾ 3.8 ml/
(over 65 years old) groups, those with AcoA and IC min/100 g. This difference was significant (p ⬍ 0.05).
aneurysms, those operated by interhemispheric ⌬rCBF in frontal lobe after surgery was significantly
and pterional approaches, and those with and with- decreased in contrast with those before surgery.
out systemic diseases. There were no statistically The resting rCBF and ⌬rCBF in parietal, temporal
significant differences in size of aneurysms and and occipital lobes in cases showing deterioration
number of aneurysms. did not significantly decrease after surgery. Cases
showing preservation, resting rCBF, and ⌬rCBF in
any lobes did not show significant changes after
Factors of Deterioration of Neuropsychological surgery.
4 Functions After Surgery
NUMBER OF
DETERIORATED/
TOTAL STATISTICAL Discussion
FACTORS PATIENTS (%) DIFFERENCES PURPOSE OF THIS STUDY
Age The treatment of unruptured cerebral aneurysms
ⱕ64
ⱖ65
8/30 (27%)
9/13 (69%) ] p ⬍ 0.05 ultimately depends on the relative risk of subse-
quent aneurysm rupture in untreated patients ver-
Site of ANs
sus the risk of surgical treatment. Many previous
AcoA
MCA
IC
5/7 (71%)
4/10 (40%)
1/16 (13%)
] p ⬍ 0.01 reports have estimated the risk of aneurysm rup-
ture as approximately 2% per year. However, a re-
Size of ANs cent study [5] indicated that the cumulative rate of
⬍5 mm 2/10 (20%) aneurysm rupture was less than 0.05% per year. On
5–9 mm 8/19 (42%)
⬎10 mm 2/6 (33%) the other hand, surgery is accompanied with little
Number of ANs mortality and infrequent morbidity according to the
Single 12/35 (43%) GOS. Comparison of these operative risks with the
Multiple 5/8 (64%) natural history of unruptured aneurysm will allow
Systemic diseases detailed evaluation of the surgical outcome. How-
⫹
⫺
15/29 (57%)
2/14 (14%) ] p ⬍ 0.05 ever, there have been few reports of neuropsycho-
Approach logical evaluation of aneurysmal patients before
Interhemispheric 4/5 (80%) and after surgery [4,11]. Fukunaga et al [4] per-
Pterional
Dominant side
12/36 (33%)
5/16 (31%)
] p ⬍ 0.05
formed three neuropsychological examinations be-
fore and after surgery in 30 patients with unrup-
Nondominant side 7/20 (35%)
tured cerebral aneurysms. In their study, 1 month
Neuropsychological Function after Aneurysmal Surgery
5 Changes in Cerebral Blood Flow Study Before and 1 Month After Surgery
RESTING rCBF (ml/min/100g)
BEFORE 1 MONTH AFTER
SURGERY
Patients showing deterioration
Frontal 48.7 ⫾ 3.6a
Parietal 46.1 ⫾ 6.3
Temporal 50.3 ⫾ 5.5
Occipital 48.7 ⫾ 4.6
Patients showing preservation
Frontal 51.2 ⫾ 9.3
Parietal 46.5 ⫾ 8.6
Temporal 50.4 ⫾ 8.8
Occipital 48.5 ⫾ 9.3
The values represent ⫾ S.D.
a
A significant difference (p ⬍ 0.05) was observed between the resting rCBFs in frontal lobe before and 1 month after surgery.
b
A significant difference (p ⬍ 0.05) was observed between ⌬CBFs in frontal lobe before and 1 month after surgery.
Abbreviations: rCBF: regional cerebral blood flow, ⌬rCBF: increase in rCBF after acetazolamid loading.
after surgery the scores of the MMSE decreased in
10 cases (33%), the scores of the “Kana-hiroi” test
decreased in 17 cases (56%), and the time of the
Maze test increased in 13 cases (43%). The total
number of patients showing deterioration of neuro-
psychological function 1 month after surgery for
cerebral aneurysm was 22 (73%) of 30 cases. Koba-
yashi et al [11] studied 21 patients with unruptured
aneurysms using the Wechsler adults intelligence
scale revised (WAIS-R). Although the results of
WAIS-R was not significantly different after surgery
in any of the patients, total IQ for the patients with
AcoA aneurysms showed a significant decline com-
pared with patients with other aneurysms after
surgery.
NEUROPSYCHOLOGICAL OUTCOME
AFTER ANEURYSMAL SURGERY
In our study, all 43 subjects were evaluated as
showing good outcome by the GOS. Seventeen
(40%) of the 43 patients demonstrated neuropsy-
chological deterioration 1 month after surgery,
which was better than the incidence of neuropsy-
chological deterioration reported previously [4].
This difference was thought to be dependent on the
criteria used to define neuropsychological deterio-
ration. If the results of this previous study were
evaluated by our criteria, the total number of pa-
tients showing deterioration was 12 (40%) of 30
patients in previous study [4].
The Miyake’s Memory test was the most sensitive
test for evaluating neuropsychological deteriora-
tion after surgery in our study. This test is consid-
ered to be suitable for screening of immediate mem-
ory disturbance. Kobayashi et al [11] reported that
Surg Neurol 273
2003;59:269 –76
⌬rCBF (%)
BEFORE 1 MONTH AFTER
SURGERY SURGERY SURGERY
44.6 ⫾ 3.8a 41.0 ⫾ 7.2b 33.6 ⫾ 8.1b
45.3 ⫾ 2.5 41.9 ⫾ 10.8 36.1 ⫾ 13.3
47.5 ⫾ 3.2 40.6 ⫾ 8.6 37.0 ⫾ 10.1
45.1 ⫾ 3.0 46.0 ⫾ 7.4 44.5 ⫾ 8.9
48.9 ⫾ 8.3 36.6 ⫾ 10.6 36.8 ⫾ 10.6
47.7 ⫾ 7.8 38.9 ⫾ 11.7 38.2 ⫾ 9.8
50.7 ⫾ 8.0 39.0 ⫾ 16.5 40.4 ⫾ 10.6
49.0 ⫾ 7.6 38.1 ⫾ 12.7 43.4 ⫾ 10.5
5 of 8 AcoA aneurysmal patients showed a specific
reduction in verbal IQ of WAIS-R, suggesting dete-
rioration of recent memory. The regions to which
memory function is located in the brain are unclear,
but memory impairment has been reported to re-
sult from disturbance of cerebral-associated field,
frontal lobe, medial temporal lobe, or diencephaly.
In patients with cerebral aneurysms, postoperative
memory disturbance may be because of frontal lobe
destruction after surgical manipulation. During the
pterional or the interhemispheric approach, it may
be possible to cause injury of unilateral or bilateral
frontal lobes if their retraction during surgery is
excessive. The disturbance of frontal lobe function
may explain why “Kana-hiroi” test was a sensitive
test after aneurysmal surgery not only in the previ-
ous report [4] but also in our study. The “Kana-
hiroi” test is considered the most suitable test for
screening of frontal lobe function [7]. On the other
hand, none or few patients showed neuropsycho-
logical deteriorations in the MMSE or Kohs’ Block
Design test. These results suggest that posterior
cerebral function was preserved after surgery.
In the present study, patients over 65 years old,
those with AcoA aneurysms, those operated by in-
terhemispheric approach, or those with systemic
diseases showed a significantly higher incidence of
neuropsychological deterioration after surgery.
These results were consistent with those reported
previously [4,11]. Patients with ruptured AcoA an-
eurysms were reported to show memory impair-
ments because of basal forebrain infarct induced by
disruption of blood flow through the perforating
274 Surg Neurol
2003;59:269 –76
branches of AcoA after surgery [1,15,19 –21]. In our
study, the destruction of perforators from AcoA
during surgery was unlikely to have occurred be-
cause we preserved these arteries in all cases. For
patients with AcoA aneurysms, we used two differ-
ent approaches: interhemispheric and pterional ap-
proaches. Surgery through the interhemispheric
approach might damage the medial side of bilateral
frontal lobes because of brain retraction by spatu-
las, leading to detrioration of neuropsychological
function. In patients treated via the pterional ap-
proach, we used rectal gyrus aspiration for aneu-
rysmal clipping [23]. This technique may also be
related to neuropsychological deterioration.
RELATIONSHIP BETWEEN
NEUROPSYCHOLOGICAL
EVALUATION AND CBF
In this study, the rCBF on Xe-SPECT in patients with
neuropsychological deterioration after surgery was
decreased significantly compared with those with-
out neuropsychological deterioration. This result
suggests that the surgical manipulation caused a
decrease in CBF at the regions where neuropsycho-
logical function was localized, resulting in reduc-
tion of neuropsychological function. CBF in patients
over 65 years old or with general complications
may be especially susceptible to surgery.
LONG-TERM NEUROPSYCHOLOGICAL
OUTCOME
Fukunaga et al [4] reported that patients with dete-
rioration of neuropsychological function showed
recovery almost to preoperative levels by 3 months
after surgery. In this study, all patients showing
neuropsychological deterioration in Kohs’ Block
Design test 1 month after surgery showed full re-
covery 6 months later. On the other hand, only 67%
and 40% of the patients with neuropsychological
deterioration in “Kana-hiroi” and Miyake’s Memory
tests 1 month after surgery showed full recovery 6
months later. Therefore, some neuropsychological
deterioration remained in these subjects.
These results suggest that some patients with
good outcome experienced permanent deteriora-
tion of neuropsychological function after surgery.
Therefore, the neuropsychological outcome after
operation for unruptured cerebral aneurysms is not
yet satisfactory.
Conclusions
Seventeen (40%) of 43 patients who were evaluated
as good outcome, according to the GOS, showed
Ohue et al
deterioration of neuropsychological function 1
month after surgery. Memory function showed the
most significant deterioration after surgery. Of the
patients in whom neuropsychological function was
deteriorated 1 month after surgery, about half still
showed some cognitive deterioration 6 months af-
ter surgery. Patients over 65 years old, those with
AcoA aneurysms, those operated by interhemi-
spheric approach, or those with systemic diseases
showed a significant higher incidence of deteriora-
tion in neuropsychological test scores. These re-
sults suggest that the neuropsychological outcome
after operation for unruptured cerebral aneurysms
is still not satisfactory. We conclude that such stud-
ies should be required in deciding whether the pa-
tients can return to their normal life or not.
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COMMENTARY
Dr Ohue and his colleagues have presented an in-
teresting evaluation of a group of 43 patients with
unruptured cerebral aneurysms who were carefully
evaluated with neuropsychological examination be-
fore and after surgery. None of these patients had
significant morbidity. All of them were considered
to have excellent outcomes based on the Glasgow
Outcome Scale. However, 17 patients had some
type of neuropsychological dysfunction one month
after surgery. Six of these patients showed com-
plete recovery in 6 months. Therefore, in terms of
long-term neuropsychological deterioration, 11 pa-
tients had significant long-term problems related to
the operative procedure. Review of Table 4 indi-
cates that 4 of the 11 patients had an interhemi-
spheric approach and therefore bilateral frontal
lobe retraction. Nine of the 11 patients were greater
than 65 years of age. Therefore, patients under the
age of 65 who had unilateral approaches actually
had a very small number of long-term neuropsycho-
Surg Neurol 275
2003;59:269 –76
logical difficulties after surgery. These factors
should definitely be taken into account when select-
ing patients for prophylactic surgery and when
choosing the route for surgical clipping. I think that
it is unwise to ever subject a patient to bilateral
frontal lobe injury, even with gentle retraction. Nu-
merous studies have indicated a high incidence of
neuropsychological dysfunction after this type of
manipulation. Similarly, elderly patients do not re-
spond well to brain retraction. They should proba-
bly be considered for prophylactic surgery only in
exceptional circumstances. In summary, neuropsy-
chological deterioration after unruptured aneurysm
surgery needs to be considered as a possibility.
This problem can be minimized by careful patient
selection and choosing the appropriate surgical
route to minimize any risk of bilateral frontal lobe
injury.
Robert A. Solomon, M.D.
Neurosurgeon
New York, New York
Clinical survey of unruptured cerebral aneurysms is
becoming popular by using detection system for
asymptomatic disease using MRA in Japan. Surgical
clipping or endovascular coiling is performed for
their prophylactic treatment of subarachnoid hem-
orrhage. The surgical complication must be mini-
mized in consideration with higher brain function.
This is an important data of neuropsychological
testings. They concluded that 40% of patients
scored GOS I showed deterioration of neuropsycho-
logical function, temporary or permanent, espe-
cially in patients with Acorn aneurysms. The neu-
ropsychological testings concerning memory
recalling are becoming important for the evaluation
of return-to-work projections.
Takeshi Kawase, M.D.
Department of Neurosurgery
Keio University School of Medicine
Tokyo, Japan
I think this article highlights several important
questions, and although the study is not large
enough to provide the answers to those questions,
it does add significant weight to the realization that
neuropsychological examination of patients after
treatment for unruptured aneurysms is paramount.
The study is focused on a small cohort of patients
who underwent surgery for unruptured, predomi-
nantly anterior circulation, aneurysms. It is inter-
esting to note that on Glasgow Outcome Score and
Mini-Mental evaluations, all of the patients did well.